More than a year after the deadly Marco Polo blaze, KHON2 has obtained the fire department’s internal review.

The document is called an “after action review,” and it shows that while a few changes have been made, significant disputes linger about what should be done to better prepare for high rise fires. 

In July 2017, a fast-moving fire spread through upper floors of the Marco Polo building. More than 100 firefighters battled the flames. Many residents were rescued, but four perished. 

“You can train and you can train and you can train and we do,” said Capt. Scot Seguirant, Honolulu Fire Department spokesperson, “but you never know until it happens. We’re not happy with the results. We lost four people and we’re very unhappy about that, but I know it could have been worse.”

Just what happened that day, and what could have been done better, is the topic of an after-action review that the department last year told the Honolulu Fire Commission would be a key follow-up. Just this month, Always Investigating obtained the document. 

In its pages, the incident commander alone is tasked with writing what went well, and what went wrong:
* There were flaws that made the building a death trap in this kind of fire — no sprinklers, louvered and open doors feeding unprotected wind tunnels, broken elevators.
* Firefighters’ own equipment malfunctioned or was insufficient, from radios and batteries, vehicles, air monitoring and decontamination provisions. 
* There were human factors such as delayed initial notification, elevator technicians reluctant to come help, and firefighters self-describing an overwhelming scene where they were shorthanded and inundated by the complex and chaotic situation. 

The incident-command author was a battalion chief who was catapulted into command of one of the largest responses in island history. Out of his more than 70 recommendations, the department responded “disagree” to about half of them.

Oftentimes they’re marked disagree in terms of putting the discretion back on the incident commander who, in this action review, stated time and again how overwhelming it was to add anything more to his plate. Always Investigating pointed this out to HFD and asked for a response.

“That’s true, however, it is the responsibility of the incident commander,” Seguirant said. “So at that point we need to look at if I need more help, I need to ask for more help. Maybe I need to give different assignments to different folks within my staff.”

KHON2 asked: In retrospect, though, isn’t that hard to put on somebody’s shoulders who was facing a monumental task that day? 

“It can be, but as far as changing policy, those things need to actually work for all incidents, not just one specific incident,” Seguirant said. “So I think that’s where some of the disagreement is.”
The union representing firefighters takes issue with that. 

“The incident commander did a hell of a job considering what he was faced with,” said Bobby Lee, president of the Hawaii Fire Fighters Association. “A lot of emphasis for the entire fire is put on that one incident commander, which really looks to be very overwhelming. You have got to be superman to do everything that was done during that day. With the number of companies on scene, 130-plus firefighters, there really should have been more help from the upper-level chiefs.”

For dozens of the items where the incident commander and department do agree to make changes, the higher-ups write back they’ll “follow up” or “review” next steps. 

KHON2 asked HFD, what is the deadline for this and how will responsive action be tracked and reported? 

“There’s no specific timeline,” Seguirant said, “but it’s going to vary depending on how accomplishable those things are, and some of them are more difficult.”

Some action items include getting bigger hoses and nozzles to get more water farther on high rise flames. 

“Those things need to be evaluated and determined,” Seguirant said. “If this is the direction we’re going to go in, what the cost is, what the deployment model is, the training that is need.”

“Something as simple as making sure all the doors are closed, and that’s the actually standard or what’s expected for occupants to do, those things take education as the inspector goes through,” Seguirant explained.

KHON2 asked, has anything specifically changed in high rise responses since Marco Polo? 

“We have added an extra engine company to the initial engine response, no matter what,” Seguirant said.

The department also took swift action advocating for a high-rise sprinkler retrofit law. The mayor signed a measure making every building 10 stories or more get a fire safety evaluation within three years, and they may have to install sprinklers or an alternative. 

HFD is also being much more strict on hazmat issues after frayed and burning asbestos blanketed much of the Marco Polo damage area. 

“We made a big issue of the decontamination when the fire first took place,” Lee said, “and the department did put some effort into creating rules as far as having our guys be more conscientious, and what to do on procedures on how to decon our equipment, which is good.”

In the after-action review, the incident commander calls for a high-rise working group and better procedures specific to tall buildings. The department wrote back “disagree” on that whole section. 

“We need to get a high-rise plan, which unfortunately as far as I know the Honolulu Fire Department does not have,” Lee said. “Pretty much all metropolitan cities have (high-rise procedures), and still after the Marco Polo I don’t believe that they’ve moved in that direction to have one.”

KHON2 asked HFD, does the department have a high-rise specific standard operating procedure? 

“We have what we call a SOG, standard operating guideline,” Seguirant said. 
KHON2 asked, how is that different from putting it in an SOP (standard operating procedure)? 
“The ‘P’ is a procedure, it means it has to be and should be carried out that way. The guideline gives you a little more discretion” Seguirant said.
KHON2 asked, with so many high rises going up, and so many people moving into these situations, is the guideline good enough? 
“I think so,” Seguirant said.”And if it needs to change it will change.” 

The union plans to keep pushing for that, and for a more in-depth review. 

“I’ve seen other after-action reports that have gone into hundreds of pages,” Lee said. “It was pretty disappointing, it wasn’t even close to what we expected to see from them after waiting over a year. At this point in time, we are in communication with our international union and they are working with us to try to secure funding to bring in an independent third party entity to do a very comprehensive study of the Marco Polo.”

KHON2 asked HFD, is this after-action review complete or is it still being worked on? 

“I think the actual report is complete,” Seguirant said. “Timelines, how things are going to be actually implemented, those things are still being addressed and will continue to be addressed.”