CHARLOTTE FIRE DEPARTMENT

LIBERTY ROW FIRE

AFTER ACTION REPORT
INCIDENT # 23-0147427
 CHARLOTTE FIRE DEPARTMENT

LIBERTY ROW FIRE

AFTER ACTION REPORT

TABLE OF CONTENTS

EXECUTIVE SUMMARY.......................................................... 3

CFD TERMINOLOGY............................................................... 11

CHAPTER ONE: STRATEGICAL AND TACTICAL OPERATIONS

ANALYSIS .......................................................................... 13

CHAPTER TWO: MAYDAY/RIC REVIEW.................................... 30

CHAPTER THREE: FIRE INVESTIGATION TASK FORCE REPORT.....56

CHAPTER FOUR: FIRE COMMUNICATIONS RESPONSE REPORT ... 69

APPENDIX A: IMPROVEMENT PLAN (SUPPLEMENT TO FIRE

COMMUNICATIONS RESPONSE REPORT)..................................87

APPENDIX B: GLOSSARY (SUPPLEMENT TO FIRE

C O M M U N I C A T I O N S R E P O N S E R E P O R T ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 5

INCIDENT # 23-0147427
 LIBERTY ROW FIRE - AFTER ACTION REPORT

EXECUTIVE SUMMARY
PREPARED BY
DEPUTY CHIEF PETER J. SKERIS, CFD
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EXECUTIVE SUMMARY

The following executive summary was completed with input from those
members on-scene and external SMEs to depict an accurate account of
the events of May 18,2023 while under no time-sensitive deadline, and in
climate-controlled conditions. The units that operated under high stress
showed true dedication and commitment to saving lives and property.
Their actions saved others, saved multiple properties, and resulted in few
injuries to civilians and firefighters. This report is designed for all of us to
learn valuable lessons, evaluate our response, and to ensure our future
success.

INCIDENT SUMMARY

At 0902 on May 18, 2023, the Charlotte Fire Department was dispatched to
7741 Liberty Row Drive for a reported trailer on fire in the parking deck. The
trailer was not attached to a vehicle. The units dispatched were Battalion
5, Engines 02, 12, 14, and Ladder 16. At 0907, Ladder 16, under the command
of Captain Brian Benson, arrived reporting heavy smoke showing and
requesting an upgrade to a working fire. The additional units were BC01,
E43, Rescue 10, and Safety 1. Ladder 16 entered off Piedmont Row Drive onto
Barclay Downs Drive (see photo 1). Ladder 16 established Command and
Barclay Downs became the Alpha (“A”) side of the incident. The fire was
around a trailer designed to spray insulation within a 7-story mid-rise
building under construction, with the 2 bottom floors being concrete, and
the top 5 floors being uncompartmentalized wood framing. (See photo 2).
While locating the fire and ensuring the construction crews had
evacuated, 2 workers were discovered unaccounted for. They were
reported to be on the 4th floor. In reality, this was the fourth residential
floor which corresponds to the sixth floor of the building.

Despite valiant efforts Demonte Sherrill and Ruben Holmes would perish in
this fire.

What followed, and detailed within this report became one of the largest
fires in the recent history of the Charlotte Fire Department reaching 5-
Alarms.
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EXECUTIVE SUMMARY

THE TIMELINE OF DISPATCH AND ALARMS

0902: Initial Alarm- Battalion 5, Engines 2, 12,14 and Ladder 16

0907: Working fire- Battalion 1, E43, R10, Safety 1
0908: Ladder 1, 2 were added as a special call
0909: 2nd Alarm- Car 2, Car 10, Car 20, Battalion 7, Engines 20, 24, 39,
Ladder 24 and Tower 26
0911: Hazmat 13, Engine 32, Ladder 32, and Car 901 were added as a
special call
0920: 3rd Alarm: Car 1, Car 4, Battalion 3, Engines 19, 17, 10, and
Ladder 4
0931: 4th Alarm: Battalion 8, Engines 3, 4, 5 and Ladder 3
0956: 5th Alarm: Battalion 4, Engines 11, 28, 15 and Ladder 27

THE BUILDING

The building was under construction and designed to be a 7-story 239-unit

luxury apartment building (photo 3, 4, 5) of podium construction, consisting
of a 5-story wood frame apartment over 2-story concrete parking garage.
An overview would show the building was to be in the shape of a W. The
building was approximately 355’ long and 120’ deep. It was framed, but with
no compartmentalization. Therefore, no sheetrock or other barrier existed
to prevent unimpeded fire growth. An exact duplicate building, in nearly
the exact stage of construction, was located across Liberty Row Drive
approximately 60’ away.
Side Alpha: Barclay Downs Dr. (near 4801)
Side Bravo: Liberty Row Dr
Side Charlie: Fairview Rd
Side Delta: Parking Deck

LOCATION OF THE FIRE

The fire was originally located in and around a mobile trailer housing a
generator and supplies for spray foam insulation. The trailer was staged
on the ramp between the ground level and level 2 near the Alpha side of
the building.
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EXECUTIVE SUMMARY

WEATHER

The weather at the time of dispatch was partly sunny with a reported high
of 68F with winds from the Southeast at 13-14 mph and 61% humidity. The
highest temperature of the day was 81F, with humidity dropping into the
mid-30% range.

INITIAL ACTIONS (NOT ALL ENCOMPASSING)

For full account see Chapter One: Strategical and Tactical Operations Analysis

Ladder 16 arrived and initially made attempts to:

1. Locate the fire.
2. Ensure workers were evacuated.
3. Locate and rescue the two known missing workers. (Placement of a 40’
ground ladder)
4. The master stream was operated on the Alpha side.

Engine 14 established a water supply on Barclay Downs and hooked into

the FDC (Fire Department Connection) (although they were told it was
operational, it was not.), and supplied Ladder 16.

Engine 12 took their hose bundles into the lower deck and stretched to the
standpipe. (It again was non-operational).

Engine 2 located on the Charlie side and supplied Ladder 2.

Ladder 2 positioned in the Bravo side roadway between the fire building
and the Bravo Exposure around the tower crane. Once the decision was
made to abandon L-2 due to the high potential for collapse the aerial
stream was focused on the tower cranes steel structure.

Ladder 1 was positioned in the driveway at the Bravo/Charlie corner and

operated their master stream. The crew took the construction stairs up and
into the building to attempt a rescue before being evacuated due to a
rapid change in fire conditions. L-1 would ultimately call a May-Day but
was able to self-evacuate.
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EXECUTIVE SUMMARY

LESSONS LEARNED/RECOMMENDATIONS
(SUMMARY - MORE DETAILS CAN BE FOUND IN CHAPTERS 1-4)

·Implementation of Command Aide/Field Technician.

·Provide training on Command Post operations and securing.
·Staff Field Communications Unit (Field Comm) and provide training on its
operations.
·Reduce the ability for companies/units to self-dispatch.
·Enter buildings with navigation aids. (Search rope or handline)
·Fireground communications
·Crew Complacency
·Calling the Mayday
·Communications Center (ALARM) staffing and use of the administrative
line
·Develop a SOG (Standard Operating Guidelines) for mutual aid (operations
and requesting)
·Include Telecommunicators in MAYDAY training.
·Develop a SOG that dictates the use of the ALARM administrative phone
line.
·Develop a SOG that establishes a communications method between
ALARM and the EOC (Emergency Operations Center).
·Develop (research/purchase) technology solutions that enhance unit/area
tracking and citywide coverage.
·Consider the development of a consolidated CFD/CMPD/CMED dispatch
center

CHAPTERS:
1: Strategical and Tactical Operations Analysis
2: MAYDAY/RIC Overview
3: Fire Investigation Taskforce Report
4: Fire Communications Response Report
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EXECUTIVE SUMMARY

PHOTO # 1

CHARLIE (C)

BRAVO (B) DELTA (D)

ALPHA (A)

PHOTO # 2
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EXECUTIVE SUMMARY

PHOTO # 3

PHOTO # 4
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EXECUTIVE SUMMARY

PHOTO # 5
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CFD TERMINOLOGY
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INTRODUCTION
The fire service uses a variety of terms and acronyms in day-to-day
operations. This chapter is intended to provide clarity regarding terms
utilized throughout the additional chapters of this report.

TERMINOLOGY
ALARM CFD COMMUNICATIONS CENTER
BC BATTALION CHIEF
C CAR
E ENGINE
EOC EMERGENCY OPERATIONS CENTER
FDC FIRE DEPARTMENT CONNECTION
FIELD COMM FIELD COMMUNICATIONS UNIT
L LADDER
R RESCUE
TW LADDER TOWER

CAR ASSIGNMENTS
C01 FIRE CHIEF
C02-C04 DEPUTY CHIEFS
C06-C10 DIVISION CHIEFS
C13-C19 ADMINISTRATIVE STAFF CHIEFS/CAPTAINS
C20-C21 HEALTH & SAFETY DIVISION
C200 SERIES TRAINING DIVISION
C300 SERIES FIRE MARSHAL’S OFFICE
C500 SERIES EMERGENCY MANAGEMENT (CMEMO)
C600 SERIES COMMUNICATIONS DIVISION
C700 SERIES LOGISTICS DIVISION
C800 SERIES FIRE INVESTIGATION TASKFORCE/FITF
C900 SERIES SPECIAL OPERATIONS DIVISION
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CHAPTER ONE
STRATEGICAL AND TACTICAL
OPERATIONS ANALYSIS
PREPARED BY M.H. WILSON, BATTALION CHIEF (RETIRED, CFD)
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

INCIDENT SUMMARY

The incident at 7741 Liberty Row Drive occurred on the morning of 18 May
2023. The incident is categorized as a Type 3 incident under FEMA’s incident
command system. Additionally, the incident can be categorized as
extremely low frequency in occurrence but severe in impact. The fire
involved a building under construction that was rapidly fully involved
resulting in the deaths of two construction workers and the complete
destruction of the building of origin as well as multiple exposures
sustaining damage from radiant heat as well as flying brands from the
thermal column that was created. Four Charlotte firefighters were almost
lost in rescue attempts for the two construction workers. Two ladder trucks
were left unserviceable with another engine apparatus sustaining damage.
The impact of the incident negatively affected the SouthPark community
for several days.

CHARGE AND PURPOSE

I was contacted by the CFD Deputy Chief of Operations on behalf of the

Chief of Department and asked to study the incident operations and
provide a “lessons learned” document. This document will identify
successful tactics and strategies as well as areas to focus training and
identify areas that improvements could be made for future incidents of
this type. There were no restrictions or conditions placed on my research
or findings.

METHODOLOGY

Research included a physical trip to survey the site, interviews conducted

either telephonically or in person of key personnel that answered the
alarm, reviews of CFD procedures and response efforts, and a
comprehensive presentation by the Fire Investigation Division with
accompanying surveillance camera video from the time the fire was
discovered by construction personnel.
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INCIDENT SYNOPSIS

The building of origin was a seven-story approximately 355’ by 120’ in

dimension. The building was in the wooden frame phase of construction
with no windows or doors yet finished. There was only one wooden stairwell
in existence located on the Charlie side of the building. This meant that
any access to upper floors on the Alpha side (where the fire started and
where first arriving fire companies reported to) had to be done by aerial or
ground ladder. The reach of the longest ground ladder is 40’, which may
not reach the 4th floor depending on grade and placement. The fire pump
and standpipe system were not in service at the time of ignition, although
first arriving Ladder 16’s officer was informed by the construction foreman
that it was.

The fire, of undetermined ignition source, began at a construction

apparatus used to spray insulation during the building process. The
location of the spray apparatus was interior of the building and close to
the Alpha/Delta corner. The fire was accelerated by combustible materials
used in the spray process, and impossible to confine due to the open
construction phase.

Surveillance camera footage shows construction workers reacting to the

fire’s origin at 08:55 hours. Footage also indicates that unsuccessful
attempts to fight the fire with portable extinguishers occurred. The first 911
notification to Fire Alarm was received at 09:02 hours, 7 minutes after the
discovery of the fire. Companies were dispatched at 09:02 hours, with
Ladder Company 16 arriving at 09:07 hours.

From ignition, the fire communicated unimpeded throughout the structure

with only brief and partial extinguishments affected by aerial master
streams. There were little or no physical barriers to confine the fire or slow
its progress, unlike one would encounter in a finished structure.
Additionally, there were no building systems intact that firefighters
normally depend on when operating at multi-story buildings. Using the
National Fire Academy’s formula to determine fire flow required for a given
space, 355’ X 120’ divided by 3 yields a need for 14,200 gallons of water per
minute to extinguish 1 floor of involvement at this structure. Exacerbating
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the rapid flame spread was the existence of a 14mph wind at the time of
the fire that rendered 1000 gallon per minute master streams less than
effective.

Had all pumping apparatus been flowing their master streams at capacity
even in the opening minutes of the operation, it is likely that it would not
have even been close to the fire flow required to extinguish the fire.

Extinguishing efforts were further hampered by the discovery that two

construction workers were trapped on the 6th floor, and the crane
operator (who chose to stay his post to provide a rescue platform for
workers), was trapped in his apparatus, unable to descend due to the
smoke and heat.

Additionally, it was necessary to direct fire streams on to exposures

including adjacent buildings, the crane itself, and fire apparatus. This was
executed successfully with few exceptions. It is quite remarkable that a
sister building in the same phase of construction sustained only topical
thermal damage from radiant heat. Ladder Company 2’s relentless efforts
to keep their master stream trained on the exposed steel superstructure of
the crane likely prevented the failure of the steel.

Once the firefighters were forced to abandon the rescue attempts; and
themselves declared “mayday”, and once the crane operator was able to
descend, the fire became fuel regulated and diminished as the building
was consumed.

INITIAL OPERATIONS

Ladder Company 16 encountered “volume driven smoke” and initiated

offensive operations as well as requesting an additional alarm be struck
and requested the hazardous materials team. The MSDS data on the
burning spray materials was not produced. The officer assigned to Ladder
16 that morning was familiar with the hydrant system as they had flowed
them earlier in 2023. The officer also had experience with the construction
industry and understood the urgency in accounting for all of the workers
as well as ensuring the evacuation was complete.
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Ladder 16’s officer reported that about the time of the 5th Battalion Chief’s
arrival the smoke gained velocity and turned black. Battalion 5 chief
assumed command of the incident and Ladder 16 reported two workers
trapped on the 4th floor and deployed a 40’ three-section ground ladder to
attempt a rescue. Due to uneven terrain and the fly section pawls not
locking on the ground ladder, Ladder 16 had to descend the ladder and
attempt to re-deploy it.

Ladder 16’s officer moved to the aerial of Ladder 2 instead of the ground
ladder, but the crew was able to re-set the 40’ and ascend. With Ladder 16’s
officer on the aerial of Ladder 2, and one firefighter on the 40’, the third
Ladder 16 firefighter made it close enough into the building to see the two
trapped workers. It was then that the pressurized smoke turned into a
fireball and the order to evacuate was given. Ladder 16’s firefighter was
able to dive out onto the 40’ and slide down into the waiting arms of the
Ladder 16 firefighter on the ladder. Both descended along with the officer
(from Ladder 2’s aerial) and assessed for injuries (there were none).

It is at this point that the responding Division chief assumed command and
issued the order for the evacuation tones. The Battalion 5 chief was
reassigned as the search and rescue group supervisor, and soon after
reassigned as the division A supervisor.

There is little evidence of an ICS being formed at this point; officers

reported that they did not know what group or division they were assigned
to or even what the geographical designations of the building sides were.
Further investigation yielded that these designations were made, but the
radio did not function, or the channel was so overwhelmed that the
information was not broadcast. This was exacerbated by a personnel
accountability report being conducted, further tying up the tactical
channel. Companies simply responded to the call for PAR in no particular
order making it difficult to track their actual status.

CFD Tac 501.04 is clear that a PAR is to be conducted by radio or face to

face with the accountability officer or incident commander and that each
division or group supervisor is responsible for tracking companies assigned
to him or her. It is not possible for an individual incident commander to be
involved in this tactical function and still maintain strategical awareness.
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Despite the immediate focus on life preservation mandated by the

accounting of the workers and reports of two trapped on the 4th floor,
efforts at an offensive attack were initiated by Engine Company 12 by
utilizing the non-existent standpipe system. Engine 12’s officer reported that
he and his crew were able to get within sight of the fire, but their hose
packs were useless without the standpipe.

Also, it is from Engine 12’s officer that one of the first reports of inability to
communicate on the portable radio. He had to exit the IDLH and doff his
SCBA mask in order to communicate but was not acknowledged.

Returning to the offensive attack, Engine 12 attempted to stretch an attack

line from Engine 2. At this point Engine 12’s officer reported that “the sound
was so loud he could not even communicate face to face with his
firefighters”. The officer did not hear the order to evacuate or the
evacuation tones. Conditions deteriorated rapidly, and out of options,
Engine 12 self-evacuated.
1
MAYDAY

While the initial operations were being conducted on the Alpha side and
the incident commander was attempting to organize resources and
account for personnel, Ladder Company 1 which had spotted on the Charlie
side of the fire building asked for and received permission to attempt the
rescue of the two trapped workers on the 6th floor. Leaving the FF/Engineer
to setup the aerial and prepare for deploying a master stream, Ladder 1’s
officer and two firefighters ascended the construction scaffold/stairs and
made their way to the sixth floor to begin the 300+’ trek to get to the Alpha
side.

Making a tactical judgement call not to deploy the search rope he carried
with him (“the floor was wide open and visibility was good”), the officer led
his crew close enough to hear the two victims. At this point, conditions
deteriorated so rapidly that Ladder 1 had no alternative but to turn back. It
was during their retreat that the PAR was called for and Ladder 1
responded in the affirmative, not yet knowing their exit would become
involved in fire.
1
CHAPTER TWO IS THE SEPARATE MAYDAY/RIT REPORT COMPLETED BY BC BOBBY CASH
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

Upon this turn of events, Ladder 1’s officer used his portable to send a
mayday alert, forcing the incident commander to react accordingly and re-
prioritize incident strategy and resources. Rescue Company 10, who was
assigned to rescue the crane operator was now redeployed to rescue
Ladder 1. Meanwhile, Ladder 1’s FF/Engineer was sweeping the Charlie side
of the structure with the aerial master stream in order to facilitate his
company’s escape.

Ladder 1’s officer told Rescue 10 to enter the stairwell beside where Engine 2
was spotted. Unbeknownst to the officer, Engine 2 had been moved from its
original location for being in too close proximity to the fire building. Rescue
10 was confounded by this and made attempts to verify the location, but
heavy radio traffic continued to make communications difficult.

Ladder 1 was able to make their way to an exterior opening and look down
on Tower Ladder 26 and her crew, but he could not get their attention either
via the radio or hand signals to send their aerial so they could exit.
Fortuitously, the member of Ladder 1 now almost out of air found the way
back to the construction stairwell and Rescue 10 actually met Ladder 1 on
their way out.

Rescue 10 was then re-deployed to return to the crane operator.

DEFENSIVE OPERATIONS

With the mayday resolved and Rescue Company 10 executing a plan to

extricate the crane operator, efforts focused on protecting exposures and
flowing as many master streams as possible. There were some master
stream devices serving combination nozzles, and even set on the
straightest stream, reports were that the stream was turning to steam
before reaching the fire. Research indicates that a separate radio channel
was designated for the rapid intervention team operations, and the crane
operator was communicating with Rescue 10’s officer via construction
radio. A division C appeared to organize organically with safety officers
initially establishing it then being relieved by subsequent arriving ranking
chiefs. After two or three collaborations between the incident commander
(Division 1) and the Chief of Operations, the operations chief assumed
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

command of the incident. Division 1 then served as an aide to the incident

commander. There are other reports of subsequent arriving officers
attaching themselves in the aide role to supervisors and command.

STAGING

Staging was established before the 2nd alarm companies arrived by an

officer from the Training Division. The officer reported that he was
confused as to the location of the command post, but chose to shut down
the intersection at Tyvola Road and communicated that as the staging
location to Fire Alarm.

Besides the RIT group being assigned its own radio channel, staging was
apparently the only other function assigned a separate radio channel. The
officer further reported that companies did well checking in, and he kept a
written list of companies and resources as he deployed them.

He did not, however, record where the resources were deployed. This was
largely due to the rapid growth of the incident and resources barely
arriving in staging before they were put to work. Additionally, Fire Alarm
would request companies from staging to respond to other calls for service
that may have been related to the primary incident but geographically
distal. Designating a large area was very beneficial, but the officer
reported that he could have certainly used an assistant staging area
manager. He also stated that he was initially unclear as to the
geographical designation of the fire building and had difficulty following
the ICS groups and divisions formed. As the resources were depleted,
staging transitioned to collocate with rehab.

INCIDENT COMMAND

Per CFD Tac orders, command was established by the first arriving
company, assumed by the first arriving battalion chief, transferred to the
ranking division chief, and subsequently transferred to the Chief of
Operations. An offensive strategy was quickly confounded by the extreme
fire growth and imminent rescue attempts of the workers, and then Ladder
1’s mayday situation. Although the appropriate succession of command
occurred, the incident commander was quickly overwhelmed with
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

addressing tactical issues and was unable to establish the support

sections that are crucial to managing an incident of this magnitude.

Those support sections are Planning, Logistics, and Finance/Admin.

Although Finance/Admin could have been established late in the incident,
the absence of Planning and Logistics meant a deficiency in tracking
resources, preparing for operational periods, and incident communications.

A Type 3 incident such as this requires a fully expanded ICS; with

Operations being established to execute the tactics that Command has
established. The Operations section chief manages the branches, groups
and divisions that perform the tactical functions.

The Incident Commander would then have the ability to form the Planning
and Logistics sections, and engage with the command staff (public
information officer, safety officer, and liaison officer).

The Incident Commander and section chiefs must have aides and/or
assistants and in some cases, deputies in multi-operational period
incidents.

It is not possible to have formal communications with more than 5-7

subordinates, as span of control is quickly eroded. An example operations
section for this incident would have established at least three branches
(fire, rescue, RIT) with each branch organizing appropriate divisions or
groups.

With so many individual staff chiefs and chiefs not normally assigned to
operations responding, there exists a great resource to be tapped for the
ICS positions formally referred to. The key is that these individuals must be
assimilated into the ICS structure that has been established. “Freelancing”
chiefs and captains most certainly are well-intentioned, but cause chaos
and confusion by bypassing the established chain of command. Almost
each individual interviewed for this project related a story of being given
orders by more than one or two chief officers that were in conflict with
their established chain of command. If a ranking officer arrives on scene
and is not content with the present strategy or operation, that chief must
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

assume command of the incident and make adjustments. If a ranking or

other officer arrives at the incident and does not take command, they
should report to staging just like all other resources and be deployed from
there.

2
COMMUNICATIONS

Communications are critical at all incidents, especially one of this

magnitude. Formal communications (orders being issued, progress reports,
urgent reports), must be separate from informal communications (admin or
informational) by utilizing separate channels or talk groups. If Operations
has functional or divisional branches formed, it is desirable to assign each
branch its own channel. This requires section chiefs, branch directors and
the Incident Commander to monitor multiple radio channels.

This cannot be done and maintain situational awareness. Branch directors,

operations section chiefs, and the Incident Commander must have aides
monitor, filter by formal or informal, and respond to radio transmissions.
Responding a fully staffed Field Comm Unit with ICS trained personnel as
soon as a 2nd alarm is sounded would significantly minimize
communications issues. Members could develop a communications plan on
scene and implement it based on the ICS structure established. This would
be the beginning of the communications unit assigned to logistics in a
multi-operational period incident. A communications plan must be initiated
as soon as possible to minimize the need for tactical resources to switch
radio channels in an IDLH atmosphere.

The question of Ladder 1’s officer not depressing the emergency button on
his portable is in hindsight a judgement call under mayday conditions that
was correct if for no other reason than the company survived physically
unscathed. If the system still works as it did before I retired, depressing the
E-button switches the radio to an emergency channel that can be
monitored by the RIT team. It is speculation as to what difference this
would have made but having a mayday situation on its own channel is
desirable.
2
CHAPTER FOUR IS THE SEPARATE COMMUNICATIONS REPORT COMPILED BY HOMELAND SECURITY-CISA.
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

COMMAND POST

The command post must be secured and unmolested by all, but the
essential personnel assigned to it. This is also true for operations and
branches. Several Members interviewed reported citizens, construction
workers, and others approaching the command post and making inquiries
and requests.

While the need to be responsive to citizens’ concerns and coordinate with

other agencies is very important, a commander or operations section chief
cannot manage tactical operations and respond in such matters. This is
the function of the liaison or public information officers on the command
staff.

COMMAND AIDES

The requirements to monitor multiple radio channels, secure the command

post, track resources, maintain situational awareness, and initiate the
planning process early in an incident of this magnitude is far more than a
single chief officer can accomplish. The solution in the traditional
American Fire Service is the assignment of an aide to each on-duty
battalion chief. Many metro fire departments assign an aide to division
and deputy chiefs as well.

The absence of command aides or chief’s aides greatly diminishes the

ability to manage type 4 or greater incidents. Although type 4 and greater
incidents are less frequent, our existence is predicated on the fact that
these incidents have and will occur and we must be prepared to respond
with the greatest ability to minimize their impact.

Without the preferred addition of the position of command aide, the

resource that can be drawn to fulfill this function are the fire companies
themselves. A fire company can be requested from staging to be a
command post company; bringing a captain, three firefighters, and four
portable radios to meet the needs of the incident commander, operations
chief, or branch director.
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SAFETY

Firefighter safety is an oxymoron. Personal protective gear is limited in its

capabilities, and operating in an IDLH atmosphere that is rapidly
deteriorating is inherently not safe. It can, however, be done with threat
minimization and constant risk versus gain contemplations.

The attempts to rescue the trapped workers were valorous and intrepid.
Tragically, they were unsuccessful but worthy of the risk. The successful
rescue of the crane operator required Members to operate at extreme risk
but the outcome was worth it.

There were several reports of Members not wearing appropriate personal

protective equipment (PPE) while operating apparatus. This has been an
issue since the creation of PPE. The Department has in place solid
procedures and consequences for failing to don appropriate PPE.

It is obviously unreasonable to expect FF/Engineers to operate pumps and

aerial devices in full PPE, but they must take the seconds necessary to don
at least thermal protection from radiant heat. Truthfully, the fire will
remind personnel of the level of PPE they should utilize. Injuries sustained
for lack of proper PPE are unacceptable, but the best monitor in this regard
is the individual company officer. It is the company officer that must be
depended upon to instill compliance by training before an incident and
held accountable for failures during and after. It is also the company
officer that must correct the action at time of occurrence, not the safety
officer on the command staff. The incident safety officer must issue the
safety message that is approved by the incident commander, but the
company officer must ensure compliance.
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

AFTER ACTION CRITIQUE

Conceding that this fire was insurmountable from the arrival of the first
fire company, there are several positive lessons that can reenforced and
relied on for future operations.

STRATEGY

Although the default approach of the Department is an offensive attack to

prioritize the saving of life and stabilizing the incident, it was recognized
early-on by company and battalion commanders that this was at best a
defensive operation even with a compulsory rescue attempt. Even so,
resources were appropriately deployed with the greatest emphasis on
saving lives.

From my review of operations, it is clear to me that the commitment and

ultimate sacrifice of Ladder Company 2’s apparatus was essential in
protecting the exposed steel crane superstructure and the successful
rescue of the operator.

TACTICS

Spotting apparatus at the corners of a building anticipating a collapse

was key in preventing the loss of the apparatus.

Exposure protection was extraordinary considering the proximity and

combustibility of structures on all sides of the fire building.

The great majority of the time that master fire streams are deployed, the
intent is to deliver the greatest amounts of gallons of water per minute to
the seat of the fire and/or to keep an exposure wet to prevent heat
transfer from radiation. There are situations where combination nozzles
are desirable on master stream devices; dispersing vapor clouds, applying
foam, and mass decontamination are examples. But these situations are
not as common as defensive fire attack.
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

A solid cylinder of water at 80psi nozzle pressure from a smooth bore

nozzle attached to a stream straightener provides the greatest advantage
in attempting to quench the fire. All fire streams begin to break apart at a
certain distance; and although straight streams from combination nozzles
are traveling at a higher velocity, they are still broken streams from the
nozzle. There were reports of straight streams from combination nozzles
turning to steam before reaching the fire or were deflected by the wind.

Attempting to relocate fire apparatus that is connected to a supply line

and then reestablishing the supply line and developing a fire stream is
labor intensive, time consuming, and requires the interruption of what may
have been an effective fire stream. Consideration should be given to
stretching a line from another apparatus to keep the threatened rig wet,
as an exposure would be protected. Of course, this tactic will not protect
the apparatus from collapse; at which time a risk versus gain assessment
must be made in relocating the apparatus.

LEADERSHIP

Avoiding mayday situations while completing the mission is always

preferable. The reality is that even with the best procedures, equipment,
and tactics, firefighters operate in an atmosphere of chaos and are
vulnerable. When the situation presents itself, the company officer’s
leadership skill is key in the survival of the company.

The officer of Ladder Company 1 displayed calm and calculating

countermeasures when the conditions turned. He had a plan, a backup
plan, and a last resort. There was no panic or confusion in his voice or his
actions. He was able to communicate his plans to his crew and lead from
the front. His actions and the actions of his company under extreme
conditions should be studied by every firefighter survival student and
company officer candidate that attends the Fie Academy. His competence
and confidence are what brought Ladder 1 back to quarters intact.

The officer of Ladder Company 16 displayed solid leadership and kept the
incident priorities in order when overwhelmed by an impossible situation.
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

The Acting Division Chief that assumed command was forced to shift
strategies and was somehow able to come back with an appropriate
action at each turn in the incident.

My research did not yield any reports of deficiencies in leadership at the

tactical levels of command.

COMMUNICATIONS

The Achilles Heel of almost every operation is communications. On going

training must be conducted in operations and Fire Alarm as to the
difference between formal and informal incident communications, and the
proper application of each. Radio discipline for all parties must also be
included in the training. A stronger effort to have a communications plan
developed for the incident early instead of later should be addressed.
Managing the number of resources required for this type of incident
requires more than one radio channel.

COMMAND

The addition of the position of command aide, staffed by an officer (relief

captain, lieutenant) would meet the need of the command and operations
function and also be a training platform for future chief officers. Duties
and certifications should include complete NIMS ICS certifications,
emergency vehicle operations, communications equipment operations and
setup, and must come from operations personnel.

The Training Academy could be directed to research and develop a block

of in-service training for all companies in the duties and functions of a
“command post” company. Topics would be the same as implementing
command aides.

Self-dispatching operations personnel, regardless of rank, are well

intentioned and a valuable resource. However, they must report to staging
for assimilation and assignment to the established incident command
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

system. The only exception to this should be a ranking superior officer that
intends to assume command of the incident. Additionally, when an incident
commander is relieved, he/she should be immediately reassigned to
another function or returned to staging.

CONCLUSION

When an organization whose primary mission is to save lives and property

experiences any incident where lives and property are lost, it must study
the operations and note things that worked and things that can be fine-
tuned in order to be made better. That is the purpose of this document.

The fire at 7741 Liberty Row Drive on 18 May is similar to an incident

involving a plane crash or mass transportation accident; impossible to get
ahead of and an extreme threat to responders and citizens. The fact that
incidents like this do not occur frequently denies us experience that can
only be overcome with training and redoubled efforts to evaluate our
procedures and response criteria.

As tragic as this fire was, the potential for far greater loss existed and was
prevented by the actions of the men and women of the Charlotte Fire
Department that travelled in harm’s way that morning, and continue to do
that each day to save the lives and property of the citizens of the City.

RECOMMENDATIONS

Implement the position/rank of Command Aide. The position should be

assigned to all operations battalion and citywide tour commanders.
Qualifications/certifications should include but not be limited to ICS
300-400, Operations Section Chief, EVOC, communication systems
operations, fluency in Tablet Command and conventional command
white boards utilized in the command vehicles, certification to operate
mobile command post and mobile operations vehicles.
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STRATEGICAL AND TACTICAL OPERATIONS ANALYSIS

Provide an in-service block of training for all companies in establishing

and securing the command post and operating communications.
Staff Field Communications and provide for them the training,
equipment, and response criteria to develop communications plans for
all multi-alarm and special incidents. Communications plans can be
developed ahead of the occurrence for specific incidents and multi-
alarms and then implemented early on to minimize communication
problems.
Affect two culture changes:
Section chiefs and branch directors must be unsaddled with the
complication of directly operating communications devices. There
must be aides to filter and respond to direct communications and
differentiate between formal and informal communications.
Self-dispatched companies, staff officers, non-operations resources
and chiefs are valuable resources that can contribute to the
successful resolution of any incident, but they must report to staging
unless they have a specific assignment directly from command. The
only chief officer that should go directly to the command post is one
that intends to relieve the current incident commander and assume
command. This will minimize freelancing of individual resources as
well as conflicting or divergent tactical and strategical orders.
 LIBERTY ROW FIRE - AFTER ACTION REPORT

CHAPTER TWO
MAYDAY/RIC
OVERVIEW
THE FOLLOWING CHAPTER WAS PREPARED BY
BATTALION CHIEF BOBBY CASH, CFD
 LIBERTY ROW FIRE - AFTER ACTION REPORT

MAYDAY/RIC OVERVIEW

DATE: 05/18/2023
INCIDENT: #23-0147427
ADDRESS: 7741 LIBERTY ROW DRIVE
WEATHER: WARM AND SUNNY

TIMES:
Dispatched: 09:02:49
On-Scene: 09:07:21
L16 urgent message: 09:14:51
L01 MAYDAY declared: 09:31:38
L01 MAYDAY cleared: 09:38:52

RESOURCES:
1ST Alarm: BC05, BC01, C10, E12, E14, E02, E43, L16, L02, L01, R10, SFT01, HM13,
FITF03
2nd Alarm: BC07, E20, E24, E39, L24, E08, REHAB01, FITF 05, TW26
3rd Alarm: BC03, E19, E17, E10, L04, L32, HM32
4th Alarm: BC08, E03, E04, E05, E06, E32, L03
5th Alarm: BC04, E11, E15, E28, L27
Additional Resources: BC02, Cars 01, 02, 04, 07, 08, 13, 14, 15, 16, 19, 20, 202,
205, 209, 300, 309, 311, 350, 502, 600, 711, 800, 900, 901, 902, 904, FITF 01, FITF
02, FITF 05, R11, D10, STK10, Engines 02, 16, 22, 24, 26, 31, 33, 40, 42, 65, 72, 73,
74, 75, 76, 81, 83, 84, L31

Building Construction: Platform type construction; Two-story Type I parking

deck with five-story Type 5 construction above

Conditions Upon Arrival: Ladder 16 reported heavy smoke showing from the
parking deck area, declared the working fire, and established command.
Due to the construction type, L16 requested two additional ladder
companies while lines were stretched. E14 established a water supply and
attempted to locate the FDC. E12 attempted to locate the standpipe
connection. Due to intensifying smoke and heat, a second alarm was
struck. Subsequent companies stretched additional lines and performed
searches.
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INCIDENT SUMMARY

While en route, Alarm advised that there was a trailer on fire in the parking
deck area. A second caller reported a fire at the new construction site. L16
arrived, established command, struck the second alarm, and began making
assignments for arriving companies. The fire progressed vertically from the
paring deck area into the unprotected, wood frame portion of the building.
Fire progression outran CFD efforts due to the lack of temporary fire
protection features and the unprotected wood throughout the upper five
floors. There were reports of construction workers missing. Searches were
attempted via interior stairs, ground ladders, and aerial ladders. L16
experienced a close call while attempting to find the reported missing
workers. Shortly thereafter, L01 issued a MAYDAY. This report will provide a
glimpse of the close call but will give a thorough review of the MAYDAY
situation. The report will contain company interviews, building diagrams,
pictures, etc. to delve into what was experienced that day. Members from
the affected companies will provide “lessons learned” and allow us to learn
from their near miss.

TIMELINE

This timeline is provided to set out, to the extent possible, the sequence of
events that occurred up to, during, and the clearing of a MAYDAY call from
Ladder 1. Some of the times are approximate and were obtained from
review of CAD notes and fireground recordings from CFD Alarm. In some
cases, the times may have been rounded to the nearest minute, and not all
events have been included. The timeline is not intended, nor should it be
used, as a formal record of events.

0906 Hours
L16 arrives, reports heavy smoke showing, and establishes Command

0908 Hours
Command requests two additional ladder companies

0909 Hours
Command requests a 2nd alarm
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MAYDAY/RIC OVERVIEW

0913 Hours
BC05 assumes Command. L16 reports that they feel heat but cannot locate
any fire

0914 Hours
L16 relays an urgent message about two people trapped on the sixth floor

0916 Hours
L01 speaks to a worker and gets an understanding about where to access
the upper floors. L01 reports to Command that they are heading to the floor
6 to search for the two missing workers

0918 Hours
L16 attempts to enter the building via a 40’ ground ladder. One FF had to
evacuate the floor and dive back onto the ground ladder due to changing
conditions

0920
Car 10 assumes Command

0922 Hours
Command orders an evacuation of the building (PAR is initiated)

0927 Hours
L01 reports being PAR via radio

0931
L01 issues a MAYDAY call

0935 Hours
L01 reports that they are looking at the top of Tower 26

0937 Hours
L01 FF locates a stairwell

0938 Hours
L01 crew exits the structure
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MAYDAY/RIC OVERVIEW

The following was submitted by Captain Brian Benson (L16-A):

“On Thursday, May 18, 2023, at approximately 0900 Ladder 16 was

dispatched with other units to 7741 Liberty Row Drive for a report of a
vehicle fire. Information was given enroute that there was a trailer in a
parking deck that was on fire. Ladder 16 arrived on scene and entered the
location from the Piedmont Row Drive South side of the structure. Ladder 16
was directed to the Barclay Downs side of the structure by several
individuals waving. Ladder 16 stopped at the Liberty Row and Barclay
Downs corner of the structure. Ladder 16 established command and began
to work towards locating the seat of the fire.

Upon arrival I observed heavy smoke conditions coming from the

parking garage area of the structure on the southeast corner (Alpha side).
There was no visible fire upon arrival. My initial observation of the smoke
indicated that the smoke was volume driven. The smoke was gray and
brown in color. At the time of my arrival the smoke was emitting mainly
from the openings for the parking garage entrance at the Alpha/Delta
corner. After approximately 2 to 3 minutes the color of the smoke changed
from gray and brown to black. The smoke still appeared to be volume
driven with no heat conditions observed but was starting to emit from
windows on the third floor at the A/D corner. As smoke conditions changed,
I requested that Alarm transmit a working fire assignment for a mid-rise
building. On the Alpha side of the structure at the A/D corner there were
two large door openings with no doors installed yet. Firefighter II Sherrod
Coates and FFI Chris McMillan entered the parking garage through the
large door opening on the left. This door was later learned to be a long
hallway that ran from the Alpha side to roughly the middle of the structure
at a “T” intersection where an elevator shaft was located. At the “T”
intersection, to the left was a hallway leading the exterior on the Bravo
side. The right of the intersection was the parking garage area where the
trailer was located. FFII Coates advised that he was not able to locate the
seat of the fire. FFII Coates reported heavy smoke conditions with little to
no heat conditions.

Upon arrival of Engine 12 and Engine 14 I requested that the captain

of Engine 12 try to locate the superintendent in charge of the construction
site as he made his way to the command post at the A/D corner.
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MAYDAY/RIC OVERVIEW

I instructed Engine 12 to lay a supply line into Ladder 16, and Engine 14 to
lay a second supply line for the FDC. Engine 12 approached from the
Piedmont Row Drive South side, and Engine 14 approached from the Barclay
Downs side. Engine 12 Captain Matthews found the Superintendent and
brought him to my location at the A/D corner. I asked the Superintendent
to perform a head count of his employees, and if there were any MSDS on
site for the material in the trailer. I also asked the Superintendent, in the
presence of Engine 12 Captain Matthews if the FDC was connected and
functional. The Superintendent stated that the FDC was connected and
functioning. At that time instructed Engine 12 to enter the structure for fire
suppression efforts.

After contacting the Superintendent, smoke conditions continued to

increase, however the smoke remained volume driven. At this time, I
requested a Second Alarm be transmitted and to have a HazMat unit
assigned to the call. Battalion 5 arrived on scene and was given a report
face-to-face at which time Command was transferred. At the same time as
Command being transferred, I observed that the volume of smoke had
drastically increased and was being to emit from most if not all openings
of the second floor. The smoke continued to remain volume driven with no
notable heat conditions. At approximately 0922 while Ladder 16 and Ladder
2 were attempting to access the victims from the Bravo side, smoke
conditions went from volume driven to heat driven. In the next two seconds
the fire flashed over on the second floor of the structure.”

Note that there were no pictures for the near miss involving L16.Nobody on
scene was taking pictures yet. L16 experienced a near miss due to rapidly
changing conditions. Reach out to that crew with any questions.

The following was submitted by Battalion Chief Eric Withers (BC01-A):

“As I reflect on May 18, 2023—The Liberty Row fire I cannot help but go back
to the heroic actions that I witnessed on this date. I’m proud of the men
and women who performed, and it never can be expressed enough by me
to them about their courage and selflessness acts. Our firefighters and
telecommunicators did an extraordinary job for this fire and everything it
produced. It is my hope that reading this will provoke conversation that
leads to training—at the company level, battalions and department.
Training is and will always be the foundation to our success.
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MAYDAY/RIC OVERVIEW

For this date, I was riding C10 and not in my normal assignment of B-01. I
carry my portable radio regularly to listen to calls being dispatched, etc.
When this call was dispatched, I was on the apparatus floor with a few
others and went to the MST to read the notes. This behavior is normal if I
hear a ‘working incident’ and I’m close to the CPU, but the uncertainty of
this call was different. After reading the notes I started my response non-
emergency, waiting on the first apparatus to arrive and size-up the
incident. L16 arrived and when he finished his size-up, I checked enroute on
‘conference’ and started an emergency response. While enroute and a few
blocks out, I noticed smoke in the horizon but nothing that was really
alarming.

On arrival I pulled up to what will be later determined as the C side of the

structure. I turned left onto Liberty Row from Fairview and was immediately
met with workers blocking the road. Their backs were turned to me with
their phones out and their eyes taking in moments of the fire. When I got to
the building, I recognized the following- 100+ workers in the streets; podium
building under construction; smoke was moderate to heavy on floors 1 and
2, but light on floor 3 and greater; fire visible on floor 1 at what will be
called the C/D corner; and E02 arriving as the lone fire apparatus from this
position.

Immediately, I pulled up the map to see where Chief Brown was located.
The map determined he was on the opposite side of the building at
Piedmont Row Drive South. The construction fence was blocking access on
Liberty Row Drive South which split the two buildings, so I had to go back
out to Fairview Rd. and come around to join Chief Brown in the parking lot
of Piedmont Row Drive South. When I finally got around to side A of the
building, I identified the following- Very few workers; smoke conditions
were a lot different, in that, heavy smoke on floors 1 and 2, but smoke was
much greater on floor 3 with no visible flame.

From my initial approach and personal size-up, I thought to myself that we

had a fire that warranted an offensive attack and search for victims. Fire
was visible on the first floor of a non-combustible floor and it appeared
the wooden floors were non-threatened. By the time I got around to where
Chief Brown and command was located, I knew this was going to
eventually be a defensive fire. I stepped out of the car with the intent to
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MAYDAY/RIC OVERVIEW

take command. We were ten minutes into the fire with two victims
unaccounted for and potentially more inside the structure, and we had not
located the fire nor put handline(s) in place. Needless to say, internal
alarms were sounding as time increased without having a location of the
fire. Chief Brown was still inside his car when I walked up and told Tim I was
going to take it and move him forward to Search/Rescue Group Supervisor.
I think I told him we are looking for two victims and gave him a run-down of
companies I was giving him to start the aggressive search. I took command
and moved to the back of the Tahoe to begin using the ‘white board’ for
accountability.

I assumed command over the radio and attempted to begin organizing

companies along with giving a handful of assignments out. I was at the
back of the car trying to capture companies and their assignments as well
as their locations on the fire ground. I was multitasking as this was
occurring as well as reading the building and planning our next moves. I
remember focusing on the building as I was looking around at companies
who were on-scene. My thoughts were to pull back to a defensive posture,
but I knew we had a window of opportunity and firefighters who were with
me in taking the risk to save a life. I remember telling myself as I continued
to scan for hazards that the building and its conditions will let me know
when it is time to cease efforts with any type of rescue. Keep in mind that I
had just came from an area that we would know as the C side where there
were ~100+ subcontractors walking away from the buildings.

The conditions in the building did change. It went from smoke on floors 1
and 2 to fire showing from the windowless openings. The changeover to fire
did not occur instantaneously but it was rapid. I remember it moving from
opening to opening. When this occurred, smoke condition also changed,
and conditions became more intense. I knew at this point our time
occupying the building was over. This moment was also the first time that I
accepted we were not going to be able to retrieve the two unaccounted
victims. Conditions now warranted a defensive position for obvious
reasons. It was ordered to evacuate the structure and stand by for a PAR.
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MAYDAY/RIC OVERVIEW

After we pulled out and collected a PAR, the incident command structure
changed to divisions for the three sides of the building that we were going
to attack with large master streams. We also had exposures that I was
concerned with and was developing a plan to capture and protect these
from the transfer of heat to include embers. The main incident objectives
included the rescue of the crane operator along exposures and
confinement of the fire. Or so I thought…

When the order was given to evacuate the structure, ample time was
given before a PAR was initiated by Alarm. It was my decision to give the
PAR to Alarm, and to communicate a report of accountability on personnel
or a company. Alarm done a very good job handling the PAR, but our
members didn’t conduct the PAR the way we train. The PAR was out of
control and unprofessional. In my 24 years with the fire department, I have
never heard companies just call over the radio their company number
without being asked first. We also had useless information during what
would be a critical component of the incident which I participated in and
allowed. At some point I had to tell all over the radio to cease radio traffic
and for Alarm to finish the PAR. I mention this to identify our short comings
and to also set the stage for the MAYDAY.

When the firefighter keyed up the radio, I immediately recognized the

vibra-alert which signifies low air to the user and in this case to everyone
on-scene. I found it odd or out of place considering everyone was out of
the building. When I heard the voice I knew it was Captain Watts, and when
I heard the word—Mayday, my heart literally fell to my ankles. Captain
Watts was calling the Mayday for him as well as the crew of L01. Captain
Watts provided Location and Unit in his first call for assistance. During his
+/- 10 second transmission, I believe that every thought and feeling that
resonates with the safety and survival of a firefighting crew or Mayday
flashed before me. My very first thought was disbelief just for a split
second- I remember telling myself this can’t be happening. This thought
rapidly went to being mad and frustrated. I think this can speak for itself,
but I was also mad at Captain Watts and L01. There were a few other
thoughts that many would find irrelevant so I will share with you my final
thought. The last thought took me back to the third-floor landing at Gaston
College and Breathing Equipment School. Often I will play the role of the
RIC Group Supervisor for the final drill to help with the drill. I went back to
 LIBERTY ROW FIRE - AFTER ACTION REPORT

MAYDAY/RIC OVERVIEW

what I know or the reps in training(Recognition Prime Decision Making)

which put me in position to be successful with this Mayday.

First, I knew through his voice the unit, name, and assignment just from
giving him permission to enter and make an attempt for the rescue. I was
looking for Location, Unit, Name, Assignment and Resources—the key
fundamentals that Dr. Burton Clark identified with his ‘Calling the Mayday’
drill. I even knew L01 was on the sixth floor at one time, but I wasn’t about
to start RIC without knowing for certain their location in the building. The
building was too big and conditions were such where risks need to be
calculated, not reckless. I asked for his location a second time and only
heard they were on the sixth floor. It was a quick thought about sending
crews to the sixth floor, but the thought was quickly erased when I
considered a well-known LODD fire that occurred in the late 90’s. The
building, equipment, and circumstances are different, but oddly enough, I
didn’t want to send someone without a specific mission or purpose. I asked
a third time, and only received about the same information. The fourth and
final time I tell Captain Watts I know you are on the sixth floor but what
side of the building are you located It is at this point I hear through the
vibra-alert that he is on the C side and near the stairwell where E02 is set-
up. At this point RIC is started, but at the same time L01 finds the stairwell
and walks out of the building. I requested RIC to stay engaged with the
Mayday until the firefighters from L01 were out of the building. This
included entering and traveling inside the building if necessary until the
company was intercepted by the RIC companies. L01 was able to self-
extricate and RIC confirmed before the Mayday was cancelled through
Alarm.”

The following was submitted by Captain Mike Watts (L01-A):

“On May 18th I heard in the captain’s office, a vehicle fire box go out. I
went to the computer and saw that it was a vehicle fire in a parking deck. I
told my crew to get on the truck to ride that way in case it went working. I
noticed that Ladder 16 was on it, Tower 3 was on another call, and I cannot
recall if Ladder 2 was on a call or not. With the notes given, something told
me this was going to be a working fire. Car 10 left the station ahead of us
with lights and sirens. As we drove the call was upgraded to a working fire.
With Car 10 still in sight, I called on the radio and asked Battalion 5 for
permission to add as the second Ladder for a commercial building fire.
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The request was approved by command, and we made our way. I pulled up
the map and gave directions to my driver. I then looked at the scene to see
where our best access was and where L1 would need to position. The call
was upgraded to a Second Alarm while we were en route. When we got to
Fairview Road, Ladder 2 was in front of us. We entered the scene with L2
onto Liberty Row from Fairview. They made their way down the alley
between the buildings, and we stopped at what would become the CB
corner of the structure.

After we got off the truck, FF Pettit grabbed a construction worker and
asked where the stairs were. The worker led us to the stairwell door that
was behind an 8ft chain-link fence with vinyl decals over it and we headed
up. I stopped the crew and told them to mask up on the second floor due
to smoke conditions in the stairwell. I called command on the radio to
notify him that we had found the stairs and were heading up to the 6th to
locate the victim. Command said 10-4 and we headed up. Once we reached
floor 4, the smoke started to lighten up. When we got off on 6, there was
good visibility and no smoke where we were at. The hallway we took from
the stairwell door was straight for about 20 feet, then left for another 40 to
50 feet to the corner of the hallway. We turned right to start down the long
hallway and for another approximately 50 feet conditions were clear. Then
I realized smoke was at eye level, so we started duck walking and then
were on our knees due to low-no visibility. We crawled for a few more feet
and I thought I heard someone yell as the evacuation order was given, I
slowed to a stop and as the radio traffic ceased, I heard a person yelling
“Help” directly in front of me. I told my crew I heard someone yell, and to
push a little further before turning back. We pushed 20 or so feet and all
three of us heard “Help me!” directly ahead. The crew kept pushing down
this long hallway going toward the voices. When we stopped, I pushed out
about 20 feet past my crew so I could hear better. I banged my Halligan on
the floor three times as hard as I could and yelled “Fire Department where
are you” and then held my breath. I immediately heard “Help me Help me”
and then a noise that sounded like someone banging on the floor and wall.
At this point, I knew we could not go any further, my crew and I banged our
tools and yelled and waited a few seconds to see if the victim could come
to us. The voice sounded like they were close, but I knew that sound
probably traveled far due to the lack of contents in the structure and the
current phase of construction. At this point I told my crew to head back
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MAYDAY/RIC OVERVIEW

and out. We did a 180 turn and kept on the right-side wall. While crawling
quickly down the hall, I heard alarm say “Ladder 1 PAR.” I reached up in
stride and clicked my MIC and said “PAR.” I kept moving forward and at
some point, I came off the wall to feel the opposite side of the hallway
which was studs with OSB on the inside of the apartment, with my crew
directly behind me staying on the right-hand wall. I felt a break in the
studs that was wider than a doorway and recognized this as a hallway
back to the stairs. I turned left and crawled forward at a quick pace, my
crew still behind me at the entryway. I crawled until my head ran into a
wall. I felt to my right and felt a wall, felt to my left and found a wall, and
quickly realized I was in a dead-end hallway and not the stairwell hallway.
This moment I screamed “F**k!” I knew at this moment this was my only
chance to get out my frustration as I did not want my crew to witness this. I
knew that I would have to keep a cool head once I got back to them so we
could keep working to find a way out. I met Pettit at this entry and said,
“This isn’t it, it’s a dead end.” At this point, Pettit yelled “F**k.” This was also
the only moment that Firefighter Pettit showed any glimpse of frustration
out loud. He stayed calm and kept working and kept moving forward. At
this point we started moving on the exterior wall and kept going towards
the stairwell. Pettit checked a room to the left and I followed with Tom in
tow. We piled in the entryway of this room, and I pulled the TIC up to check
the room. I wiped my facepiece, then the TIC, and by the time I had wiped
the TIC I had to re-wipe my facepiece. After 3 or 4 attempts to look through
the TIC, I put the screen to my facepiece and just went with that. I could
see the patio burning and a white screen on all window openings and
balcony. I turned around and said, “We’re not going that way” and we
returned to the exterior wall. Tom started vibing while we were in that
room. It was at this point that I put my hand on my mic and rehearsed in
my head what I was going to say. Pettit said to me “we probably need to
call a MAYDAY.” I said to Pettit, “I’m already on it.” I took a breath,
squeezed the MIC, heard the chirp and said, “MAYDAY MAYDAY MAYDAY,
Ladder 1 crew, 6th floor, were low on air, we need two RIT packs and help
with a way out.” While doing this, Pettit was coaching Tom through his
breathing and had crawled a few feet away and started breaching a wall. I
then remember answering command who asked for a better location, I
replied, “We entered the stairwell where Engine 2 is parked.” At this point I
crawled to my crew and started breaching the wall next to Pettit.
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I hit the wall with the ADZ/Spike end of my Halligan twice and it bounce off.
I turned the tool around and my forks punched through. I used the forks to
chop across and then down and then punched through with the other side
of the Halligan. We looked out and could see a parking deck that was too
far to bail out to. In my mind I thought, this hole is our last resort if we
cannot find a better way out in a few minutes. I looked at the size and
noticed it was 16 inch on center and the hole was about 20 inches tall. My
plan was that we could take our packs and helmets off, Tom and Pettit
could take one last breath of air, swim through hole headfirst and I would
push them out. Then I would follow. I knew this had to be the last option as
we were on the 6th floor and our rope would not get us to the ground. This
would leave us hanging there waiting for a ladder, or we would have to
untie the knot at the end of the line and fall the last 1.5 to 2 stories. After
the hole was breached, I started vibing. I kept Tom behind me and started
down the exterior wall towards the stairs, while Pettit pushed on ahead on
the same wall. I wanted to keep good orientation on the wall and the hole
we just made in case we needed it. I kept a bit slower pace since Tom was
already vibing for a bit and wanted to make sure he conserved his air. I
then heard a tool banging on the floor and thought at first the RIT team
had found us. At this time, I activated my pass device, and we started
crawling towards the banging. I saw a flashlight swinging and thought I
saw a white shield, again thinking this was the RIT team. We got into a
room with almost no smoke but had been charred by fire where I saw Pettit
and realized it was him banging his tool. The room was clear enough and
so the crew and I unclipped our regulators, trying conserving as much air
as we could. I looked down and saw Tower 26 and called on the radio
“Tower 26, get the bucket in the air, I’m staring at the top of your truck,
we’re on the 6th floor, come get us.” I heard no response, and the bucket
was not moving. I saw an Engine 11 Captain Shield looking up as well. As I
keyed up to call again Pettit threw a chunk of drywall out, that struck the
ground between the E11 Captain and Tower 26. No one noticed so I called
again. “Tower 26, I’m staring at the top of your truck, get the bucket to the
6th and come get us.” At this time Pettit had stepped back into the hallway
and moved towards where he though the stairs were. We knew we were
close as we were in the corner apartment and knew the stairs were on this
wall. I had my Halligan in my hand and was about to throw it out towards
Tower 26. This was the heaviest thing I had, and I knew would be the
loudest noise to garner attention. At that moment Pettit tapped me on the
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MAYDAY/RIC OVERVIEW

shoulder and said, “I found the stairs, let’s go.” I grabbed Tom, we clipped
back in and followed Pettit into the hallway where he had located the
stairs about 40 feet from the apartment. There was zero visibility in the
hallway until we reached the stairwell door and saw light from the
windows. I called command and said, “Ladder 1 to command, we found the
stairs.” The stairs were very clear, and we unclipped and walked down and
out. I then radioed to command “Ladder 1 to command, we are out of the
structure.”

At this point we got to the truck and had a few minutes to take our packs
off and breathe. Right away, we had to go straight to work moving the
truck because the fire had spread, and the heat was intense. Where we
just were at on the sixth floor, was now fully involved. We got all equipment
out of the way and started getting the supply line shut down, aerial
bedded, out riggers in and the truck moved. Luckily the manpower was
there and crews from Engine 5 and 17 helped pick up the 5 inch and walk
with it as Levi moved the truck. We positioned out of the collapse zone and
then began resetting the truck for aerial flow. We fought through some
trees and immense heat but finally were able to get the aerial flowing
again. The controls at the back of the ladder for the out riggers were so
hot you had to use gloves to touch them. The rest of the fire went like any
other as a Ladder in a defensive position. The firefighters rotated climbing
the aerial and flowing water and Ladder 1 maintained this position until
released by command.

An important piece to our survival, that we only found out later in the
incident, is that Levi had extinguished that apartment we were in on the
6th floor. He had used the aerial and extinguished the entire Charlie side of
the structure. Had he not done this, we may have been left with no option
other than to return to the hole we made and bail out. The apartment had
burned about 12-15 feet in from the window, so the odds of it overcoming
that side of the building before we got to it are high. We also realized
afterwards that while making that hole, we were surrounded by fire and
the only way out was the hole we made on the Delta side of the structure.”
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MODERA SOUTHPARK

Seven-story, luxury apartment building that contained 239 units. Twin

buildings, each consisting of studio, one-, two-, and three-bedroom homes
with an average square footage of 1,100. Building is designed around two
courtyard and/or pool areas.
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BUILDING ORIENTATION

“Alpha” side – this is Barclay Downs Dr. as well but it is where the round-
about is
“Bravo” side – Liberty Row Dr. (between the buildings/parking decks)
“Charlie” side – Fairview Rd.
“Delta” side – Barclay Downs Dr

CHARLIE (C)

DELTA (D)
BRAVO (B)

ALPHA (A)
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Liberty Row Drive (Alpha) side

Floor 6 floorplan
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Ladder 1 – positioned on the “Bravo/Charlie” corner between the two

buildings under construction.
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Interior (top picture) and exterior (bottom picture) wall construction

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Top picture – Hallway at center corridor, looking towards the “Alpha” side.
Bottom picture – Hallway looking towards the exit.
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Top picture – Hallway that L01 entered from the stairs. Flashlight indicating
stairwell location.
Bottom picture – The apartment that L01 found themselves in while
searching for the exit.(Look left, and up, of the aerial stream on the top
floor) This is the “Charlie/Delta” side
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MAYDAY/RIC OVERVIEW

L01 crew attempted to tell the RIC where they were located. They used a
landmark of Tower 26, but the message was either covered up or unheard.
Running out of options, Captain Watts thought about dropping a tool out
to get someone’s attention on the ground.
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MAYDAY/RIC OVERVIEW

Notice the hole in the exterior sheeting and Tyvek wrapping. This is the
hole L01 crew made in an attempt to identify where they were in the
building once conditions rapidly deteriorated.This is the “Delta” side.
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LESSONS LEARNED/REINFORCED

PROVIDED BY L01-A

Navigation aids – use search ropes and/or hose lines to stay oriented
inside buildings. The majority of MAYDAY incidents involve firefighters
calling for help due to being lost or separated from a search rope or hose
line. Not just commercial buildings, but structures with large square
footage mandate the use of some type of orientation measures. The fire
service loses 1-2 firefighters in residential structures. During incidents in
commercial and large square-footage buildings we usually see losses of
companies of firefighters.

Communications – almost every NIOSH report written has communications

as a contributing factor for firefighter injuries or LODD’s. Captain Watts
stated that he attempted to transmit information several times with no
luck. During preplan activities, we must identify areas or buildings where
communications will be reduced or nonexistent. This also applies to
communications among crew members. Members of L01 maintained voice
contact through the majority of their MAYDAY event.

Complacency – upon making the 6th floor, conditions were favorable for a
thorough search. As L01 proceeded deeper into the building, conditions
changed drastically and in a short amount of time. Smokey areas went to
blackout conditions within seconds. Maintain orientation and
communications with each crew member when conditions are bad. It is
extremely easy to develop tunnel vision. We are assigned tasks, so we do
what needs to be done to complete those tasks.Don’t allow clear or
tenable conditions to let you get too deep in structures. Expect conditions
to change and became untenable. Always keep in mind how fast
conditions can change.

Making the MAYDAY call – we are all taught to stay calm and collected
during any type of MAYDAY incident, whether involving ourselves or
another member. It’s pretty safe to say that this is going to be anything
but calm and collected.Stop, figure out what needs to be done (transmit
the MAYDAY, announce pertinent information-LUNAR, work towards self-
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MAYDAY/RIC OVERVIEW
rescue, try to figure out a solution to the problem, etc. Take a moment and
freak out, scream, whatever is needed and then hit the reset button, so to
speak. Remain calm as possible, conserve air, tell the IC where you are and
what is needed, and work to solve the problem or guide members in to
assist.

PROVIDED BY FF/ENG. NISWANDER

Assignment(s) – when given an assignment, complete that assignment. This

is barring anything preventing you from doing so. Numerous people may be
trying to get you to do something else. If possible, complete your assigned
task and then help them out.

Water supply – during incidents where large volumes of water are going to
be needed, anticipate this and secure water if possible. Numerous aerial
ladders were used during this fire. Establishing water early to ladder
companies is essential. Trust your instincts and continue to flow water,
even when the aerial is utilized for rescue purposes.

PROVIDED BY BATTALION CHIEF WITHERS

Personnel Accountability Report- It is a report and companies should

acknowledge when roll call is established that “L01 is PAR” or report “L01 is
PAR but on the seventh floor making our way out”. The latter message
should stimulate the Incident Commander to have a further conversation
with L01.

Calling out company numbers without being called is not the right
way to address PARs and unacceptable. It creates chaos to an
already controlled chaotic incident and can create confusion.
Members need to maintain discipline during the PAR regardless of the
incident by waiting on their company name to be called.

I did not establish RIC until the first or second company of the second
alarm. Regardless, RIC wasn’t established until we had retreated to a
defensive stance. You hear and I fell victim to it that other assignments
need to be carried out to make the incident safe. While there is truth to
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MAYDAY/RIC OVERVIEW

this, it was not an apartment building nor a commercial building. This was
a vertical lumber yard that was unprotected and, in most cases, open with
little opportunities for confinement, We have to understand the building
and its conditions and change our current culture with RIC assignments
and when it is established.

My ‘command post’ was the back of C10 with just a white board and two
radios. If I had a chief aid or an officer at the car prior to or when the
Mayday was executed, I know that I would have been better prepared.

The incident commander must recognize this is not going to be a

normal operation. He/She needs the extra staff for the complexities
that come with incident management and to accomplish this is with
assistance of chief’s aide(s).

The fourth and final call is the moment when I decided if I don’t get the
specifics to their location this time then we will have to move channels. I
felt as if Captain Watts was talking but I did not want to hear the message,
he was sending. Recognizing that we are still actively fighting a fire should
have been enough to know that the Mayday and the fire needed to be on
two separate channels.
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CHAPTER THREE
FIRE INVESTIGATION
TASK FORCE REPORT
THE FOLLOWING CHAPTER WAS PREPARED BY
FIRE INVESTIGATOR J.G. BOGGS, CFD
AND TECHNICALLY REVIEWED BY
E.E. SHAVER, CHIEF FIRE INVESTIGATOR
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CFD Incident #: 23-0147427

CMPD Incident #:20230518 0902 01

Date/Time: Thursday, May 18, 2023 / 0902 hours

Incident Address: 7741 Liberty Row Drive, Building B, Charlotte, North

Carolina.

Victim(s): Baker Insulation / Mill Creek Residential Construction

Lead Investigator Assigned: J.G. Boggs, Fire Investigator Charlotte Fire

Investigation Task Force

Other Investigator(s) Assigned: S.F. Southworth, Fire Investigator, Charlotte

Fire Investigation Task Force, E.E. Shaver, Chief Fire Investigator Charlotte
Fire Investigation Task Force, C.S. Steele, Senior Fire Investigator Charlotte
Fire Investigation Task Force, E.R. Wall, Fire Investigator Charlotte Fire
Investigation Task Force, T.A. Goforth, Fire Investigator Charlotte Fire
Investigation Task Force.

Outside Agency Investigators On-Scene: Taylor Marsh, Fire Investigator,

North Carolina Office of State Fire Marshal, Kevin Head, Fire Investigator,
North Carolina Office of State Fire Marshal.

Report Date: 11/16/2023

The procedures utilized throughout the course of this investigation and the conclusions
reached herein are based upon scientific principles currently accepted within the field of
fire investigation. These references include, but are not limited to, NFPA 921 and NFPA
1033.

The examination of this scene was justified by the statutory authority given to the fire
department to search for the fire’s cause, origin, and circumstances (NCGS 58-79-01).
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ASSIGNMENT SUMMARY

On Thursday, May 18, 2023, Charlotte Fire Department (CFD) Communications

(Alarm) received a call reporting a trailer on fire in a parking deck at 7741
Liberty Row Drive, in Charlotte, North Carolina. CFD personnel and apparatus
responded on the first alarm which occurred at 0902 with Ladder 16 arriving
first on the scene at 0907 hours; Captain Benson established command,
reported heavy smoke showing and was attempting to locate the trailer fire
within the parking structure. The second alarm was dispatched at 0909 hours.
This investigator responded due to the fire being upgraded to a 2nd alarm
“working fire” incident and arrived on the scene at 0926 hours. The third
alarm was sounded at 0920 hours, the fourth alarm at 0931, and the fifth
alarm at 0956. This incident reached a 5-alarm response for Charlotte Fire
Department and resulted in fire damage to 6 buildings, 14 cars, and 4 fire
apparatus. Two construction workers perished in the fire.

This investigator was assisted by the following members of the Charlotte Fire
Investigation Task Force: Jason Boggs, Fire Investigator, Lead Fire
Investigator, Robert Klass, Arson Detective, Lead for CMPD, Steven
Southworth, Fire Investigator, Edwin Shaver, Chief Fire Investigator, Eric Wall,
Fire Investigator, Charlotte Steele, Senior Fire Investigator, Thomas Goforth,
Fire Investigator/K9 Handler, Mark Oddo Fire Investigator, Phillip Levett, Arson
Detective, Terrell Macklin, Arson Detective, Charles Strong, Sergeant
Bomb/Arson.

The fire scene was fully documented with digital photographs, scene
sketches, videos, notes, and various other forms of data and are included in
the case file.

SCENE SECURITY

Scene security was maintained by CFD and Charlotte-Mecklenburg Police

Department (CMPD) personnel during the entire incident. Immediately after
the incident, the owner and site managing company brought in a private
contractor to put up a perimeter fence to cordon off the area for safety and
subsequent investigation. CFD maintained control of the fire scene for two
days, then private security was brought in to provide additional security of
the scene.
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SCENE DESCRIPTION

The involved structure was a Podium-style eight-story, multi-family

condominium building constructed over a concrete slab foundation. The
first two stories were non-combustible concrete construction and would be
used as a parking deck with a few business spaces along the street side on
the main level. The upper floors were wood-framed and covered with fire
resistant plywood as the building was currently under construction. The
roof was flat and currently being worked on with no finished roof materials
in place. The structure was identified as Building B and part of a two-
building apartment site with the two mirroring each other. The square
footage was approximately 259,179 for one building.

The structure’s utility services (electric and natural gas) were examined
and were unremarkable.
Fire protection in the form of a standpipe and fire sprinklers were in place
in various stages of installation. The standpipe was located on the exterior
of the building and extended up approximately 15 to 20 feet. The
installation was not complete or in service. Fire sprinklers were installed
inside the parking structure but also not operational at the time of the fire.

The involved vehicle of fire origin was an enclosed eight and one-half by
twenty-foot enclosed trailer. Based on information provided by involved
personnel, the trailer was a 2014 model with a vehicle identification number
of 53NBE2024EI022810.No manufacturers name or the company who
outfitted the trailer with the spray foam equipment was provided. The
trailer was owned and operated by Baker Insulation based in Versailles,
Kentucky. Ronald Baker was the listed owner and Jarod Moss was the
operator of the trailer at the time of the fire. Baker Insulation was a
subcontractor of Diversified Insulation (Randal Knight, owner) who was the
main contractor for the job. Mr. Baker was on site in the second building at
the time the fire was discovered.
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WEATHER CONDITIONS

The weather at the time of the fire was partly sunny and clear, 66 degrees,
65% humidity, with 13 mph winds out of the ENE.A detailed weather report
was obtained from the website Weather Underground
(http://www.wunderground.com) and is included in this case file. Weather
was not a factor in the fire cause, however high winds contributed to the
spread of this fire to other buildings and areas.

INTERVIEWS

Tony Rolfes, VP Construction Mill Creek Residential

In summary Mr. Rolfes reported he was Vice President of the construction
division. He advised that Bob Nelson was the site superintendent for the
project. He said that they both would remain on scene and provide any
information they could to assist fire operations and investigations. He said
at the time he was advised that the fire started in one of the spray foam
insulation trailers in building B. He said he would work to obtain the
information for the contractor who owned the trailer. Mr. Nelson advised
there were possibly still two employees unaccounted for.

Randal Knight, Diversified Insulation, 573-887-1960

Mr. Knight is the owner of Diversified Insulation. His company was
contracted to do the insulation work. He said that due to the size of the
project, he subcontracted with a friend who owns an insulation company.
Their name was Baker Insulation. He said there were four spray foam
trailers being utilized and located in building B. As they reached
approximately 90% completion of the job in building B, he moved three of
the trailers to building A to begin work. The remaining spray trailer was
owned by Baker Insulation. Mr. Knight explained that the enclosed trailer
was 8.5 feet wide by 20 feet long and contained two areas. One was for the
diesel generator which provided power for the trailer and to run the foam
operating equipment. The other side was used to store chemicals used in
the spray foam insulation process, general storage and to provide a small
work area. He said the spray hose was heated and could extend up to 300
feet. Mr. Knight said they got to the site around 0730 hours prior to the fire
occurring.
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Jared Moss, Baker Insulation, 502-604-5181

Mr. Moss was the spray nozzle operator for Baker Insulation. He said he
was on the second level of the parking garage spraying and the trailer was
located on the first level ramp. While he was spraying, he noticed lost
pressure and spray pattern from the nozzle. When he went downstairs to
identify the issue, he discovered the fire. Mr. Moss said the fire he saw was
around the rear of the trailer. He stated the fire was coming from the
generator room and that there was fire dripping out of the trailer’s door
and burning underneath. Mr. Moss advised that after discovering the fire,
he ran next door to notify his boss.

Paul Groff, Lead Super Intendent, Mill Creek, 1st 911 Caller, 910-691-5680
Mr. Groff made the first 911 call to CFD Alarm. Mr. Groff said there was a
trailer in the parking deck on fire. He said the trailer contained some
equipment and was not hooked to a trailer. He said they sprayed some
extinguishers on it and that it continued to burn. He said they were
evacuating the building.

A later interview with Mr. Groff revealed the following. He said employees
arrive around 0700 and they have a safety meeting around 0800 to 0830
hours. He said there are approximately 120 or more people working on the
jobsite. He then began to walk the jobsite with a contractor and received a
call, in reference to the trailer on fire around 0900. When he arrived at the
trailer, he saw fire coming from the end of the trailer. He said they used
several fire extinguishers on it and it kept coming back.

Keith Suggs, Prestige Windows & Doors, 404-569-4226

Mr. Suggs was interviewed on scene the morning after the fire. He owns
Prestige Windows & Doors and advised the two missing construction
workers worked for him. The first employee was identified as Ruben Lydell
Holmes, DOB: 12-20-1964. He had worked for him for a while. He identified
the second individual as Demonte Sherrill. He said Demonte started
working for him on Tuesday of that week. He did not have any personal
information on Mr. Sherrill. Mr. Suggs said his company had been working
on the job site for about a month. He said he received a call from both
stating that the building was on fire, and they could not get out. Mr. Suggs
said he was on the jobsite earlier that day and they were currently working
on the 6th floor balconies, in the front right corner of the structure.
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Charlie Rose, Creative Polymer Solutions, 205-597-8363

Mr. Rose is the supplier of the two-part foam solution for the two foam
companies. He said the expanding foam product is used for spray-on
building insulation. He advised it comes in two parts; Isocyanate is part A,
and Accufoam is part B. When both products are mixed in the proportioner
and applied to the surface they become the finished product. He provided
both Safety Data Sheets (SDS), and they are included in the case file.

Quincy Morris, Crane Operator

Mr. Morris is a crane operator for Superior Services and had been working
on the job site at SouthPark for over a year. He became aware of the fire
when he noticed smoke and took a photo with his cell phone. He used the
crane to rescue workers and tried to rescue the two trapped workers on
the sixth floor. He said for reasons he doesn’t know they did not get on the
platform.

CMPD Arson Detective Klass, Macklin, and Levett conducted numerous

interviews, see KBCOPS report and supplements for further information.

VICTIMS
Upon arrival of fire apparatus and personnel, two employees were
reported as missing. Several workers and bystanders reported hearing
people screaming for help. The tower crane operator, Quincy Morris later
reported to this investigator that he used the crane and platform to rescue
several people who were trapped on the open-air courtyard. He attempted
to rescue the two trapped workers on the 6th floor of the apartment
building by placing the platform on the balcony where he saw the two
workers, but they failed to get on.

Two fire crews attempted to rescue the two trapped workers. Ladder 1
entered the sixth floor through the only operating stairwell. They were able
to get approximately one-third of the way through the corridor before
being pushed back by extreme heat and smoke conditions. Ladder 16’s
crew made access to the courtyard/pool deck located on the third floor of
the building. This was an open-air courtyard. Firefighters were able to
make eye contact with the trapped workers, but conditions changed
rapidly and forced the firefighters to exit down the ladder, out of harm’s
way.
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During the scene exam, the two missing workers were identified as Ruben
Holmes, DOB 12/20/1694 and Demonte Sherrill, DOB 1/14/1993. During this
investigator’s scene investigation, I was made aware of a Facebook video
in which Mr. Sherrill streamed live being trapped inside the building. The
video revealed two male workers trapped on what appeared to be the fifth
or sixth floor, both trying to yell for help and attempting to shield
themselves from the smoke.

On May 19, 2023, this investigator and other members of the Fire
Investigation Task Force met to conduct a search of the fire scene to find
the two victims. Prior to arrival of all investigators, this investigator was on
the third floor of the adjacent parking structure and located what
appeared to be the remains of one of the victims in the fire debris. The
location was approximately 5 feet from the edge of the platform from the
parking structure. Given the last known location of both victims, this
investigator began visually inspecting the areas around the first victim. A
short time later, the second victim was located.

Once both victims were located it was determined that CFD Rescue 10
would formulate a plan for the recovery. Captain Bright, and firefighters
Brewer, Llwellyn, Bell, Blackwelder, and Whitesides performed the recovery
in coordination with the FITF, CMPD Detectives, and the Medical Examiner.
The bodies were recovered at 0907 hours (Holmes) and 0929 hours (Sherrill).

SCENE EXAMINATION
This investigator conducted a fire scene examination of the involved
structure to determine the origin and cause of a fire that occurred on this
date. All areas within the fire scene were carefully examined to accurately
determine the origin and cause of this fire.

This investigator conducted an exterior fire scene examination of the

above referenced fire scene on the date of the loss listed above. The
exterior scene exam contained six different building examinations and one
parking deck examination which included 14 vehicles.
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EXPOSURES
Two SouthPark (exposure) located at 6135 Park South Drive. This building
is a five-story office building.
Residence Inn (exposure) is located at 6030 Piedmont Row Drive. This
building is a seven-story Marriott owned property.
Canopy (exposure) is located at 4905 Barclay Down Drive. This building
is a five-story building owned by Hilton hotels.
SouthPark Towers (exposure) is located at 6100 Fairview Road. This
building is fourteen (14) story office building.
Modera SouthPark was located at 7741 Liberty Row Drive, Building A.
2003 Toyota Camry LD Sedan Gray 4 door. VIN#: JTDBF32K53014435
License Plate: TEL3302/North Carolina.
2006 Honda Civic EX Coupe 2 door Gray. VIN#: 2HGFG11896H521921 License
Plate: RND7831/Texas.
2008 Chevrolet Silverado 1500 Crew Cab LT Black. Pickup VIN#:
3GCEC13JX8G246729 License Plate: SUGGS2/Georgia.
2009 Kia Borrego LX Sport Utility Black 4 door. VIN#: KNDJH741295026320
License Plate: HHN3270/North Carolina.
2012 Honda Civic LX Sedan 4 door. VIN#: 19XFB2F58CE025775 License Plate:
KMJ7994
2013 Nissan Rogue S Sport Utility Red 4 door. VIN#: JN8A55MT9DW043601
License Plate: 269CEF/Louisiana.
2017 Nissan Sentra S Sedan Black 4 door. VIN#: 3N1AB7AP1HY384054
License Plate: RAE-4221/North Carolina.
2018 Mazda CX-5 Grand Touring Sport Utility Dark Gray 4 door. VIN#:
License Plate: 3593/South Carolina.
2019 Chevrolet Cruze LT White Hatchback 4 door. VIN#:
3G1BE65M9K5532736 License Plate: FLF5325/North Carolina.
2019 Honda HR-V Sport SUV Blue 4 door. VIN#: 3CZRU6H13KG727119 License
Plate: HXS5935/Ohio.
2022 Chevrolet Colorado Crew Cab Z71 Gray Pickup. VIN#:
1GCGTDENXM1298916 License Plate: KDY8635/North Carolina.
2022 Ford F150 Super Crew Cab XL White Pickup. Owner: AIRO Mechanical
VIN#: 1FTEW1EP4NFB81141 License Plate: RB4/24
L-2: 2018 Spartan/Smeal Metro Star.
L-16: 2019 Spartan/Smeal Metro Star.
L-24: 2018 Spartan/Smeal Metro Star.
E-14: 2019 Spartan/Smeal Gladiator.
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MAIN FIRE BUILDING/AREA

Modera SouthPark located at 7741 Liberty Row Drive, Building B. Please see
above in the scene description for detailed information on this building.
Based on eyewitness accounts, fire pattern analysis and damage
assessment this building was identified as the area of fire origin. Exterior
examination revealed total collapse of the upper 6 floors which were
constructed of wood framing and fire resistive plywood exterior covering.
No gypsum wall boards had been installed on interior walls or ceilings. The
wooden structure burned almost complete with the remaining debris being
severely charred and collapsed on the concrete base, top of the podium,
or the surrounding areas.

This investigator conducted a limited interior fire scene examination on

May 19, 2023, at 0800 hours. The interior examination was conducted with
this investigator, Detective Levett, Fire Investigator Oddo, Fire Investigator
Southworth, Office of State Fire Marshal (OSFM) Fire Investigator Head, and
a forensic engineer from US Forensics. The engineer was provided by the
CFD USAR team who has several engineers on contract. The interior
investigation was limited in area due to the concern of stability due to the
excessive heat and duration of the fire in the area of origin. The extended
heat and flame damaged the concrete structure spalling concrete and
exposing rebar and support cables in the concrete.

Investigators made entry into the south entry door that accessed the
hallway on the main level of what would have been business occupancy
area. Investigators utilized the long hallway to access the area of the
center stairwell and elevator shafts which opened into the parking area of
the first floor. Smoke patterns and water were noted in the corridor area.
Smoke damage and fire patterns were documented in the parking area
and elevator shafts. Clean burn patterns were observed on the walls
adjacent to the location of the trailer. These areas contained large
amounts of fiberglass tubs and shower inserts adding to the fuel load of
the parking deck. This area was located approximately 25 feet from the
area of the open and unobstructed elevator shaft. Several pallets of the
two-part foam mixture were also found in the parking deck near the trailer.
The 55-gallon drums were on pallets, however, not ruptured during the fire.
Spalling of concrete was observed to the concrete walls adjacent to the
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trailer on both sides and to the ceiling above. Many of the rebar and
concrete support cables were exposed.

The spray foam trailer was located in the parking garage portion of the
building. It was positioned halfway up the ramp towards the second floor.
The trailer was also about 25 feet from the open elevator shaft. The trailer
sustained high heat and prolonged burning. The structural components of
the trailer were twisted, warped, and pulled downward towards the floor of
the trailer. The trailer was photographed from three sides at a distance of
about 20 feet due to structural stability concerns. Fire patterns were
directional from the trailer indicating the area of fire origin to be the
trailer.

Several weeks after the fire this investigator received a copy of a TikTok
video post by the username “leolrz”. The video displayed the fire in its
earliest known stage. The video was taken as the unknown individual
walked by the trailer on fire while he was exiting the building. The video
confirms fire issuing from the rear door of the trailer where the generator
room was located. Fire is also seen under the trailer. No other fire was
noted around the exterior of the trailer. Attempts to contact the individual
were unsuccessful.

All movements and observations were under the direction of the engineer.
After visual examination and documentation by photographs, investigators
cleared the structure around 0845 hours.

ITEMS PRESERVED / EVIDENCE COLLECTED

1 8.5’ X 20’ enclosed trailer was identified and preserved in place for future
interested parties. No tag or label was applied due to the area where the
trailer was located being considered unsafe.

PHOTOGRAPHS AND CASE FILE DOCUMENTS

Digital photographs were taken have been added to the case file along
with the recorded interviews of those involved, which were taken by both
fire and police members of the Fire Investigation Task Force. The Incident
Detail Report (CAD) report, historical weather report, the Charlotte Fire
Investigation Task Force (FITF) Fire Scene Investigation Worksheet with
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handwritten notes, a scene diagram, property reports, and the fire

investigator’s incident synopsis are included within this case file.
Numerous security videos, photos and videos obtained from bystanders
and other personnel are included in the case file.

CONCLUSION / OPINION

The fire originated on the first floor of the parking garage of building B
which was under construction by Mill Creek Residential. More specifically
inside the rear room of the spray foam trailer set up. This location is where
the diesel generator is located. The most probable heat source was a
failure of components within the generator room of the trailer used to
spray foam insulation in the parking garage. Items considered were
charging lithium-ion batteries, numerous electrical items, hot surface
ignition of ignitable liquids, and a catastrophic failure of the generator
engine. At this time the material first ignited is unknown but diesel fuel,
and other combustible materials found within the generator room could
not be eliminated. The act which brought the first material ignited and the
heat source together was unintentional. Based on all known facts, witness
statements, and remaining physical evidence, and this investigator’s fire
scene examination this fire has been classified to be UNDETERMINED, and
recommend the case be Closed.

CASE UPDATE / OPINION

A joint scene exam was conducted on September 11, 2023, by the various
third-party companies involved in the loss. The foam spray trailer in
question was removed from the interior of the building to a safe location
outside for examination. Once removed, company officials and insurance
investigators contacted Fire Investigator Boggs and notified him of the
removal. Boggs contacted Chief Fire Investigator Shaver and both he and
Senior Fire Investigator David Williams responded to photograph and
examine the trailer. Two large holes were found to the engine block. On
one side of the motor, a piston connecting rod was sticking through the
hole. The trailer was taken to SEA Limited in Charlotte for storage and
further examination. A catastrophic failure of the diesel engine was
determined as cause of this fire. This mechanical failure resulted in
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combustible fluids contacting the hot surfaces of the engine and its
vapors igniting. The small fire then spread to other items in proximity and
the exposed wood framing of the structure before the fire was discovered
and eventually extinguished. This concluded the fire investigation for CFD.
Based on all known facts, witness statements, and remaining physical
evidence, and this investigator’s fire scene examination this fire has been
classified to be ACCIDENTAL, and recommend the case be Closed.

This conclusion is based upon the known facts and information available at the time this
report was written. This investigator reserves the right to change or alter his/her
opinion(s) based on new facts, evidence, or information that may arise after the date of
this report.

This report is a compilation of the actions and findings of the Charlotte Fire Investigation
Task Force for this incident.

Estimations, evaluations, and opinions made herein represent 'most likely' and 'most
probable' unless specifically stated otherwise.

Report Completed by: J.G. Boggs, Fire Investigator

Date: 12/10/2023

Report Technically Reviewed by: E.E. Shaver, Chief Fire Investigator

Date: 12/11/2023
 LIBERTY ROW FIRE - AFTER ACTION REPORT

CHAPTER FOUR
FIRE COMMUNICATIONS
RESPONSE REPORT
THE FOLLOWING CHAPTER WAS PREPARED BY DHS CYBERSECURITY AND
INFRASTRUCTURE SECURITY AGENCY (CISA), INTEROPERABLE
COMMUNICATIONS TECHNICAL ASSISTANCE PROGRAM (ICTAP) AS PART OF
WORK ORDER # WO23-345.
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EXECUTIVE SUMMARY

The City of Charlotte, North Carolina Fire Department (CFD) requested

assistance from the Department of Homeland Security (DHS) Cybersecurity
and Infrastructure Security Agency (CISA) Interoperable Communications
Technical Assistance Program (ICTAP) to develop an after-action
supplemental report (AASR) to summarize the strengths and challenges of
the telecommunications response to the Liberty Row Five-Alarm Fire, with a
focus on communications successes and challenges that occurred during
this event.

OVERVIEW

This AASR discusses issues associated with the CFD communications

response to the 2023 Liberty Row Five-Alarm Fire. The AASR is also intended
to summarize strengths, identify challenges, and present recommendations
to ensure the processes of interoperable communications and alert &
warning systems function as smoothly as possible in the future.

The 2023 Liberty Row Five-Alarm Fire was a vehicle fire within a high-rise
structure that was under construction. The fire rapidly progressed through
multiple alarms with a fifth alarm being requested fifty-four minutes from
the initial report. Mutual aid units responded to provide assistance and
back fill and were able to communicate effectively on Charlotte Fire Zone 1,
for those that had it. Communications issues include call capacity at the
PSAP and Fire Alarm dispatch centers, self-dispatching of units, over-
reliance on dispatch to provide information to non-responders, and
incident command staff being over-tasked without support.

Information was obtained from two local agencies from the City of
Charlotte. The information provided was consolidated into this AASR.
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KEY FINDINGS
In most instances, the strengths and challenges were generated by the
stakeholders who contributed directly or indirectly to this report.
Recommendations should be considered as just that, recommendations. In
some instances, organizations may find recommendations to be
impractical, and thus may wish to find other solutions that will fit with their
already existing plans, processes, procedures, and infrastructure. An
improvement plan is included in Appendix A of this report, which will guide
the City of Charlotte in researching and implementing recommended
improvements.

Public safety response to the 2023 Liberty Row Five-Alarm Fire incident
highlighted several successes:

Although experiencing one of the largest and rapidly evolving fires in

the city’s recent history, due to the relationships and coordination of
the region, the city was able to handle all of their day to day response
as well as another large fire, all while operating on the Liberty Fire.
In general, the ecosystem of the Fire Alarm staff allowed for the second
shift to come in early and rapidly get involved in the operation.
Telecommunicators are trained to handle all the functions of an
emergency communications center, so the second shift was able to pick
up any gaps in personnel coverage caused by the Liberty Fire.
The dispatcher, who did an excellent job of fielding the original call,
had just recently completed his training and was on a mandatory
second shift. He then continued to run this very complex call and
performed commendably.
A unit became lost in the smoke at the incident and called in a MAYDAY.
The unit was able to successfully self-rescue. The culture of the CFD
allowed this potentially lifesaving action without fear of retribution or
loss of face.
Multiple Personal Accountability Reports (PAR) were conducted in a
timely manner.
Second-shift dispatchers voluntarily reported to work early and were a
valued resource.
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The City of Charlotte Land Mobile Radio(LMR) radio system reached 34%
utilization, allowing for additional expansion of the incident if needed.
A Wireless Emergency Alert (WEA) was successfully used to help reduce
the 911 call volume.

The 2023 Liberty Row Five-Alarm Fire incident also identified several
opportunities for improving the knowledge and preparedness of City of
Charlotte response entities. These observations, detailed in Section 4 of
the AASR/IP, offer insight into findings documented during the planning
and execution phases of the exercise.

Major recommendations include:

Develop a plan, that is similar to other cities, that assigns an aide to the
Incident Commander (IC).
Consider developing a Standard Operating Guideline (SOG) that will
designate when and how mutual aid should be requested and
dispatched.
Consider forming or formalizing a mutual aid resource request group
made up of representatives from the regional fire agencies.
Consider developing an SOG that outlines when outside agencies are
requested for major response or back fill.
Create an SOG for large scale and/or extended incidents that directs
when FieldComm (a Communications Unit or COML) is assigned to the
response.
Formalize the MAYDAY SOG and conduct training with all field and
dispatch personnel.
Develop an SOG that designates how the CFD Dispatch Center
administrative line should be used, who is authorized to use it, and for
what reasons.
Develop an SOG for large incidents that establishes a communication
method between the dispatch center and the Emergency Operations
Center (EOC).
Develop an SOG, research and purchase technology solutions that will
enhance unit accountability, city fire protection coverage, and noise
reduction within the CFD Dispatch Center.
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Develop an SOG that dictates who and what activities are allowed on
the dispatch center floor.
Consider the development of a consolidated CFD/Charlotte-
Mecklenburg Police Department (CMPD) / Central Medical Emergency
Dispatch (CMED) Center.
If a consolidated dispatch center is not a viable solution, immediately
begin work to expand the CFD Dispatch center (in size) or relocate the
Dispatch to a newer and larger facility, to allow for expansion of a
command and control center within the Charlotte Fire Department
Operations Center during a similar large scale and or extended
incident.

The lessons learned from the Liberty Row Five-Alarm Fire are an important
step toward increasing and improving communication interoperability
within the City of Charlotte in preparation for future catastrophic incidents
and large planned events. By continually assessing progress and making
improvements, public safety entities will continue to excel in their
dedication to disaster preparedness and their mission to achieve an
optimal level of secure interoperable communications. Acting on the
various recommendations in this AASR/IP should further interoperable
emergency communications capabilities.
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INTRODUCTION

The City of Charlotte, North Carolina Fire Department (CFD) requested

assistance from the Department of Homeland Security (DHS) Cybersecurity
and Infrastructure Security Agency (CISA) Interoperable Communications
Technical Assistance Program (ICTAP) to develop an After action |
supplemental report (AASR) to summarize the strengths and challenges of
the telecommunications response to the Liberty Row Five-Alarm Fire, with a
focus on communications challenges occurred during this event.

PURPOSE
The AASR discusses issues associated with the CFD communications
response to the 2023 Liberty Row Five-Alarm Fire. The AASR is also intended
to summarize strengths, identify challenges, and present recommendations
to ensure the processes of interoperable communications and alert &
warning systems function as smoothly as possible in the future.

AASR DEVELOPMENT PROCESS

The primary information collection method used to generate this AASR was
to request information from local stakeholders. ICTAP conducted an in-
person discussion attended by the leadership and dispatch personnel of
CFD, Emergency Management staff, and responders to the incident.

Stakeholders
The following agencies or organizations represent the major stakeholders
that provided information, documentation, and/or reports to assist with
the development of this AASR:
Charlotte Fire Department
Charlotte-Mecklenburg Emergency Management Office

AASR Recommendations
The AASR discusses issues associated with the CFD communications
response to the 2023 Liberty Row Five-Alarm Fire. The AASR is also intended
to summarize strengths, identify challenges, and present recommendations
to ensure the processes of interoperable communications and alert &
warning systems function as smoothly as possible in the future.
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FIRE COMMUNICATIONS REPONSE REPORT

Recommendations should be considered as just that, recommendations. In

some instances, organizations may find recommendations to be
impractical, and thus may wish to find other solutions that will fit with their
already existing plans, processes, procedures, and infrastructure. An
improvement plan is included in Appendix A of this report, which will guide
the City of Charlotte in researching and implementing recommended
improvements.

COMMUNICATIONS

INCIDENT REVIEW
On May 18, 2023 the Charlotte Fire Department engaged in one of the
largest and most devastating fires the city has ever seen. The initial call
for the incident was received at 9:02am for the initial call of a vehicle fire
in a parking garage. This incident was a rapidly evolving and escalating
fire that resulted in an escalation to a 5th alarm within 54 minutes from the
initial call. A number of mutual aid units from surrounding counties
backfilled empty stations to assist and due to the sharing of the radio
programming of Charlotte Fire’s Zone 1, they were able to seamlessly
backfill the empty fire stations. Over the course of the response, fire
personnel had to address a number of life-threatening challenges
including a trapped construction worker in a crane, two trapped
construction workers on the 6th floor (4th floor of the wooden section, but
6th floor overall), and a Mayday from a lost fire team who were eventually
able to self-rescue.

Unfortunately, the two trapped on the 4th floor perished in the fire.
Communications technologies worked very effectively for those agencies
that had the proper programming throughout the incident. Fire Alarm staff
worked exceptionally well to handle an extreme increase in volume of 9-1-1
calls and resources they were responsible for dispatching and tracking.
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FIRE RESPONSE OVERVIEW AND TIMELINE OF CRITICAL EVENTS

As is to be expected, public safety personnel in Charlotte are well-versed

in fire incident response. Area communications plans are alreadyin place
and are implemented rapidly upon information that a large-scale incident
is occurring. These incident communications plans are readily available
and well-practiced.

Timeline
May 18, 2023
9:02am - Initial9-1-1 calls start
Ladder 16 first to arrive
Initial call corrected to a mid-rise structure fire
9:09am - 2nd Alarm Declared
Calls coming in from trapped people
9:20am - 3rd Alarm Declared
Crane operator trapped
Cannot access the source of the fire and chemicals discovered
Mayday Call for lost firefighters
Ladder 1 is trapped too close to fire
9:31am - 4th Alarm Declared
Crane is in jeopardy of collapse and Ladder 2 is working the collapse
Ladder 1 finds its way to safety
FieldComm reports to the scene to help with communications and
battery swap, and sets up a recharging point immediately while
assisting as the Chief’s Aide.
Trainees report to back up center to reduce call volume on Alarm
9:56am - 5th Alarm Declared
After other requests were taking too long, Rescue 10 Climbs Crane
and helped the operator to safety
Spot fires popping up around the area
Personnel begin to rehabilitate
CFD on-scene throughout the night
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STRENGTHS IDENTIFIED

As has been discussed previously, personnel in the City of Charlotte are

well-versed in response to major incidents. The experience, dedication,
creativity, and hard work of responders are commendable, and many
strengths were identified during discussions around the 2023 Liberty Row
Five-Alarm Fire response.
The dispatcher, who did an excellent job of fielding the original call,
had just recently completed his training and was on a mandatory
second shift. He then continued to run this very complex call and
performed commendably.
A unit became lost in the smoke at the incident and called in a MAYDAY.
The unit was able to successfully self-rescue. The culture of the CFD
allowed this potentially lifesaving action without fear of retribution or
loss of face.
Multiple Personal Accountability Reports (PARs) were conducted in a
timely manner.
Second-shift dispatchers voluntarily reported to work early and were a
valued resource.
The City of Charlotte Land Mobile Radio(LMR) radio system reached 34%
utilization, allowing for additional expansion of the incident if needed.
A Wireless Emergency Alert (WEA) was successfully used to help reduce
the 911 call volume.

GAP ANALYSIS

Throughout the process of stakeholder discussions, research of

information available on the Internet, and review of the information
provided, a number of areas were identified where improvements should
be considered. The gaps and recommendations noted below were either
extracted directly from the information provided or developed as a result
of our discussions. The recommendations are included in an Improvement
Plan, provided in Appendix A of this report.
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STAFFING GAPS

The following set of gaps and recommendations may be relevant to the

interoperable communications response during the 2023 Liberty Row Five
Alarm Fire.

Incident Command Staffing

Description:
During the interview and data collection process, interviewees identified
that the Incident Commander (IC) was monitoring and responding to radio
communication, mobile phone calls, information being provided over
Mobile Data Terminal (MDT), and face-to-face communications. These
information sources were from CFD dispatch, units on scene, outside
agencies in unified command, and witnesses. While monitoring all these
the IC is also expected to keep a visual perspective to see if there are
changes to the incident. During this incident Ladder 1, who had called the
MAYDAY, was trying to communicate with Tower 26. Their calls were
monitored at dispatch but no one at the incident responded. Additionally,
as the incident grows it challenges the span of control that a single person
can handle. While additional command staff may be assigned it still leaves
all the communication and documentation to the IC.

Although there were very few issues that came up with communications, it
was a very complex incident that required quick adaptation and thinking
from the operational staff. Due to this rapidly evolving environment,
communications complexities were introduced and mitigated. If additional
problems had come up, the flexibility may not have been available in
communications planning due to a Communications Unit Leader (COML)
not being established early on.
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Recommendations:
1. Develop a plan, that is similar to other cities, that assigns a Chief’s Aide
to the IC. During incidents, they will help relieve the burden of
monitoring all the communications and tracking responsibilities
allowing the IC to devote their efforts to information analysis and
decision making.
2. Develop a plan for large incidents that would utilize operations-trained
staff that are currently in administrative roles to assist the IC and their
staff.
3. Formalize the MAYDAY SOG and conduct training with all field and
dispatch personnel.
4. Consider assigning tactical dispatch personnel on scene to monitor any
and all incident related repeated or tactical talk paths.
5. Create an SOG for large/extended incidents that directs when a
Communications Unit or COML is added to the response.
6. Consider the automatic assignment of field communications staff to
coincide with the activated Alarm level for any given incident. (e.g., if a
third alarm is hit, a COML is automatically deployed).
7. Create an SOG for large/extended incidents that directs when an
Incident Communications Technology Branch or COML is added to the
response.

Self-Dispatching

Description:
Several agencies within the region self-dispatched to the back fill
locations. While their intent was good this created a significant impact on
dispatch. Tracking and coordinating these units required the use of paper
maps outside the Computer Aided Dispatch (CAD) system and was very
time-consuming. These units are not equipped with the same
communications, paging, and tracking equipment which made assigning
them difficult. Additionally, CFD staff members reported to the dispatch
center. At times their help was appreciated, but their well-meaning
presence added to the controlled chaos that exists during any large
incident. Coordination of these units was very difficult and, at times, there
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was a duplication of efforts by Charlotte Fire Alarm and EOC staff.

Additional coordination would have allowed for more personnel to be
available to do other duties. Also, preplanning for this type of major
incident in the future will allow units to know exactly where they are
supposed to go, allowing dispatch to track them as well. CFD staff also
mentioned that they currently do not have any type of technology, system,
or software that would allow them to better track the necessary mutual aid
and back fill that took place during this incident.

Recommendations:

1. Consider developing an SOG that will designate when mutual aid should
be requested. This SOG will also designate who should be filling this
role.
2. Consider forming or formalizing a mutual aid resource request group
made up of representatives from the regional fire agencies. This group
should develop SOGs for large and small incidents within the region.
3. Consider developing an SOG that outlines when outside agencies are
requested for major response or back fill. These units may or may not
have the same communications equipment as CFD units and would
require the use of “day alerting” in the stations and repeating the call
information twice to allow for copying of the address and other
necessary information.
4. Investigate the possibility of integrating outside agency resources into
the current City of Charlotte Automatic Vehicle Location (AVL)
technology.
5. Determine if a communications resource can be identified to coordinate
incoming mutual aid resources.
6. Create an automatic communications pathway between EOC and Alarm
staff to allow for efficient communications and coordination for large
incidents.
7. Research the plausibility of acquiring a resource management system
that would allow for the better tracking of incoming mutual aid
resources and units backfilling local units.
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Public Information Officer and Joint Information Centers

Description:
Due to the rapidly evolving nature of this incident, there were significant
challenges to informing the public of what was going on until after the
incident was under control. Conflicting messages from public alerts and
the news at the time left the public wondering what information was
accurate. The primary reason for the conflict in information was due to
multiple agencies sending out alerts to the public without coordination
between them. A joint information center with representatives from each
agency and elected officials could have mitigated this issue.

Recommendations:
1. Consider developing a policy that dictates under what circumstances
and escalations that a Joint Information Center should be activated.
2. Ensure all public messaging is coordinated by the appropriate
personnel and agencies before release.

Staffing Shortages

Description:
Just like most of the country, Charlotte telecommunications are typically
short-staffed and having trouble recruiting and retaining personnel.
Although since the Liberty Fire took place the staffing shortage has been
somewhat alleviated, there is always the ongoing future concern of
maintaining enough personnel to handle extended operations.

Recommendations:
1. Identify staffing shortfalls for all agencies’ telecommunicator staff.
2. Consider identifying how staffing would be affected by consolidating to
a single PSAP.
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STANDARD OPERATING GUIDELINE GAPS

The following set of gaps and recommendations may be relevant to the

communications response during the 2023 Liberty Row Five-Alarm Fire.

Utilization of Charlotte Alarm Dispatch for Administrative Duties

Description:
The incident had a significant impact on the Charlotte Fire Alarm Dispatch
Center. Call volume was very high because of the fire and other incidents
in the area. As can be expected there was a significant amount of radio
traffic. Simultaneously, well-meaning personnel were calling dispatch on
the administrative line for a number of reasons, including asking if they
should respond and where, inquiring on how to update the Mobile Data
Terminals (MDT) in reserve apparatus, or they were offering suggestions.
Also, no direct line of communication was established between Charlotte
Fire Alarm and the City Emergency Operations Center (EOC).
These calls and other interruptions had an impact on the direct handling of
the incident and other functions within Charlotte Fire Alarm.

Recommendations:
1. Develop an SOG that designates how the Charlotte Fire Alarm
administrative line should be used, who is authorized to use it, and for
what reasons.
2. Develop an SOG for large incidents that establishes a communication
method between the Charlotte Fire Alarm and the City of Charlotte EOC.
This would allow the EOC to help relieve some of the administrative and
logistical roles.
3. Consider transferring the administrative line outside the dispatch floor
during large incidents to help reduce its impact on operations.
4. Exercise any developed SOG to failure to ensure that all of the involved
personnel and technologies of the guidelines are tested.
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Noise Level on Dispatch Floor

Description:
During the Liberty Row Five-Alarm Fire the Charlotte Fire Alarm became the
focus of many activities. Some activities were directly related to the
incident while others were more administrative in function. Additionally,
staff members were having discussions that did not need to occur on the
dispatch floor. Questions were being directed to dispatchers while they
were receiving calls from the field and trying to reply. Unfortunately, the
small size of the Charlotte Fire Alarm increased the noise level that the
dispatchers were required to work through.

Recommendations:
1. Develop an SOG that dictates who and what activities are allowed on
the dispatch center floor. Once this is established empower the
Dispatch Manager to enforce this policy.
2. Provide an area for command, planning, logistical, and administrative
staff to meet and work toward the successful resolution of the incident.
This area should be separate from the dispatch floor.

Communications System and Supporting Equipment

Description:
Many of the primary and secondary communications equipment for the
Charlotte Fire Department is aging, if not already at end of life. Equipment
like handheld radios and tablets are both examples of resources that need
to be updated. During large incidents, there is increased usage of
communication devices which in turn impacts the batteries within their
devices. Some of the situational awareness tablet technologies that are in
use are reaching the end of their usable lifespan and losing their charge
quickly, to the point of needing to be tethered to a power source.
Additionally, the radios currently in use are aging rapidly and nearing end
of life. They are several generations old and the manufacturers are
supporting these models less as they get older. Large incidents usually
expand rapidly, and communications needed to bring the incident to a
satisfactory conclusion take a while to be met.
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Recommendations:
1. Review the current status of all communications and situational
awareness technologies and replace them if they are nearing their life
expectancy.
2. Replace existing tablets that have no battery capability.
3. Consider starting to update end of life radio equipment in an annual
cycle to alleviate the large costs all at once.

FACILITY GAPS

The following gaps and recommendations may be relevant to the

communications response during the 2023 Liberty Row Five-Alarm Fire.

Consolidated Dispatch Center

Description:
Charlotte Fire Alarm was built many years ago when the City of Charlotte
and CFD were much smaller. During the Liberty Row Five-Alarm Fire it
became apparent the center was not adequate. When calls to the CMPD
are not answered they roll over to CFD Dispatch. If these calls are not then
answered by Charlotte Fire Alarm they just continue to ring. This is a threat
to life safety of citizens of Charlotte. There is no space in the Center for
additional call takers or radio operators. As mentioned above, there is a
lack of space for command, planning, and logistics personnel to meet and
coordinate activities. Since the CFD and CMPD Dispatch Centers are not
co-located information that is critical to responders and the citizens they
serve can be lost. Consolidation of the dispatch centers would allow the
leveraging of technologies and personnel to better serve the public.

Recommendations:
1. Consider the development of a joint CFD/CMPD/CMED Dispatch Center.
Virtual options are available if co-location is not plausible.
2. Consider space utilization plans within the current facility to maximize
all available space efficiently until a new center can be developed.
3. Consider standardizing CAD across the region which will allow for a
virtual co-location of resources if a physical co-location is not plausible.
 LIBERTY ROW FIRE - AFTER ACTION REPORT

FIRE COMMUNICATIONS REPONSE REPORT

Charlotte Fire Alarm Visual Notifications

Description:
Currently within Charlotte Fire Alarm, there is no way for personnel to
recognize if any of the dispatch staff is on a call outside of getting close
enough to hear if a conversation is taking place. As was noted above, the
noise floor often became unreasonable within the communications center
and made jobs more difficult. A simple automatic visual display would help
to inform those around Charlotte Fire Alarm staff when additional
conversations may be causing a disruption. Many of the staff said they did
not realize that the dispatchers were on a call when they were discussing
other matters. One additional example of difficulties supervisors have is
that they do not have an elevated position in the room which makes it
more difficult to monitor communications with staff and to know what their
status is.

Recommendation:
1. Consider installing a light or other type of visual notification system
within Charlotte Fire Alarm that would allow for personnel to know the
status of the current dispatcher. For example, a stop light system with a
simple red and green light can let people know if they are busy.

CONCLUSION

The Liberty Row Five-Alarm Fire AASR/IP identifies operable and

interoperable communications challenges related to the incident and
provides recommendations to address those challenges. Using this
AASR/IP, the City of Charlotte can develop priorities and focus its efforts
on achieving and improving public safety communications.
The Liberty Row Five-Alarm Fire AASR/IP also identified opportunities for
improving communications and interoperability proficiency when
responding to natural or human-caused incidents and large planned
events. Challenges were identified in communications assets governance,
SOGs, technical, training, and usage. The AASR provides descriptions of
each communications challenge and provides recommendations on how to
 LIBERTY ROW FIRE - AFTER ACTION REPORT

FIRE COMMUNICATIONS REPONSE REPORT

address noted issues in the Improvement Plan (Appendix A).

The lessons learned from the Liberty Row Five-Alarm Fire are an important
step toward increasing and improving communication interoperability
within the City of Charlotte in preparation for future catastrophic incidents
and large planned events. By continually assessing progress and making
improvements, public safety entities will continue to excel in their
dedication to disaster preparedness and their mission to achieve an
optimal level of secure interoperable communications. Acting on the
various recommendations in this AASR/IP should further interoperable
emergency communications capabilities.

A COPY OF THIS CHAPTER IS AVAILABLE IN ITS ORIGINAL FORMATTING UPON REQUEST.

 LIBERTY ROW FIRE - AFTER ACTION REPORT

APPENDIX A
IMPROVEMENT PLAN
APPENDIX A WAS PREPARED BY DHS CYBERSECURITY AND
INFRASTRUCTURE SECURITY AGENCY (CISA), INTEROPERABLE
COMMUNICATIONS TECHNICAL ASSISTANCE PROGRAM (ICTAP) AS PART OF
WORK ORDER # WO23-345.
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Develop a plan, that is similar to other cities, that assigns
a Chief’s Aide to the IC. During incidents, they will help
relieve the burden of monitoring all the communications
and tracking responsibilities allowing the IC to devote
their efforts to information analysis and decision making.

Develop a plan for large incidents that would utilize

operations-trained staff that are currently in
administrative roles to assist the IC and their staff.
Incident
Command
Staffing Formalize the MAYDAY SOG and conduct training with all
field and dispatch personnel.

Consider assigning tactical dispatch personnel on scene

to monitor any and all incident related repeated or
tactical talk paths.

Create an SOG for large/extended incidents that directs

when a Communications Unit
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Consider the automatic assignment of field
communications staff to coincide with the activated
Alarm level for any given incident. (e.g., if a third alarm is
Incident hit, a COML is automatically deployed).
Command
Staffing
Create an SOG for large/extended incidents that directs
when an Incident Communications Technology Branch or
COML is added to the response.

Consider developing an SOG that will designate when

mutual aid should be requested. This SOG will also
designate who should be filling this role.

Consider forming or formalizing a mutual aid resource

request group made up of representatives from the
regional fire agencies. This group should develop SOGs for
Self- large and small incidents within the region.
Dispatching

Consider developing an SOG that outlines when outside

agencies are requested for major response or back fill.
These units may or may not have the same
communications equipment as CFD units and would
require the use of “day alerting” in the stations and
repeating the call information twice to allow for copying
of the address and other necessary information.
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Investigate the possibility of integrating outside agency
resources into the current City of Charlotte Automatic
Vehicle Location (AVL) technology.

Determine if a communications resource can be

identified to coordinate incoming mutual aid resources.

Self-Dispatching

Create an automatic communications pathway between

EOC and Alarm staff to allow for efficient
communications and coordination for large incidents.

Research the plausibility of acquiring a resource

management system that would allow for the better
tracking of incoming mutual aid resources and units
backfilling local units.

Public
Information Consider developing a policy that dictates under what
Officer and Joint circumstances and escalations that a Joint Information
Information Center should be activated.
Centers
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Public
Information
Officer and Joint Ensure all public messaging is coordinated by the
appropriate personnel and agencies before release.
Information
Centers

Identify staffing shortfalls for all agencies’

telecommunicator staff.
Staffing
Shortages
Consider identifying how staffing would be affected by
consolidating to a single PSAP.

Develop an SOG that designates how the Charlotte Fire

Alarm administrative line should be used, who is
Utilization of authorized to use it, and for what reasons.
Charlotte Alarm
Dispatch for
Administrative Develop an SOG for large incidents that establishes a
communication method between the Charlotte Fire
Duties Alarm and the City of Charlotte EOC. This would allow the
EOC to help relieve some of the administrative and
logistical roles.
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Consider transferring the administrative line outside the
Utilization of dispatch floor during large incidents to help reduce its
impact on operations.
Charlotte Alarm
Dispatch for
Administrative
Exercise any developed SOG to failure, to ensure that all
Duties of the involved personnel and technologies of the
guidelines are tested.

Develop an SOG that dictates who and what activities

are allowed on the dispatch center floor. Once this is
established empower the Dispatch Manager to enforce
this policy.
Noise Level on
Dispatch Floor
Provide an area for command, planning, logistical, and
administrative staff to meet and work toward the
successful resolution of the incident. This area should be
separate from the dispatch floor.

Communications
System and Review the current status of all communications and
situational awareness technologies and replace them if
Supporting they are nearing their life expectancy.
Equipment
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Replace existing tablets that have no battery capability.
Communications
System and
Supporting
Equipment
Consider starting to update end of life radio equipment
in an annual cycle to alleviate the large costs all at once.

Consider the development of a joint CFD/CMPD/CMED

Dispatch Center. Virtual options are available if co-
location is not plausible.

Consolidated
Consider space utilization plans within the current facility
Dispatch Center to maximize all available space efficiently until a new
center can be developed.

Consider standardizing CAD across the region which will

allow for a virtual co-location of resources if a physical
co-location is not plausible.
 Primary Responsible
Recommendations

Completion Date
Agency POC
Challenges

Start Date
Agency
Actions
Consider installing a light or other type of visual
Charlotte Fire notification system within Charlotte Fire Alarm that
Alarm Visual would allow for personnel to know the status of the
current dispatcher. For example, a stop light system with
Notifications a simple red and green light can let people know if they
are busy.
 LIBERTY ROW FIRE - AFTER ACTION REPORT

APPENDIX B
GLOSSARY
APPENDIX B WAS PREPARED BY DHS CYBERSECURITY AND
INFRASTRUCTURE SECURITY AGENCY (CISA), INTEROPERABLE
COMMUNICATIONS TECHNICAL ASSISTANCE PROGRAM (ICTAP) AS PART OF
WORK ORDER # WO23-345.
 LIBERTY ROW FIRE - AFTER ACTION REPORT

GLOSSARY

AASR After Action Supplemental Report

AVL Automatic Vehicle Location

CAD Computer Aided Dispatch

CFD Charlotte Fire Department

CISA Cybersecurity and Infrastructure Security Agency

CMED Central Medical Emergency Dispatch

CMPD Charlotte-Mecklenburg Police Department

COML Communications Unit Leader

DHS Department of Homeland Security

EM Emergency Management or Emergency Manager

EOC Emergency Operations Center

IC Incident Commander

ICS Incident Command System

ICTAP Interoperable Communications Technical Assistance Program

IP Improvement Plan

LMR Land Mobile Radio

MDT Mobile Data Terminal

NIMS National Incident Management System

PAR Personnel Accountability Report

POC Point of Contact

SOG Standard Operating Guideline

WEA Wireless Emergency Alert