The 115-page report into the cause and aftermath of burns sustained by a Sedona Fire District firefighter was released this week and shows human error was a contributing factor.

The report centers on an incident that took place Oct. 27 at Station 5 in Oak Creek Canyon. A barbecue propane tank exploded, injuring Capt. Matt Fleece and causing damage to the exterior of the fire station.

“I see it as a freak accident that a number of people could have prevented had they known what the lack of a heat shield and tank stored underneath the barbecue could have done,” Asst. Chief Jeff Piechura. “The report does a really good job of showing how we got to that point through the chain of events.

It also offers us some good recommendations as to how to prevent this in the future — findings we plan to share with others.”

According to the report, at around 6:30 p.m., Fleece placed 10 to 12 burgers on the barbecue grill. At 6:38 p.m. crews were dispatched to a call on Jordan Road. The grill was not turned off and remained burning until the crew returned to the station at approximately 8:18 p.m.

After returning to the station, Fleece retrieved 10 to 12 additional burgers from the freezer, cleaned the burned remains of the previous burgers off the grill and put the new ones on to cook. After all the burgers had finished cooking, he turned off the grill and began to move toward the door into the station with the burgers.

He then noticed a glow in the cabinet beneath the cooking surface of the grill. Fleece placed the tray with burgers on the side of the grill. He then opened the cabinet, saw flames on the propane tank and immediately closed the cabinet. After a few seconds, he opened the cabinet and reached in to remove the tank. During the process of removing the tank, the gases venting from the pressure relief valve ignited and enveloped Fleece in fire.

He dropped the tank and exited the area, making his way to the front of the station where he met with the Engineer Mike Pace. Pace extinguished the fire while Fleece called 911.

Fleece’s injuries included burns to 12 percent of his body, primarily both hands and forearms, and a foot fracture. After three weeks of inpatient treatment at Maricopa Medical Burn Unit, he returned home to continue rehabilitation and outpatient care, which is ongoing. He’s expected to return to work for light duty in March.

The report includes the following as contributing factors to the incident:

• The grease drip tray, which also serves as a heat shield, was not installed. The grill had been moved from Station 1 to Station 5 on Oct. 24. However, the grease drip/heat shield was left at Station 1. This issue was known to the captain and the engineer at Station 5 and they had discussed the need to retrieve it from Station 1 prior to the event and it was discussed between crews at shift change.
• When the grill was installed at Station 5, it was hard-plumbed into the LPG system. The five-gallon propane tank no longer used to fuel the grill was left in the cabinet beneath the grill.
• The grill was turned on prior to the commercial assignment dispatch, which occurred at 6:38 p.m. and remained on until approximately 8:30 p.m.
• The foodstuff normally caught in the grease drip tray had dripped onto the tank and was burning. This provided an ignition source.

“The events that occurred on Oct. 27, 2016, have had a significant impact to SFD as a whole and life-changing impacts to one of our veteran members,” the report states. “The need to take lessons-learned opportunities to reduce potential future opportunities is critical. While the impacts of this event are difficult to truly assign a dollar amount, the reality is the damage to Fire Station 5 is in excess of $50,000. The bulk of that is being covered by insurance.

“The injuries to the SFD employee who spent over three weeks in the burn unit, as well as significant outpatient rehab post discharge, will be very expensive, and are primarily covered by our workers compensation carrier, which means in the end, SFD and future budgets will be impacted by annual renewal increases.”