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Final report into death of Firefighter Scott Deem calls for changes with fire department

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A detailed report by state investigators made eleven recommendations for changes within the San Antonio Fire Department following the deadly fire that took the life of Firefighter Scott Deem. (Scroll down to read the full report)

The report was released on the same day that Emond Johnson was scheduled to appear in court on charges of murder, arson and bodily injury. He is accused of starting the massive fire last May.

Johnson owned The Spartan Box, where Deem lost his life and where state investigators would later find the fire's point of origin.

According to the report, the fire at the Ingram Square shopping center was first reported at 9:12 p.m. on May 18, 2017 by a passerby.

Five minutes later, SAFD Ladder 35, Deem's unit, arrived and the captain alerted dispatch to keep sending more companies and that a second alarm may be needed.

At some point, the report states Deem and another firefighter made forcible entry through the gym doors. Deem and Firefighter Brad Phipps were then assigned to search the gym, doing so through heavy smoke and low visibility.

About ten minutes after arriving on the scene, a 'mayday' call went out. Phipps and Deem tried to get out of the gym, but were "overcome by the fire and became separated."

It would be nine minutes before crews could rescue Phipps. It would take two hours before Deem's body could be recovered.

The report also provides a detailed, and at times scathing, review of the San Antonio Fire Department's procedures and culture.

Perhaps the most critical of the findings includes a call for a change in culture at the San Antonio Fire Department.

The report states, " While San Antonio Fire Department has many good policies and procedures in place, pockets of members remain who are resistant to change." While not directly related to the incident that claimed Deem's life, the report offers several safety initiatives to encourage the SAFD to closely look at how it handles and responds to firefighter injuries and deaths.

Also among the findings was that firefighters at the scene took actions outside of their assignment without informing Command. The report refers to the practice as "freelancing." "Essentially, it is firefighters doing what they want to do, when they want to do it," the report states. The report adds that the practice can compromise a firefighter's safety and the team's integrity. The report recommended that freelancing among firefighters be handled by superiors through training or discipline.

Other findings include the treatment of the shopping center fire as though it were a house fire, and the decision to search the gym when it appeared it was closed; the doors were locked and the lights were off.

The report also revealed The Spartan Box and a computer repair store, two of the businesses involved in the fire, did not have approved inspections, adding that the gym had recently failed a fire inspection. Neither business had a valid Certificate of Occupancy with the city.

Among the recommendations of the report:

  • Match fire suppression tactics to the structure and conditions
  • Ensure proper ventilation and PPV fan usage
  • Incident Command and Risk Management
  • Prevent freelancing
  • Improve accountability
  • Evaluate and train on Mayday procedures
  • Ensure pre-fire plans are in place
  • Conduct fire code inspections of all commercial buildings using a risk analysis approach
  • Provide easy access to current versions of SOPs/SOGs
  • Adopt “cultural change” with a greater emphasis on firefighter accountability and safety
  • Follow recommended Practice for Fire Service Training Reports and Records



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