Death in the line of duty Fighter Fatality Investigation and Prevention Program

Fire Fighter Fatality Investigation and Prevention Program

D eath in the line o f du ty...

Two Fire Fighters Die and Two Are Injured in Townhouse Fire—District ofColumbia

The Fire Fighter Fatality Investigation and PreventionProgram is conducted by the National Institute forOccupational Safety and Health (NIOSH). The purpose ofthe program is to determine factors that cause or contributeto fire fighter deaths suffered in the line of duty.Identification of causal and contributing factors enableresearchers and safety specialists to develop strategies forpreventing future similar incidents. To request additionalcopies of this report (specify the case number shown in theshield above), other fatality investigation reports, orfurther information, visit the Program Website at:

http://www.cdc.gov/niosh/firehome.html

or call toll free 1-800-35-NIOSH

SUMMARYOn May 30, 1999, fire fighters responded to a boxalarm involving a townhouse fire. The initial report camein as a house fire, and it was later reported that the firewas in the basement (all fire fighters did not receive thefollow-up report of fire in the basement). Engine 26(Lieutenant and 3 fire fighters) was the first to arrive onthe scene and reported smoke showing on the front(side 1) of a row of townhouses (see Diagram 1). Afire fighter (Victim #1) from Engine 26 advanced a 1½-inch attack line through the front door (1st floor). Soonafter, the layout man from Engine 26 entered to backup Victim #1. Engine 17 (Lieutenant and 3 fire fighters)arrived shortly after and stretched a 350-foot 1½-inchhose line to the rear (side 3) (see Diagram 1). Truck 15(Captain and 3 fire fighters) arrived on the scene andbegan ventilation on the front. Truck 4 (Lieutenant and3 fire fighters), responding for Truck 13 (out of service),arrived later and began ventilation in the rear. Engine10 (Lieutenant, Victim #2, and 2 fire fighters) arrivedon the scene as the third-due engine and backed upEngine 26 on side 1. Engine 12 arrived as the fourth-due engine and proceeded to side 1 of the building.Battalion Chief 1 (the Incident Commander [IC]) and

Rescue 1 (Lieutenant and 4 fire fighters) also respondedas a part of the box alarm.

Engine 26 and Engine 10 advanced their lines throughthe front door in a search for the fire and the basementdoor (at the top of the basement steps). As the twocrews searched, Truck 4 made forcible entry througha sliding-glass door in the rear (basement entrancedoor at ground level). Engine 17 (at the basementdoor with a charged line) reported to the IC thatthey were on the first floor, in the rear, with a smallfire showing (Engine 17 was actually at the basementlevel). Engine 17 radioed the IC for permission toopen their line and knock down the fire. Knowingthat he had two engine crews on the first floor in thefront, the IC denied Engine 17’s request until he couldlocate the interior crews’ positions. He radioed theofficer from Engine 26 several times for their position,but received no response.

Engine 17 asked a second time for permission to hitthe fire, as it began to grow. The IC denied therequest a second time and again tried unsuccessfully

F-21

November 23, 1999A Summary of a NIOSH fire fighter fatality investigation

Basement entrance

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Two Fire Fighters Die and Two Are Injured in Town House Fire—District of Columbia

Investigative Report #99F-21Fatality Assessment and Control Evaluation


to radio the officer from Engine 26. Conditions inthe interior rapidly deteriorated, forcing the firefighters on the first floor to search for an exit. A firefighter in the interior recalled seeing fire appear froma doorway on the first floor. After seeing the fire, thefire fighter stated that everything went black and hefelt an intense blast of heat. Victim #1 and Victim #2were unable to escape, while the Lieutenant and afire fighter from Engine 26 escaped with severeburns. All injured fire fighters were transported to alocal hospital. The Lieutenant and fire fighter wereadmitted with burn injuries. Victim #1 was treatedfor severe burns and was pronounced dead thefollowing day. Victim #2 was pronounced dead onarrival at the hospital.

NIOSH investigators concluded that, to minimize therisk of similar incidents, fire departments should:

• ensure that the department’s StandardOperating Procedures (SOPs) are followedand refresher training is provided

• provide the Incident Commander with aCommand Aide

• ensure that fire fighters from the ventilationcrew and the attack crew coordinate theirefforts

• ensure that when a piece of equipment is takenout of service, appropriate back up equipmentis identified and readily available

• ensure that personnel equipped with a radioposition the radio to receive and respond toradio transmissions

• consider using a radio communicationsystem that is equipped with an emergencysignal button, is reliable, and does notproduce interference

• ensure that all companies responding areaware of any follow-up reports fromdispatch

• ensure that a Rapid Intervention Team isestablished and in position immediatelyupon arrival

• ensure that any hose line taken into thestructure remains inside until all crews haveexited

• consider providing all fire fighters with aPersonal Alert Safety System (PASS)integrated into their Self-ContainedBreathing Apparatus (SCBA)

• develop and implement a preventivemaintenance program to ensure that allSCBAs are adequately maintained.

INTRODUCTIONOn May 30, 1999, two fire fighters died and twowere injured while battling a townhouse basementfire. Two fire fighters—Victim #1, a 30-year-oldnozzleman from Engine 26, and Victim #2, a 29-year-old nozzleman from Engine 10—had to berescued when interior crews were hit by an intenseblast of heat and flames. Victim #1 was rescued andtransported to a nearby hospital where he waspronounced dead the following day. Victim #2 wasrescued and pronounced dead on arrival at thehospital.

On June 1, 1999, the International Association ofFire Fighters notified NIOSH of the incident, and onJune 21, 1999, a Safety and Occupational HealthSpecialist, the Senior Investigator, and the TeamLeader of the NIOSH Fire Fighter FatalityInvestigation and Prevention Program, initiallyinvestigated this incident. On July 21, 1999, aSafety and Occupational Health Specialist and a

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Safety Engineer conducted additional interviews. AnEngineer and a Physical Scientist from NIOSH alsocompleted an evaluation of the department’s SCBAmaintenance program on July 21, 1999. On August31, 1999, a Safety and Occupational HealthSpecialist returned to interview the seriously injuredfire fighter. Meetings and interviews were conductedwith: the Chief, the Assistant Chief, the two BattalionChiefs on the scene (one of whom was the IncidentCommander), fire fighters on the box alarm, thedepartment safety officer, and the investigation teamfrom the fire department involved in the incident.Representatives from the personal protectiveequipment manufacturer, the National Institute ofStandards and Technology (NIST) who evaluatedthe victims’ personal protective equipment and willbe developing the fire growth data for thedepartment, the metropolitan police, and the ownerof the townhouse were also interviewed. Copies ofphotographs, training records, Standard OperatingProcedures (SOPs), the reports completed by firedepartment investigators, the autopsy reports, andthe floor plan of the townhouse were obtained. Asite visit was conducted and photographs of the firescene were taken.

The fire department involved in this incident iscomprised of 1,764 total employees, of whom 1,182are uniformed fire fighters. The department serves apopulation of approximately 1 million in a geographicarea of 69 square miles. The fire department requiresall new fire fighters to complete fire fighter level Iand fire fighter level II requirements, EmergencyMedical Technician courses, hazmat, driver andvehicle operations, first aid, search and rescue, livefire training, and cardiopulmonary resuscitation(CPR). Fire fighters are then assigned to adepartment where they are placed on probation for1 year. Each fire fighter is also certified as anEmergency Medical Technician (EMT). Refreshertraining courses are continued throughout the year.The victims’ training records were reviewed and

appeared to be adequate. Victim #1 had 6½ yearsof experience as a fire fighter and EMT, while Victim#2 had 3½ years of experience as a fire fighter andEMT.

Additional companies responded to this incident;however, only those directly involved are included inthis report.

INVESTIGATIONOn May 30, 1999, at 0017 hours, Central Dispatchreceived a call of a house fire. Dispatch toned out abox alarm which consisted of the following:

• 1st due Engine 26 (Lieutenant and 3 fire fighters[including Victim #1])

• 2nd due Engine 17 (Captain and 3 fire fighters)

• 3rd due Engine 10 (Lieutenant and 3 fire fighters[including Victim #2])

• 4th due Engine 12 (Lieutenant and 3 fire fighters)

• 1st due Truck 15 (Captain and 3 fire fighters)

• 2nd due Truck 4 (Lieutenant and 3 fire fighters)

• Rescue 1 (Lieutenant and 4 fire fighters)

• Battalion Chief 1 (the Incident Commander)(BC-1)

The working fire alarm was dispatched at 0023 hoursand consisted of the following:

• Engine 14 (Sergeant and 3 fire fighters)

• Chief 2

• Air 2 (1 fire fighter)

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• Fire Investigation Unit (Car 43) (fire investigator)

• Alcohol Tobacco and Firearms (ATF) (Car 83)

• Medic 17 (2 paramedics)

• Department Safety Officer

The Hazmat Unit was also dispatched at the sametime as the working fire alarm.

At 0029 hours, a task force alarm was toned withthe following response:

• Engine 6 (Lieutenant and 3 fire fighters)

• Engine 4 (Lieutenant and 3 fire fighters)

• Truck 7 (Lieutenant and 3 fire fighters)

• Battalion Chief 4

As companies responded to the call of a house fire,dispatch made a second report that the fire was inthe basement. During the investigation, it becameclear that all companies did not receive the secondreport of a basement fire. Engine 26 was first toarrive on the scene at 0023 hours and reportedsmoke showing from the front of the building. Beingthe first-due engine, they positioned the engine in thesmall parking area in front of the row of townhouses(see Diagram 1). Engine 10 arrived behind Engine26 as the third-due engine company and stretched a400-foot, 1½-inch line to the front entrance (seePhoto 1). Engine 17 was the second-due enginecompany, also arriving at 0023 hours. Upon arrival,Engine 17 stretched a 350-foot, 1½ -inch line aroundthe adjacent units (see Diagram 1) to the rear of theburning townhouse. Arriving at 0024 hours wasEngine 12, as the fourth-due engine company, whichby department Standard Operating Procedures(SOPs), required them to back up Engine 17 in the

rear. Instead of backing up Engine 17, the crew ofEngine 12 went to the front. The IC (BC-1) was enroute to the scene, and from the report he receivedfrom Engine 26, he requested a working-fire dispatch.The working-fire alarm dispatched Engine 14,Battalion Chief 2 (BC-2), Air 2, Fire InvestigationUnit (Car 43), the Alcohol Tobacco and Firearms(ATF) unit (Car 83), Medic 17, and the department’sSafety Officer. The Hazmat Unit was also dispatchedat the same time. The IC ordered BC-2 to takecommand of the rear when he arrived on the scene.

The front door of the townhouse was open andemitting thick, black smoke. With a charged line, afire fighter from Engine 26 (Victim #1) approachedthe front door, as his layout man and officer donnedtheir SCBAs. Preparing to enter, Victim #1experienced a problem with his SCBA facepiece.He returned to the engine and switched facepieceswith his Wagon Driver. After switching facepieces,he told his officer at the front door that everythingwas working properly and he was taking in a line.With a charged line, he entered through the front door.Shortly after, the layout man entered, followed theline, and met the fire fighter (Victim #1). The officerof Engine 26 entered last and proceeded into thestructure to locate his crew. With a charged line, afire fighter (Victim #2) and the Lieutenant from Engine10 entered behind the officer from Engine 26 toprovide back up. The layout man from Engine 10was ordered by his Lieutenant to stay at the frontdoor and feed the line inside.

Truck 15 arrived on scene at 0024 hours as the first-due truck company, and started ventilation in the frontaccording to department SOP requirements. Theofficer and a fire fighter on Truck 15 threw a ladderto the roof and the officer began to ventilate the largefront window at ground level. Security bars wereblocking the window, so a fire fighter from Truck 15entered the structure, approximately 10 feet into thekitchen area, to vent the window from the interior.

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The fire fighter then exited the structure (see Floor PlanA-1). Next, the officer from Truck 15 climbed theladder and stopped at a window on the second floor toknock it out. After knocking out the window, he returnedto the ground as the driver and Tillerman from Truck 15climbed the ladder to the roof. The two of them cutapproximately three vent holes in the roof and statedthat thick, black smoke was emitting from the holes.Truck 4 arrived at 0025 hours as the second-due truckcompany and began ventilation in the rear of thestructure. [NOTE: Truck 4 was responding for Truck13, which was out of service at the time of thisincident. Truck 13 was housed in the same stationas Engine 10 and would have arrived on the sceneat the same time as Engine 10 (approximately 2minutes earlier) if it had been in service.] On arrival,a fire fighter and the officer from Truck 4 began forcibleentry to the rear basement sliding-glass door (whichwas protected by an iron security gate (see photo 2))as the driver and the Tillerman from Truck 4 threwladders to the windows above the door (see Floor PlanA-2). The fire fighters stated that they saw small spotfires all over the basement floor. The driver and theTillerman tried to knock out the windows on the secondfloor, but felt they were unsuccessful because they couldnot feel the ladders breaking the glass. They also triedto break the sliding-glass door on the first floor with theladder, but could not. [NOTE: The windows on thesecond floor were left open by the homeowner,which is why the fire fighters could not feel the glassbreak. The sliding-glass door on the first floor wasa two-panel sliding-glass door, which fire fighterscould not break with the ladder they were using.The sliding-glass door on the first floor had nosecurity gate over it.] The driver and Tillerman fromTruck 4 left the ladder at the window on the secondfloor and returned to the truck to get a second ladder togo to the roof.

Engine 17 was now positioned at the rear sliding-glass door as Truck 4 prepared entry (basementlevel). Using a gas-powered saw and a sledge

hammer, the officer and fire fighter from Truck 4removed the iron security gate and broke open theglass door at 0026 hours (see Photo 2). Membersof Truck 4 and Engine 17 stated that when the sliding-glass door was opened, air began to be sucked insideby the fire. They also saw small fires on the floorand stated that when the door was opened the firesgrew larger. The Lieutenant from Engine 17 reportedto the IC that they had fire on the first floor andrequested permission to hit the fire. [NOTE: Engine17 was unaware that they were at the basementlevel due to the route they took to get to the rear.As they proceeded to the rear, they noticed therow houses they went between were only twostories, which caused confusion (see Diagram 1).]The IC denied their request in fear of opposing hoselines. He then radioed the officer from Engine 26 tolocate their position. He received no response fromthem. The IC knew that the crews from Engine 26and Engine 10 had entered through the front dooron the first floor.

Rescue 1 arrived on the scene at approximately thesame time that Truck 4 made entry. They wererequired to complete search and rescue operations.Two fire fighters from Rescue 1 and a fire fighterfrom Truck 4 entered the basement to search theinterior for any civilians. Shortly after they entered,the Lieutenant from Engine 17 ordered them out asconditions began to deteriorate. One of the firefighters who exited stated that they were able tofollow a small path (limited fire) to the exterior beforethe entire basement erupted into flames.

The driver and Tillerman from Truck 4, who returnedto the truck to retrieve a second ladder, saw that thebasement was fully engulfed with fire. They decidedto pull a line from Engine 12 to provide back up forEngine 17. Engine 12 was supplying Engine 17 andhad positioned their engine towards the rear of thestructure, but Engine 12’s crew proceeded to thefront of the structure (see Diagram 1). The officer

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and a fire fighter from Engine 12 entered the front ofthe structure advancing approximately 2 to 3 feet,where they remained throughout the attack. TheLieutenant from Engine 17 requested to hit the fire asecond time and was denied. The IC denied theirrequest because he still had not received a responsefrom the officer of Engine 26. The IC radioed theofficer of Engine 26 a second time and received noresponse.

At this point Engine 26 and Engine 10 were insidethe structure searching for the basement door.Department SOPs required them to locate thebasement door and close it or hold off at the stairswith a fog spray. The fire fighter on Engine 26, whoentered the structure to back up the Nozzleman(Victim #1) stated that it was extremely hot, buttolerable, when he met up with Victim #1. He statedthat the floor was solid and as they proceeded furtherinto the structure, and visibility was improving. Herecalled seeing the sliding-glass door to the rear ofthe first floor, a table, and a sofa on his right side.This would position Victim #1 and the fire fighter inthe living room, in front of the basement-stairs door(see Floor Plan A-1). He also stated there were nosigns of fire and the heat remained constant. Hecould not recall his officer joining the two fire fighters,but did recall hearing a radio transmission. [NOTE:Only officers carry radios and he did not knowwhose radio he heard.] It was determined thatEngine 10 was inside backing them up at this time,however, the two fire fighters from Engine 26 wereunaware of any other fire fighters inside.

After hearing the radio transmission, the fire fighterfrom Engine 26, backing up Victim #1, looked overhis left shoulder and saw fire appear, filling up whatlooked to be a doorway. He stated the fire cameout of the doorway, then disappeared, and everythingwent black. At that point he felt an intense blast ofheat. He dropped the line and immediately startedsquirming around in his turnouts, in an attempt to

release the heat. He asked Victim #1 where thehose line was and related to him that something waswrong and they had to get out. Victim #1 respondedby saying that he did not know where the hose linewas. The fire fighter stated that Victim #1 soundedas if he was in a crouched position waiting to berescued. He then heard a loud scream from his leftside, which lasted approximately 15 seconds. Thescream was clear and not muffled by an SCBA. Hestated that the scream was getting closer when heheard a loud thump, as if someone dropped to thefloor, and then complete silence. He then crawledforward and found the nozzle of a hose line. [NOTE:Victim #2 was found not wearing his SCBAfacepiece. It is believed the scream was fromVictim #2.]

The Lieutenant on Engine 10 recalled that as theybacked up Engine 26, he turned back towards thefront door and could see some light from the frontdoorway (entrance). He also stated that it was veryhot inside the structure. As he turned back around,he felt an intense blast of heat and was knockedbackward by a frantic fire fighter attempting to exit.The lieutenant then exited through the front door.When the heat hit the fire fighters, the Lieutenantthought that he was in the hallway, next to thebasement door (see Floor Plan A-1). The officer ofEngine 26 stated that as he made his way toward therear of the structure to join his crew, he alsoencountered an intense blast of heat. Feeling that hewas being burned, he quickly turned, and exitedthrough the front door. The layout man from Engine10 started pulling out the hose line from Engine 10,in an attempt to assist Victim #2 in his exit. As hepulled the hose line out, he noticed there was no oneon the end, which meant Victim #1, Victim #2, andthe fire fighter from Engine 26 remained inside.

As the officers from Engine 26 and Engine 10 exited,the IC was walking up to the structure to get a betterposition. The IC was unaware of any problems until

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he got close enough to see the fire fighters exiting.He immediately ran to the front and saw the officerfrom Engine 26, who related to him that Victim #1was still inside. The IC then saw the Lieutenant fromEngine 10 and ordered him to go back inside withhis crew and search for Victim #1. The IC laterrecalled that the Lieutenant from Engine 10 appearedto be dazed and did not relate to him that anyoneelse was missing. The IC only became aware thatVictim #1 was missing at this time.

The fire fighter from Engine 26, who was still inside,stated that as he grabbed the nozzle he rolled on hisback and opened it on the ceiling in a straight streamcircular pattern. He felt the room was going to flashand wanted to cool it down. As he applied water,he recalled seeing fire on the ceiling. He stated thatthe water reduced the heat, but it was still very hot.He opened the line a second time on the ceiling anddid not see any fire. He then followed the line, exitingthe structure. He did not hear any other fire fightersinside or any Personal Alert Safety Systems (PASS)alarming at that time. He stated that he was insidefor approximately 1½ minutes from the time the blastof heat hit them until his exit. He exited the structureat approximately 0031 hours. He asked if Victim#1 had made it out and was told that he had not. Hecommunicated to the IC that he thought Victim #1was still inside, straight back through the hall, and tothe right by a sofa (see Floor Plan A-1).

The IC received an additional request from Engine17 in the rear, this time stating they were at thebasement level and had heavy fire inside the basement.Engine 17 requested permission to hit the fire andthe IC responded by telling them that they had a firefighter down inside, on the first floor, and to hit thefire with a straight stream. Engine 17 opened thestraight stream on the fire in the basement and quicklyknocked it down. At approximately 0032 hours, theLieutenant from Engine 10 reentered the townhouseto begin his search.

Joining the Lieutenant was the Lieutenant and a firefighter from Rescue 1. They entered through thefront door to begin their search, stating the heat wastolerable, and visibility was improving. As they gotinside the structure they could hear a PASS alarmgoing off. They immediately followed the shrill alarmto locate a downed fire fighter. The fire fighter waslying under a table, unconscious, and with his SCBAfacepiece off. His SCBA was equipped with anintegrated PASS alarm, which was automaticallyactivated when the victim turned on his SCBA. Afterlocating the downed fire fighter, they called forassistance to remove him. The IC ordered theHazmat crew to enter and assist removing thedowned fire fighter. Engine 14’s crew was alreadyon their way inside to provide assistance. Additionalfire fighters from Engine 6 and Engine 4 also enteredthe townhouse and helped remove the victim to thefront lawn, at approximately 0045 hours. Theyimmediately started cardiopulmonary resuscitation(CPR) and provided medical treatment to the victim’sburns. The victim, who was later identified as Victim#2, was severely burned and the IC could notdetermine if it was the fire fighter they were searchingfor, or another fire fighter. A fire fighter standingnearby related to the IC that he could tell by the sizeof the victim that it was not Victim #1. The ICcontinued the search efforts, and at approximately0049 hours, Victim #1 was found and removed. Hewas found slumped over the couch face down (seeFloor Plan A-1). He was found equipped with aPASS device (manually operated) attached to histurnout gear. The PASS device was not activatedand was found in the off position. [NOTE: ThePASS device was later inspected and wasdetermined to be working properly.] Fire fightersremoved the victim to the front lawn of the structurewhere they located a pulse and immediately providedmedical treatment. All three fire fighters, along withthe Lieutenant from Engine 26, were transported toa nearby hospital.

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Victim #1 was treated for his burns and was admittedto the burn unit. He was pronounced dead the followingday, May 31,1999, at 1450 hours. Victim #2 waspronounced dead on arrival to the hospital on May30,1999, at 0108 hours. The injured fire fighter fromEngine 26 received first-, second-, and third-degreeburns to over 60 percent of his body. He was admittedto the burn unit where he was treated for his burns. Hehas been released from the burn unit and is currentlyundergoing rehabilitation. The Lieutenant from Engine26 received treatment for burns to his hands and headarea and was released the following day. He is currentlyback to his normal duties.

CAUSE OF DEATHAccording to the Medical Examiner, Victim #1 dieddue to thermal injuries involving 60% of total bodysurface area and airways. Victim #2 died due tothermal injuries involving 90% of total body surfacearea and airways.

RECOMMENDATIONS AND DISCUSSIONRecommendation #1: Fire departments shouldensure that the department’s StandardOperating Procedures (SOPs) are followed andrefresher training is provided. 1

Discussion: “It is imperative that companiesperform their duties as described in the StandardOperating Procedures (SOPs) unless directed by,or with notification to, and approval of, theIncident Commander.”1 According to departmentSOPs, the following procedures should take place:

� Engines responding should take theirdue positions.

Department SOPs state that the first-dueengine company will layout and take aposition in the front of the building. Thesecond-due engine company should layoutand take a rear position. The third-due

engine company should back up the first-due engine company in the front and thefourth-due engine company should back upthe second-due engine company in the rear.Engine 12 was the fourth-due enginecompany, and according to departmentSOPs was required to back up Engine 17 inthe rear. On arrival, Engine 12 proceededto the front of the structure and took position,leaving Engine 17 in the rear with no backup. Throughout operations, Truck 4 backedup Engine 17 in the rear.

� Officers should keep in contact,physically or verbally, with theircrews at all times during interior firefighting.

Department SOPs state that the officer incharge (OIC) should always be in contactwith his crew by voice, touch, or sight.

� Ensure that when a fire fighter isnot accounted for, it is reported tothe IC immediately and a roll-call isordered.

Department SOPs state that a mechanismto quickly account for personnel must beavailable to the IC at any point during theincident. The officer from Engine 10 exitedthe structure without Victim #2. At that point,the victim’s position was not accounted for,and it was not reported to the IC. When theIC becomes aware a fire fighter is notaccounted for, a roll-call should then beordered. When the roll-call is taken, anyfire fighters not accounted for should beimmediately reported to the IC. In thisincident, the IC only became aware thatVictim #1 was missing at the time search andrescue efforts took place.

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� Provide adequate personnel tooperate according to departmentSOPs.

Department SOPs state that Sector Leaderscan be assigned to sectors for accountability,to monitor progress, redirect activities withinthe sector, coordinate activities, monitor safety,request additional resources as needed,communicate with command or other SectorLeaders, and reallocate resources within thesector. The Sector Leader would be acompany officer or a Battalion Chief and wouldbe designated as Sector Leader by the IC. Inthe early stages of this incident, an adequatenumber of personnel was not on the scene toperform effectively and in accordance with thedepartment SOPs. The officer on Truck 4 wasperforming tasks with one of his fire fighterswhile the officer on Engine 17 was on the initialattack line in the rear. All ventilation efforts inthe rear were not completed when conditionsrapidly changed (the sliding-glass door on thefirst floor was not vented until conditionsdeteriorated). Truck 4 eventually backed upEngine 17, because Engine 12 had proceededto the front of the structure, which also delayedventilation. With all officers in the rearperforming operational tasks, no monitoringtook place. This hindered the opportunity tocomplete proper ventilation, to provide timelyreports to the IC, and allowed a breakdown incommunication. To be compliant withdepartment SOPs, additional personnel wouldhave been needed to free up a company officerto serve as a Sector Leader.

� Ensure that first arriving companiesgive the required size-up report tocommunications on the firegroundchannel.

According to department SOPs, the firstarriving units in the front and rear of thebuilding, or the incident site, should give asize-up report to communications on the firechannel 1 and then switch to the firegroundchannel for subsequent firegroundcommunications. The fireground channel isan informal radio channel to report what yousee, what you don’t see, and what you think.It is to be used for firegroundcommunications between units, betweenunits and Sector leaders, and betweenSector Leaders and the IncidentCommander. All responding units willmonitor the fireground channel to hearreports between units on scene and theresponding Battalion Chief, and will beaware of the fireground situation beforearrival. Also, responding units shouldmonitor the fireground channel since theymay be contacted by the Battalion Chief orSector Leader for assignment prior to arrivalon the fireground. In this incident, Engine26 gave a size-up report to communicationswhen they arrived. A size-up of the rearconditions was never reported by the firstarriving unit in the rear.

Fire departments should also ensure that,whenever possible, a size-up is made fromthe inside. At the initial stage of a fire theinside size-up is more accurate and usefulthan the size-up made from outside thebuilding. The officers inside the structure arecloser to the fire and obviously can see morethan someone outside the building at thecommand post.2

Recommendation #2: Fire departments shouldconsider providing the Incident Commanderwith a Command Aide. 3-5

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Discussion: Aides are personnel assigned to assistthe Incident Commander. During large operations,Sector Leaders also may have aides to assist them.They do this by managing information andcommunications. They can keep track ofassignments, locations, and the progress ofcompanies, assist with tactical worksheets, or accessreference materials and pre-fire plans. Anotherimportant function they may perform is to providereconnaissance and operational details for the IC (hiseyes and ears). Some jurisdictions assign full-timeaides to command officers to perform routineadministration functions and to act as drivers inaddition to their fireground role. Departments shouldconsider the aide to be an individual that has theexperience and authority to conduct the requiredtasks.

Battalion Fire Chiefs are required to respond quicklyto emergency incidents. In their response, they haveto be fully aware of heavy traffic conditions,construction detours, traffic signals, and otherconditions. Also, they must monitor and comprehendwhich companies are responding, fireground activity,fire conditions, and additional information fromdispatch. If possible, they will also monitor allincoming information from dispatch and the firegroundand make important decisions. Aides could assistthe Battalion Fire Chief in processing informationwithout distraction and complete the necessary tasksen route to the scene. In this incident, an aide couldhave been directed to go to the rear of the structureand determine what floor level the fire fighters in therear were on. The aide could have also driven theIC to the incident scene, freeing up the IC to bettercomprehend all information and make importantdecisions prior to arrival.

Recommendation #3: Fire departments shouldensure that fire fighters from the ventilationcrew and the attack crew coordinate theirefforts. 2, 3

Discussion: The importance of ventilation whenattacking basement fires cannot be overemphasized.Fire can quickly spread upward into the structure causingpotential problems such as a flashover, backdraft, orweakening of the structure. Ventilation timing isextremely important and must be carefully coordinatedwith both fire attack and ventilation crews. Ideally, itshould occur just ahead of interior crews advancingtheir hose lines. Properly ventilating the heat and smokefrom buildings can reduce the possibilities of potentiallyhazardous situations fire fighters can be faced with. Thefire fighters performing ventilation tasks should be incommunication with the fire fighters attacking the fire orentering the structure to coordinate their efforts. In thisincident, fire fighters from Engine 26 entered the structureas fire fighters from Truck 15 began ventilation efforts inthe front of the structure. Truck 4 was delayed in itsventilation efforts because it arrived late as a replacementfor Truck 13 (which was out of service). The crewfrom Engine 10 also entered behind Engine 26 as backup. At that point, ventilation had not been completed.Fire fighters on the attack lines experienced considerableheat and heavy smoke conditions. They were forcedto crawl inside the structure and stated that the heatremained consistent as they proceeded into thestructure. When the rear sliding-glass door (basement)was opened by Truck 4, the small fires in the basementbegan to grow rapidly.

Recommendation #4: Fire departments shouldensure that when a piece of equipment is takenout of service, appropriate backup equipmentis identified and readily available. 5

Discussion: Equipment on the fireground is veryimportant to any fireground operation. It should bekept clean, in safe operating condition, and repairedwhen necessary. When any piece of equipment istaken out of service for repair, a new or backup pieceof equipment should be immediately placed inservice. In this incident, the truck company (Truck13) that would have responded with Engine 10 was

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out of service. A backup truck was not placed inservice to replace Truck 13 causing Truck 4 to bedispatched from a different location. Truck 4 arrivedon the scene approximately 2 minutes after Engine10 (Truck 13 would have arrived on sceneapproximately the same time as Engine 10) , whichdelayed ventilation procedures.

Recommendation #5: Fire departments should ensurethat personnel equipped with a radio position theradio to receive and respond to radio transmissions. 3

Discussion: The fireground communications processcombines electronic communication equipment, a setof Standard Operating Procedures, and the firepersonnel who will use the equipment. To be effective,the communications network must integrate theequipment and procedures with the dynamic situationat the incident site, especially in terms of the humanfactors affecting its use. The ease of use and operationmay well determine how consistently fire fighters monitorand report over the radio while fighting fires. In thisincident, radio calls were made several times by the ICto an engine company, and the IC never received aresponse. Dispatch tapes recorded the transmissionmade by the IC to the engine company, but it remainsunclear why the engine company never responded.NIOSH investigators have also reviewed a photographtaken approximately the same time the interior crewshad exited the structure. An officer in the photographhad his radio positioned in his front bottom pocket(approximately waist level) of his turnout coat. Theofficer was not identified. Fire departments shouldreview both operating procedures and human factorsissues to determine the ease of use of radio equipmenton the fireground to ensure that fire fighters consistentlymonitor radio transmissions from the IC and respondto radio calls.

Recommendation #6: Fire departments shouldconsider using a radio communication systemthat is equipped with an emergency signal

button, is reliable, and does not produceinterference.6

Discussion: Radio communication is one of the mostimportant functions on the fireground. When situationson the fireground arise, radio transmissions need to bemade in a timely and understandable fashion.

� Departments should operate on aradio frequency that does not“bleedover” or cause interference.

Radios need to be reliable, in good workingcondition, and fully charged and ready to use.They should not produce interference or“bleedover.” Fire departments should alsotake into consideration the frequency onwhich the radio communications system willoperate. The National Fire ProtectionAssociation (NFPA) recommends thatfrequencies should be 15 kHz apart in theVHF high band. The separation infrequencies is to avoid possible interference.The frequencies used by the departmentinvolved in the incident are 15 kHz apart.However, in the past, this department hasexperienced problems with interference or“bleedover” between Channels 1 and 4.Interference or “bleedover” betweenChannel 1 and Channel 4 has been notedbecause the frequencies are close to oneanother. The frequency for Channel 1 (FireChannel) is 154.190 KHz and the frequencyfor Channel 4 (Fireground Channel) is154.205 KHz. Although the frequenciesmeet the NFPA recommended standard ofseparation, there still remains a problem with“bleedover” or interference. For this reason,departments should consider changing thefireground channels or adjust the frequenciesto reduce further “bleedover” or interference.The radio of the officer from Engine 26 was

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tested after the fire and appeared to be workingproperly. The officer could not recall receivingany radio transmissions from the IC; however,the dispatch tapes recorded a radiotransmission from the IC to the officer of Engine26. There is a possibility that the officer didnot receive the call because of “bleedover” orinterference.

� Departments should considerusing portable radios equippedwith an emergency signalbutton.

Fire fighters are always encounteringpotentially hazardous situations and shouldbe prepared with the proper equipment toassist them in an emergency. Departmentsshould consider using portable radiosequipped with an emergency signal button.When fire fighters become trapped orencounter an emergency situation whereassistance is needed, they could push theemergency signal button on their portableradio. When the emergency signal button ispushed, it would transmit an emergency alertsignal to dispatch, the IC, or possibly allradios. This signal would signify that a firefighter needs assistance and would alert allfireground personnel that an emergency callis going to be transmitted.

Recommendation #7 Fire departmentsshould ensure that a l l companiesresponding are aware of any follow-upreports from dispatch. 3

Discussion: From the very beginning of firegroundoperations, the IC must use communications to initiateand evaluate fireground actions. Upon arriving, heneeds to advise all operating companies of the basicdetails of the attack plan and provide an initial status

report. This transmission should explain theconditions he can see from the command post, andshould be directed to everyone on scene, arriving atthe scene, or en route to the scene. The initial reportshould provide a standard description of the followingitems: building size, building height, occupancy, fire/smoke conditions, confirmation of any additionalreports, designation of command, and action beingtaken. If a Sector Leader is assigned, the IC cancommunicate directly to the Sector Leader to receivedirect transmissions. Additional reports initiated bydispatch should be noted and all companies, on thescene or responding, should be aware of the report.In this incident, the initial dispatch report stated thatit was a house fire. As companies responded,dispatch made a second report stating the fire was inthe basement. Some of the companies acknowledgedthe report, others did not. Fire departments shoulddevelop and implement a SOP to ensure all radiotransmissions are received by all responding units.

Recommendation #8: Fire departments should ensurethat a Rapid Intervention Team is established and inposition immediately upon arrival. 5

Discussion: A Rapid Intervention Team (RIT) shouldrespond to every major fire. The team should reportto the officer in command and remain at the commandpost until an intervention is required to rescue a firefighter(s). The RIT should have all tools necessaryto complete the job, e.g., a search rope, first aid kit,and a resuscitator to use if a fire fighter becomesinjured. The RIT will be ordered by the IC tocomplete any emergency searches or rescues. Itwill provide the companies with the opportunity toregroup and take a roll call, instead of performingrescue operations. When the RIT enters to searchand rescue, each team member will have a SCBAwith a full cylinder and will be physically prepared.In this incident, the officer on Engine 10 and firefighters from additional companies, who had alreadybeen involved in fireground operations, entered the

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structure to search for Victim #1. If a roll callhad been ordered during search operations, theofficer of Engine 10 would have been inside thestructure and would not have been able to report tothe IC that one of his crew members wasunaccounted for. If a RIT had been in place,accountability calls could have been conductedbecause fireground officers would not have beendirected to rescue operations.

Recommendation #9: Fire departments shouldensure that any hose line taken into the structureremains inside until all crews have exited. 7

Discussion: Fire fighters who enter smoke-filledenclosures should be equipped with a safety line orhose line in the event that a fire fighter becomesdisoriented or trapped. Many fire fighters who diefrom smoke inhalation, a flashover, or are caught ortrapped by fire, actually become disoriented first.They are lost in smoke, their SCBA run out of air, orthey cannot find their way to exit through the smoke.Although fire or smoke kills them, the primarycontributing factor is disorientation. By using a lifeline or hose line, the fire fighter is able to determinethe direction of exit by the couplings that connecttwo hose lines together. The male coupling signifiesthe exit direction. When trying to exit, fire fightersare trained to find the line and follow it out, which iswhat the injured fire fighter from Engine 26 did. Theline should remain inside as a guide for fire fighters tofollow.

Recommendation #10: Fire departments shouldconsider providing all fire fighters with aPersonal Alert Safety System (PASS) integratedinto their Self-Contained Breathing Apparatus.

Discussion: PASS devices, which are electronicdevices worn by the fire fighter, emit a loud anddistinctive alarm if the fire fighter becomes motionlessfor more than 30 seconds. Fire fighters entering

hazardous areas should be equipped with a PASSdevices. There are several types of PASS devicesavailable. One device that could be used is the PASSthat is integrated into the SCBA. PASS devicesintegrated into the SCBA will be activated when theSCBA air cylinder is turned on. Manual PASSdevices are also used throughout the fire service.These devices require the fire fighter to manually turnon the device each time they use it. In this incident,Victim #2 was equipped with a PASS deviceintegrated into his SCBA. Victim #1 was equippedwith a manual device. When search efforts tookplace, the fire fighters searching the structure wereonly aware that Victim #1 was missing. When theyentered the structure, they recalled hearing a PASSdevice sounding. The fire fighters followed the alarmand located a fire fighter, later to be identified asVictim #2. Victim #1 was located inside the structureapproximately 4 minutes later. Victim #1 was foundto be equipped with a manual PASS device attachedto his turnouts. However, his PASS device wasnever turned on.

Recommendation #11: Fire departments shoulddevelop and implement a preventivemaintenance program to ensure that all SCBA’sare adequately maintained. 8

Discussion. Fire departments should establishservice and maintenance procedures and rigidlyenforce them to provide respirators that aredependable and are constantly evaluated, tested, andmaintained. Equally important is record keeping, acritical element of any respirator maintenanceprogram. During this incident, Victim #1 stated thatas he prepared to enter the structure, he experienceda problem with his SCBA facepiece. He returned tothe engine and replaced his facepiece with the Wagondriver’s facepiece. NIOSH completed an evaluationof the fire department’s SCBA program on July 21,1999 and issued a report to the department (seeAttachment 1).

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REFERENCES1. District of Columbia Fire Department. WrittenStandard Operating Procedures.

2. Dunn V [1992]. Safety and Survival on theFireground. Saddle Brook, NJ: Fire EngineeringBooks & Videos.

3. Brunacini, Alan V [1985]. Fire Command. Quincy,MA: National Fire Protection Association.

4. NFPA 1201: Standard for Developing Fire ProtectionServices for the Public 1994 ed. Quincy, MA:National Fire Protection Association.

5. NFPA 1500: Standard on Fire DepartmentOccupational Safety and Health Program 1997 ed.Quincy, MA: National Fire Protection Association.

6. NFPA 297: Guide on Principles and Practices forcommunication systems 1995 ed. Quincy, MA:National Fire Protection Association.

7. International Fire Service Training Association.March 1998. Essentials of Fire Fighting, 4th ed. FireProtection Publications.

8. National Institute for Occupational Safety and Health(NIOSH). August 1999. District of ColumbiaSCBA Maintenance Program Evaluation Report,Respirator Branch, Division of Respiratory DiseaseStudies, NIOSH, Morgantown, WV.

INVESTIGATOR INFORMATIONThis incident was investigated by: Frank Washenitz,Safety and Occupational Health Specialist; RichBraddee, Project Officer/Team Leader; Ted Pettit,Senior Investigator; and Eric Schmidt, Safety Engineerall from the Surveillance and Field Investigations Branch,Division of Safety Research, NIOSH.

The SCBA maintenance program was evaluated by:Tim Merinar, Engineer, and Tom McDowell, PhysicalScientist, Respirator Branch, Division of RespiratoryDisease Studies, NIOSH.

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Photo 1: This photo depicts the front (side 1) entrance of the townhouseinvolved in the incident.

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Photo 2: This photo depicts the rear (side 3)sliding-glass door leading to the basement

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Investigative Report #99F

-21F

atality Assessm

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valuation

Two F

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District of C

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Steel I-Beam

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Documents

Death in the line of duty Fighter Fatality Investigation and Prevention Program