BY CHARLES J. KORTLANG
One of those "routine" incidents-a fire in the kitchen of a bakery on March 31, 1999-shocked the City of Mount Vernon (NY) Fire Department into a rude awakening. Although no deaths or serious injuries occurred, the experience, nevertheless, had a significant impact on the department. Immediately after the incident, the chief of operations requested an investigation. In conducting this investigation, I kept in mind the following quote from U.S. Army General George C. Marshall: "Fix the problem, not the blame."
To determine what needed to be fixed, we developed an investigation plan. Phase 1 would entail documenting the entire building, focusing especially on the occupancy involved in the fire. Phase 2 would include interviewing every member present at the incident and reviewing all pertinent department Official Action Guides (OAGs). During Phase 3, the information gathered would be analyzed, to define a course of action that would help us avoid repeating what went wrong at this incident.
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