The report: an overview

Immediately following the incident, Johnson established a significant incident team (SIT) that was led by Chief Thomas Coe of neighboring Frederick County, MD, Division of Fire & Rescue Services. The SIT consisted of 14 internal and external stakeholders and subject matter experts. They were to gather all information on the incident and identify both strengths and weaknesses in adherence to local and regional operational protocols. The report contains a comprehensive review and analysis of factors, actions and other items surrounding this incident and recommendations that are aimed at enhancing future response efforts.

Areas of concern

“Key indicators were ignored” during the initial assessment of the incident, compromising the safety of firefighters. Firefighters were caught off guard when the leak led to an explosion.

Unit officers didn’t immediately evacuate the area despite elevated gas readings from atmospheric monitors. Following the incident, personnel recalled thinking that the lower explosive limits were very high and that they shouldn’t have been in or around the structure, the report notes. “Specifically, the atmospheric monitoring devices were alarming with elevated readings, and the levels did not seem consistent with the conditions. Members provided varying reports on the presence of a gas odor.”

The incident commander (IC) was unaware initially that two firefighters entered the home to search for an occupant in the basement, and there was a “clear struggle to establish and maintain accountability of on-scene personnel.”

During the search, checks weren’t made on the location of other firefighters. The gravity of this fact is amplified by the post-incident discovery that two separate members were at one point partially submerged in the in-ground pool.

The failure to initially establish accountability and document the location of the members who were operating on scene was compounded by the lack of an initially organized command structure and the failure of units on the second and later alarms to establish and report to staging on arrival.

It’s important to note that the responding battalion chief who became the IC of this event arrived post-explosion, finding a house that exploded, one deceased firefighter and nine others injured, two of whom were trapped and calling maydays.

There were multiple communications problems. These included the mobile data computers continually refreshing, so firefighters were unable to read what was on the screens. Cross-jurisdictional CAD wasn’t fully available to automatic-aid responders, and some responding units missed the initial maydays and were trying to piece together the incident via radio traffic in real time.

A lack of command and control after firefighters were released from the scene to a central meeting place for a behavioral health assessment by Loudoun’s behavioral health clinicians and peer support team caused many of them to become “confused, angry and frustrated.”

The report recommended that a senior officer be assigned to coordinate the task of finding a meeting place after a serious incident.

The report praised firefighters for their “unwavering courage and resilience” but noted that there was a need for “continuous improvement” in communication, emergency response protocols and training to reduce risk. This applies to any department.

Incident/report overview

Risk assessment . Key indicators weren’t understood fully during the initial and ongoing size-ups, which compromised the safety of on-scene personnel.

Event escalation . The incident escalated from a routine outside gas leak call to a catastrophic explosion, which caught responders off guard.

Communication challenges . There were delays in relaying critical information and confusion regarding mayday calls, which affected the effectiveness of response efforts.

Resource allocation . There were issues with resource allocation and coordination, particularly in regard to ensuring an adequate water supply and managing the rescue operation of trapped personnel.

Command structure . The command structure faced challenges in managing the complex and rapidly evolving situation, which led to difficulties in coordinating rescue efforts and patient treatment/transport and in ensuring scene accountability.

Training . LC-CFRS requires firefighter mayday training as part of the Firefighter I and Firefighter II curriculum. Each of the trapped members credited this training to their life being saved. Prior to the incident, telecommunicators from the LCFR Emergency Communications Center (LCFR-ECC) participated in mayday training that helped to prepare them for the intricacies that are involved in firefighter rescue operations.

LCFR-ECC management and coordination . The LCFR-ECC staff worked diligently to manage and track radio communications throughout the incident and ensured that the IC was provided with the information in a timely manner.

Technical rescue expertise . Two technical rescue units, one from Loudoun County’s Kincora Station and the other from Fairfax County’s North Point Station, arrived quickly and used their extensive training to rapidly develop a victim removal plan and executed that plan in a coordinated effort.

The findings apply to every firefighter, officer, chief and department, everywhere.

Comments from Goldfeder

The report certainly underscores the need for continuous improvement in policy and protocols, training and communication strategies to manage risks and enhance the safety of responders and the survivability of civilians in everything from “daily” incidents to those of this caliber—which grow from “daily.” This applies to every fire service organization, and it’s incumbent upon leadership to use this report as a template for their agency.

When discussing this incident, it made me remember a few decades ago when “incident command” was starting to show its value. Many were reluctant or even criticized the need for a command structure on seemingly minor incidents The report—and this incident—demonstrates the critical need for command to be established on every incident, so if/when needed, it can be built upon. It also highlights the consideration that command might be “working”—and not in a “fixed” position, such as a company officer—when things take a terrible turn.

“We must continue to learn from past incidents to continue to support our fire and EMS personnel, provide for the health and well-being of our firefighters, and support legislative initiatives that improve the safety of our profession,” Johnson states.

Involuntary manslaughter

In October 2024, according to multiple news reports, a former Southern States Cooperative service technician, Roger Lee Bentley, was charged with felony involuntary manslaughter and unlawful transfer of hazardous material, unlawful release of hazardous material, failure to maintain required records of hazardous materials release and failure to control or mitigate unauthorized discharge of hazardous materials, which are misdemeanors.

One news report also indicated that Southern States first became aware of problems with the tank in 2021. Bentley’s trial has been scheduled to begin July 7, 2025.