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The Nightmare before Spring: Fire and Ice, a tale of two hazards

TINKER AIR FORCE BASE, Okla. -- Once upon a time not too long ago, in the middle of a long, cold, dreary winter on the base called Tinker, an avoidable incident regrettably occurred. The following is a detailed account of the incident that took place on a snowy and icy day that left 2 inches of the frozen precipitation coating the ground.

Bldg. 12500 was an older, small, single-level, one-entranced building housing an administrative shop and it was equipped with a functioning sprinkler system. There were six administrative workers (Barb B. Cue, Dee Mented, Belle E. Flop, Dennis Racket, Jim Shoe and Cole Kutz) who generated an overabundance of paperwork which involved the use of numerous cardboard boxes for handling and storing excess paper. They all worked in individual cubicles. The area supervisor and facility manager was Forrest Ranger. Forrest was a veteran supervisor having worked on Tinker for 30 years and supervised for 20 of those years.

Forrest was a very busy man and always had excuses for the Safety and Fire inspectors when discrepancies were discovered during routine spot and annual inspections. When twice scheduled for Supervisor Safety Training (AFMCPAM 91-104, 4.8) and (AFI 91-202; 1.5.21.14; 2.3.2.1), he always had conflicting schedules.

As a result of this haphazard method of running his office's Safety program, the workers were (not surprisingly) involved in various nefarious methods that were not sanctioned by the Safety or Life Safety Code standards. For example, due to the lack of even heating in the old building, Barb and Dee went to a local store, purchased two space heaters, and brought them into the workplace -- all unbeknownst to Forrest (TAFBI 32-2001, 11.3). None of the heaters was equipped with an automatic shut-off device (AFOSH STD 91-501, 6.2.10.1).

Due to the insufficiency of electrical outlets, Dee utilized an extension cord to power her heater, and Barb even went so far as to "daisy-chain" three power strips in order that she may have more outlets to power items on her desk in addition to the space heater (AFOSH STD 91-501, 6.2.10.2; 8.3.1 and 8.5.1), (TAFBI 32-2001, 11.1.4.1), and (TAFBI 32-2001, 11.1.5).

Around 9:30 a.m., while everyone was in the breakroom enjoying some edible goodies that Dennis brought in to share, Jim casually mentioned that he thought he smelled something burning. Everyone thought it may have come from the microwave and no one paid further attention. They all kept on munching and conversing.

Belle and Cole finished eating, and walked back out into the cubicled work area where they were greeted with the surprise of their lives. The office was on fire, and there were approximately 6-foot-tall flames licking about, but not confined to, Barb's cubicle. They both screamed "Fire!" which brought the remaining members of the office hightailing it out of the breakroom. Cole ran to the nearest fire extinguisher, kicked the three cardboard boxes away that were blocking access to the extinguisher (AFOSH STD 91-501, 6.2.4.5), lifted it off the floor where it was being used as a door stop (AFOSH STD 91-501, 6.2.4.7.1), pulled the pin, squeezed the handle -- but nothing happened. The extinguisher was woefully under-charged, and the handle was broken (AFOSH STD 91-501, 6.2.4.7.5 and 6.2.4.7.6).

With the flames and smoke growing by leaps and bounds and now covering over half the small office, the sprinkler system functioned as designed. However, because of the stacked cardboard boxes within close proximity of most of the sprinkler heads, the water spray pattern was unable to do its job (AFOSH STD 91-501, 5.6) and (TAFBI 32-2001, 10.19.2.1). In their moment of anxiety and haste, no one thought to notify the Fire Department by calling the 9-1-1 emergency number.

Everyone ran to the exit, and there was some difficulty encountered down the short hallway to the exit due to the escape route being used for cardboard box storage (AFOSH STD 91-501, 6.2.15.2) and (TAFBI 32-2001, 14.2.1). The first person to exit the door was Belle, who was wearing 3-inch high-heeled footwear on that icy day. The additional problem with this whole scenario is that Forrest failed to ensure the ice and snow around the building's entrance were properly cleared for the safety of all personnel (TAFBP 32-1002, Snow and Ice Control Plan, 3.a.(3) thru 3.a.(7).

Needless to say, Belle's shoes lost traction with the icy surface, causing her to lose bodily balance and culminating with a fall and strike to the ground. The ambulance was summoned and it was later learned that she broke her right hip as a result of the fall. The responding Fire Department was able to get the blaze under control and extinguished, but at great cost to the government. They later surmised that the overloaded "daisy-chained" power strips overheated and erupted into flames, which devoured the surrounding cubicles and other items. This brought to mind a very profound statement made by one W.H. Cameron, "We now have unshakable conviction that accident causes are man-made and that a manmade problem can be solved by men and women" ... How true!

A post-incident Safety investigation revealed that Forrest failed in the following areas:

· He failed to develop a customized workplace Job Safety Training Outline for properly training his employees (AFI 91-202, Atch 5, A5.1); (AFOSH STD 91-501, 3.2.2) and (AFMC Sup 1 to AFI 91-301, 2.14.4.1).

· He failed to conduct and document workplace safety inspections utilizing the Administrative checklist and the AFMC Form 315 (AFMC Sup 1 to AFI 91-301, 2.14.4.3).

· He failed to conduct and document workplace Safety briefings utilizing the AFMC Form 316 (AFMC Sup 1 to AFI 91-301, 2.14.4.2).

· He failed to assign an AF Form 55, Employee Safety and Health Record to each employee.

· He failed to administer and document the required annual Fire Extinguisher training for his personnel (AFOSH STD 91-501, 6.2.1.1; 6.2.4.10 and 6.2.17.10).

· He failed to conduct the mandatory monthly extinguisher checks. Investigation revealed that the three building fire extinguishers had not been inspected for more than six months as evidenced by the lack of supervisory documentation (AFOSH STD 91-501, 6.2.4.7).

It was then I suddenly awoke drenched in sweat and realized it was a bad nightmare before Spring that I experienced, probably due to eating something laced with some type of fake sugar.

I then remembered a very interesting proverb that you should too: "Prepare and prevent, don't repair and repent."

(Article written from an original idea proposed by Regi Davis, 72nd ABW/SEF.)