HomeMy WebLinkAbout4.03 1992-93AlaCntyGrndJury
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GRAND JURY
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County <:>1 Alameda
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June 28, 1993
city Council of Dublin
6500 Dublin Blvd.
DUblin, CA 94566
Dear City council Members:
Enclosed please find the 1992-93 Alameda County Grand Jury Final
Report.
Under California Penal Code section 933(c), no later than 90
days after the grand jury submits a final report on the
operations of any pUblic agency subject to its reviewing
authority, the governing body of the public agency shall comment
to the presiding judge of the superior court on the findings and
recommendations pertaining to matters under the control of the
governing body.
Please respond to recommendations 93-5, 93-7, and 93-8.
We look forward to your response by September 28, 1993 and
appreciate your time and consideration.
Sincerely,
w~8.n~J~
William S. Godfrey, Foreman
Alameda County Grand Jury
WSG: jd
1401 Lakeside Drive, Suite 1104, Oakland, CA 94612 (415) 272-6259
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OAKLAND TUNNEL FIRE, OCTOBER, 1991
Introduction:
Because of numerous citizen complaints the Grand Jury undertook an
independent review of the events leading up to, and the subsequent
suppression attempts by Bay Area public agencies during the
firestorm that devastated parts of Oakland and Berkeley between
Saturday, October 19, 1991, and Wednesday, October 23, 1991.
purpose:
The Grand Jury makes four recommendations that will make the job of
our emergency services better organized and more efficient when the
next major emergency strikes the Bay Area. The Grand Jury is aware
of the many changes which have been instituted since the fire and
supports those changes. The attention here is to focus on the
events which occurred during the firestorm.
In pointing out problems faced by the fire and police departments
of the East Bay at each stage of the fire, it is not the intent of
the Grand Jury to detract from the heroic efforts made by pUblic-
safety personnel and many volunteers who fought the blaze.
Procedures:
The Grand Jury examined written and oral complaints of private
citizens; after-action reports of major agencies responding to the
firestorm; and testimony of private citizens, commanders of the
Oakland and Berkeley Fire Departments, the Oakland Police Chief,
and several professional firefighters who were involved in
suppression efforts. Representatives of Pacific Gas & Electricity
(PG&E) and East Bay Municipal Utility District (EBMUD) also
testified. Members of the Grand Jury visited the Oakland Fire
Department Command Center, hill-area firehouses in both Oakland and
Berkeley, and the Oakland Fire Department Training Center, and
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reviewed emergency plans which had been formulated in response to
fires of earlier years.
Chronology:
On Saturday, October 19, 1991, the California Department of
Forestry issued a "Red Flag warning" because low humidity, high
temperature, and the expectation of strong wind threatened great
danger of fire in the woodlands.
About noon a fire was reported in some of the steepest land in the
Oakland hills, near Buckingham Way and Marlborough Terrace.
Firefighters from Oakland, the East Bay Regional Park District, and
the California Department of Forestry cooperated to suppress the
fire. At about 6:30 p.m. they believed that the fire was out, but
left hoses and other equipment at the site. A firefighter from a
nearby station made a routine inspection about an hour later, but
found no hot spots. The fire department made no more inspections
that night.
On Sunday morning the CDF "Red Flag warning" was still in effect.
The Assistant Chief on site, who was effectively in command of the
Oakland Fire Department, went to the site of the hill fire; some
Oakland firefighters were there to retrieve equipment. Before 9: 00
a.m. they saw hot spots--smoke and embers--and stayed to suppress
them. They had help from East Bay Regional Parks firefighters.
From that time on things happened so rapidly that it was not
possible to keep an accurate time-log. About 9:30 a.m., the
Assistant Chief on site declared "an extreme fire hazard" in the
hills; by 10:30 a.m. several companies were again suppressing hot
spots, and one was reporting "open flame" at the bottom of the
burned area.
Before 11:00 a.m. firefighters were reporting that residences were
burning. This was no longer just a woodland fire. The First Alarm
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went out at 10:58 a.m.
The progress of the fire, and its overwhelming growth, can be read
in the times of successive alarms: Second Alarm 11:04 a.m.; Third
Alarm 11:07 a.m.; Fourth, 11:15 a.m. The Assistant Chief on site
saw that a firestorm was in progress; he skipped the Fifth Alarm
and went, at 11:26, directly to the Sixth Alarm, the highest in the
system.
There were no more alarms. The Assistant Chief on site ordered
activation of the Hill Area Disaster Plan. He could not see how
far the fire had run, nor how fast it was running, but the sketchy
reports he did receive made plain that ordinary methods of fighting
fires would not be enough.
Debris--some of it burning--was being blown across roads, from
hilltop to hilltop, from house to house. Live wires were falling
across streets and roads. Fire hydrants ran dry.
Nobody in the area--not the Fire Departments, not the Police
Departments, not the Red Cross, certainly not the people whose
houses were being burned--had been prepared for a catastrophe as
swift, as heavy, as widespread as the one which fell upon them all.
Several hundred houses were burned during the first hour.
Before all was over, help had come from not fewer than nine cities,
thirty-two counties, six state agencies, and four federal agencies
including Yosemite National Park. That Sixth Alarm had the effect
of calling in help from surrounding jurisdictions under agreements
for mutual response. The California Department of Forestry could
not deliver water from the air immediately because their planes
were dropping water on a fire near Healdsburg.
The massive aid that came from all of those sources, along with the
added equipment, helped greatly in controlling the fire. The
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heroism of
volunteer,
widely.
many of the firefighters, both professional and
and of people from other agencies, has been reported
A key element which made all of those efforts successful was the
change in the weather. The wind shifted, and eventually the fire
was brought under control.
Analysis:
During the fire several deficiencies became apparent; and although
responsible officials have moved to correct many or most of these,
it seems appropriate to pay attention to some which may still need
some additional improvement.
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COMMUNICATIONS:
1. Communications within the Oakland Fire Department
Imperfect communication between the Assistant Chief and the
firefighters on the line, and among firefighters, and among the
fire departments from several jurisdictions, hampered the efforts
of all, throughout the fire.
The Oakland Fire Dispatch center had two radio frequencies on which
they could communicate with Oakland I s thirty-five companies of
firefighters, and the several fire departments could communicate on
a statewide mutual-aid frequency (the "White Fire" channel).
At the height of the fire, when twenty or thirty or forty speakers
might be competing for use of the three frequencies, all radio
communication was almost hopelessly jammed. . The commanders of
engine companies often had to decide for themselves whether to
defend endangered houses or to give up that task and save their
engines and their fellow firefighters to carryon the work
elsewhere.
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Contributing to the difficulty in communication was the terrain.
In the deep ravines'and behind steep hills: the radio waves often
failed to reach the antennas, and the transmitters were not
powerful enough to overcome that disadvantage.
The workers who were trying to keep track of the progress of the
fire could not find out where the fire was, how intense it was,
which way it was moving, what structures it had engulfed; often
they could not tell which engine it was that had just reported
something like "The fire is coming over the hill."
2. communication among Fire Departments
A. Dispatchers at the Oakland Fire Department Center had no
Standard Operating Procedures to follow in order to
request Mutual Aid. They had not been trained in
mobilization and movement of mutual-aid units, and they
had no recognized authority to command the movements of
such units. They were not familiar with air-operations
terminology, resource-status record-keeping, and tracking
designations.
B. Mutual Aid from Berkeley was delayed because the Berkeley
fire dispatchers assumed early on that Oakland was
handling "Oakland's fire." The fact that Berkeley did
not receive an early and immediate direct request for
assistance from Oakland had a lot to do with the flooding
of the Oakland Fire Department communication frequencies,
and contributed to Oakland Fire Department dispatch
problems.
3.
communications with the pUblic
A. Once the public became aware of the fire, people began an
onslaught of phone calls to the Oakland Fire Department.
In a very short period, the phone lines (both incoming
and outgoing) reached gridlock. Because of this gridlock
and the fact that there were few dedicated outside lines,
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vital calls to other emergency agencies were severely
hampered.
B. The rapid and confusing spread of the fire left firemen
little time to evacuate citizens. Both police and
firemen were hampered by lack of information as to just
where citizens should be directed to go. This was due
primarily. to the poor communication and to the rapid
spread of the fire.
C. This same lack of information was often a problem when
the media were left to gather facts from a variety of
sources rather than a central source. Misinformation was
often relayed as to the path and location of the fire,
causing citizens to fear for their friends and family, or
to delay evacuation thinking that they were safe.
INCIDENT COMMAND SYSTEM
The Incident Command System (lCS) in place at the time of the fire
was severely compromised. This system is designed to provide
specific organizational and command procedures to be followed in
the event of a crisis, and during the course of daily fire-fighting
activities.
The ICS was never able to function at its full capability on
october 20, 1991, because of the communications breakdown. Command
was difficult to establish, and control was often impossible. The
Oakland Fire Department mobile command van fell back three times in
the face of the swiftly moving fire, further complicating the field
and command officers' struggle to gain information and to direct
the efforts of the firefighters.
continually arriving mutual-aid units added more layers of command
personnel needing information and direction. It soon became
evident that the ICS plans were not adequate.
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MUTUAL AID
Mutual aid is required by state law. However, the Oakland and
Berkeley Fire Departments did not have mutual aid agreements for
contiguous areas. Citizens who called the Berkeley Fire Department
were told that "the fire is in Oakland." A coordinated mutual aid
response did not exist.
Firefighters and volunteers responded, often heroically, but lacked
overall coordination that an operational mutual-aid training
program might have provided.
As a result of the earthquake in 1989, emergency plans were in
place; yet during many months preceding the fire, training within
the Oakland Fire Department had dropped sUbstantially, as had
mutual aid exercises. Additionally, training in wildland fire-
fighting was sketchy, and departmental equipment was not complete.
EMERGENCY BROADCAST SYSTEM
The Emergency Broa~cast System (EBS) was established by the Federal
Communications Commission (FCC) in response to a perceived need to
inform citizens in the event of foreign attack. A secondary role
for EBS was developed to inform citizens of local emergericies. All
radio stations (AM and FM) are required by regulation of the FCC,
to take part in the system. However, the FCC does not require that
local broadcasters participate by making air time available. When
a local disaster occurs participation is voluntary.
Neither the local pOlice departments nor the Oakland Fire
Department tried to use the EBS during the firestorm, October 20,
1991. As the fire rapidly spread there was little opportunity to
issue a general warning or an evacuation order. The failure to use
the EBS was a result of the structure of the system, not of the
local government officials who had the responsibility to use the
system. Moreover, layers of bureaucracy inhibit swift use of the
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EBS in a local emergency.
WATER SUPPLY
The Berkeley/Oakland hills area has enough water-tank capacity to
extinguish several simultaneous house fires. The ability to
replenish the tanks is restricted by pumping capacity. The
delivery of the water from the tanks is by gravity, and varies from
area to area depending on the size of pipes and pressure within the
system.
During the Oakland Tunnel Fire, the water supply was not enough to
extinguish the hundreds of simultaneous house-fires, and was
hopelessly inadequate for the added burden of the forest fire. The
fire destroyed the electrical connections serving the pumping
systems for several tanks. The tanks therefore were not refilled.
During the fire several areas lacked adequate pressure. EBMUD has
corrected many deficiencies and has reported the changes to the
public. A state law now requires that all hose connections be
standard; EBMUD is complying with this law.
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Findings and Recommendations:
1. Other issues remain that the Grand Jury believes need to be
addressed by the citizens of the communities, local governments,
and public safety agencies. For instance, streets in the fire area
are likely to remain too narrow and too easily obstructed.
The recommendations must be supported by budget allocations made by
local jurisdictions. The community at large must share the
responsibility for its own safety and must be willing to raise
revenue to accomplish this result.
RECOMMENDATION #93-5: That all local jurisdictions within Alameda
County allocate and commit sufficient resources to ensure that the
necessary personnel, equipment, and training are in place and ready
to respond to future disasters.
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2. The standards of the National Fire Protection Association
require that Oakland have at least 500 firefighters, and that
Berkeley have at least 135. They now have 477 and 122.
RECOMMENDATION #93-6: That Oakland hir~ twenty-four additional
firefighters and Berkeley hire thirteen additional firefighters.
3. Emergency plans are required by statute to be formulated to
handle contingencies. These plans are not always kept up to date.
Also there must be training to provide a thorough understanding of
plans and of individual responsibilities of all public employees.
RECOMMENDATION #93-7: That all Offices of Emergency services
suggest and require emergency plan updates and regularly scheduled
training for all Government employees.
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4. The failure of the communications network used by the Oakland
Fire Department and the Berkeley Fire Department contributed
significantly to the chaos of the situation on October 20, 1991.
In addition, dispatchers were unfamiliar with terminology that
would translate orders from the field command to timely responses
by base personnel.
RECOMMENDATION #93-8: That training of all personnel in the newly
established 800KHZ system be given priority, and that all
juris'diotions establish regular training exercises in communicating
with all agencies involved in an emergency response.
CONCLUSIONS
This was not the first catastrophic fire in the East Bay hills. In
recent years several agencies have issued cautionary proposals and
, have urged measures for preventing such disaster. In particular,
the report of the Blue Ribbon Fire Prevention Committee -in 19821-
points out the danger of allowing fuel to build up under trees,
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in vacant lots, and especially on hillsides and in ravines.
Proposition 13, adopted in 1978, has severely limited the ability
of fire departments and other public agencies to carry out the
recommended preventive measure. The public has paid a high price
for this limitation of funds. The Oakland Tunnel Fire of 1991.
destroyed 31354 residences and killed twenty-five citizens of the
Bay Area, and cost at least $1,500,0001000. It is clear that the
present leadership is very much aware of the lessons and the
mistakes of the past. The challenge for the future is to make
certain that this present awareness by the leadership group is not
diminished in any way, but kept alive and sharpened in the years to
come.
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August 9, 1993
Honorable Joseph J. Carson
Presiding Judge of the Superior Court
Alameda County
1401 Lakeside Drive, Suite 1107
Oakland, CA 94612
Honorable Judge Carson:
The City Council of the City of Dublin has reviewed the recommendations
made by the 1992-93 Alameda County Grand Jury pertaining to the City of
Dublin and offers the following responses:
Recommendation #93-5: That all local jurisdictions within Alameda
County allocate and commit sufficient resources to ensure that the
necessary personnel, equipment and training are in place and ready to
respond to future disasters.
The City places a high priority on public safety services. The City of
Dublin jointly operates a local fire agency with the City of San Ramon
through a joint powers authority. It is a goal of the Joint Powers
Authority to improve the disaster response capability of the Fire
Department by replacing equipment at the appropriate time and providing
adequate training for Fire Authority staffing. In response to budgetary
constraints, the City of Dublin and the Fire Authority are working
closely with the cities of Livermore and Pleasanton to improve
coordination and deli very of emergency services to residents of our
respective jurisdictions. The City of Dublin is also working with these
agencies in the development of a Tri-Valley Public Works Mutual Aid
Agreement.
Recommendation #93-7: That all Offices of Emergency Services suggest
and require emergency plan updates and regularly scheduled training for
all government employees.
The City of Dublin has a comprehensive emergency operating plan. The
City will be revising and updating this plan during Fiscal Year 1993-94.
The City also recently completed an Emergency Management Training
Program offered through the International City Management Association
for all Management Personnel. The City plans to continue the training
program this year for other City personnel. The City also completed its
annual table top disaster exercise in early 1993. In addition to the
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above in-house training, the City annually sends personnel to disaster
training programs offered by the state of California.
Recommendation #93-8: That training of all personnel in the newly
established 800 MHZ System be given priority, and that all jurisdictions
establish regular training exercises in communicating with all agencies
involved in an emergency response.
Alameda County has not fully implemented the 800 MHZ System for public
safety services at this time. Since, the City of Dublin contracts with
Alameda County for Police and Dispatch Services, police service
personnel will be trained at such time that the new radio system becomes
operational. With respect, to Fire Service, our Fire Joint Powers
Authority is currently reviewing various 800 MHZ communication options.
I hope this letter adequately responds to your recommendations.
Sincerely,
Peter W. Snyder
Mayor
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