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With a safety incident unfolding, sometimes there has to be a split second decision and in the case of the West Fertilizer Co. in West, Texas, the 12 firefighters who died battling a blaze were unprepared for the ferocity of the fire and should have focused on evacuating the area rather than extinguishing the flames, said a report released Thursday.

The line-of-duty report from the Texas State Fire Marshal’s Office examined the deaths of a dozen first responders and concluded the West volunteer fire department attacked a fire at the plant “that was significantly beyond the extinguishment stage” using small hose lines and a limited water supply.

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The primary focus should have been evacuation not engaging the fire, the agency said.

The April 17, 2013, incident at West Fertilizer Co., which had operated for more than 50 years in a residential part of town, killed three residents in addition to the firefighters and caused damage estimated at $100 million.

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The cause of the fire remains unknown but the source of the explosion it sparked was ammonium nitrate stored in a wooden container at the plant, investigators said. The ammonium nitrate detonated with the force of approximately 15,000 to 20,000 pounds of TNT, according to federal officials.

“The fire department did not approach this fire as a commercial structure with hazardous materials, but rather initiated residential structural firefighting practices, with which they were familiar,” the report said.

The fire marshal’s office said it is not placing blame on the first responders, but recommended that Texas require more extensive training and planning by agencies at all levels in response to incidents like the explosion.

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