death in the fire fighter fatality investigation line of dutyinvestigative report #98f-17 sudden...

The Fire Fighter Fatality Investigation andPrevention Program is conducted by the NationalInstitute for Occupational Safety and Health (NIOSH).The purpose of the program is to determine factors thatcause or contribute to fire fighter deaths suffered in theline of duty. Identification of causal and contributingfactors enable researchers and safety specialists todevelop strategies for preventing future similar incidents.To request additional copies of this report (specify thecase number shown in the shield above), other fatalityinvestigation reports, or further information, visit theProgram Website at:

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

or call toll free 1-800-35-NIOSH

Fire Fighter Fatality Investigation and Prevention Program

Death in the line of duty...

A summary of a NIOSH fire fighter fatality investigation November 30, 1998

Sudden Floor Collapse Claims the Lives of Two Fire Fighters and Four AreHospitalized with Serious Burns in a Five-Alarm Fire--New York

SUMMARYOn June 5, 1998, a call came into fire dispatchreporting a fire in the boiler room atresidential/commercial complex. Several unitswere dispatched, and upon arrival, Engine 332reported smoke emitting from the building. Thebuilding involved in the fire was one of fivethree-story wood frame dwellings (see Figure 1).The fire building (building #1) and the collapsebuilding (building #2) were both owned by theCity, with some of the units occupied and somevacant. The building, which had undergonerenovations over the past several years, was builtaround the turn of the century. The firedepartment initiated fire fighting operations, andseveral fire fighters were conducting an interiorattack on the first floor of one of the dwellings,when it was reported that a civilian was trappedon the second floor. The Captain (Victim #1)and a fire fighter on Ladder 176, the Lieutenant(Victim #2) and two fire fighters on Engine 332,and the Lieutenant on Ladder 103 went to thesecond floor to search for the trapped civilian.Without warning, approximately 10 minutesafter the arrival of

the first unit, the rear of the second floor ofbuilding #2 collapsed, trapping five fire fighters ina burning inferno on the first floor. NIOSHinvestigators conclude that, to minimize thechances of similar occurrences, fire departmentsshould:

• ensure that Incident Commandconducts a thorough initial size up ofthe incident before initiating firefighting efforts, and continuallyevaluates the risk versus gain duringoperations at an incident

• ensure that Incident Command alwaysmaintains close accountability for allpersonnel at the fire scene

• ensure that some type of tone or alertthat is recognized by all fire fighters betransmitted immediately whenconditions become unsafe for firefighters


Fatality Assessment and Control EvaluationInvestigative Report #98F-17

Sudden Floor Collapse Claims the Lives of Two Fire Fighters and Four Are Hospitalized withSerious Burns in a Five-Alarm Fire--New York

• ensure that Rapid InterventionCrews/Teams or Firefighter Assist andSearch Teams (FAST Truck) are inplace in the early stages of an incident

• ensure that communication equipmentused on the fireground, e.g., handie-talkies, will remain operational in theevent that one unit malfunctions.

NIOSH investigators also concluded that, toprevent similar occurrences, municipalitiesshould:

• ensure that modifications/renovationsto buildings are in compliance withapplicable building codes, i.e., anyrenovation or remodeling does notdecrease the structural integrity of thesupporting members.

INTRODUCTIONOn June 5, 1998, several fire fighters wereconducting an interior attack on the first floor ofa wood frame, multiple residential dwelling,when it was reported that a civilian was trappedon the second floor. The Captain (Victim #1)and a fire fighter on Ladder 176, the Lieutenant(Victim #2) and two fire fighters on Engine 332,and the Lieutenant on Ladder 103 went to thesecond floor to search for the trapped civilian.The fire fighter on Ladder 176 went to the frontand the other officers and fire fighters went tothe rear of the structure to conduct a search.Within a few minutes and without warning, thefloor at the rear of the structure collapsed,trapping all five in a live fire situation on the firstfloor. Two fire fighters died and four wereseriously injured (includes the fire fighter on

Ladder 176 that dove over the stairwell railing).

It was reported later that the trapped civilian hadescaped through a back entrance.

On June 22-25, 1998, and September 15-17,1998, an investigation of this incident wasconducted by the Chief of the TraumaInvestigations Section, Division of SafetyResearch. Meetings were conducted with theChiefs of the Fire Department Safety Command(Fire Fighter Fatality Investigation Team), theChief of Safety, the Safety and HealthCoordinator, two Battalion Chiefs whoresponded to the incident, several fire fightersthat responded to the incident, and arepresentative of the International Association ofFire Fighters (IAFF). A site visit was conducted;however, the building had already been removed.Copies of photographs from the incident sitewere obtained from the fire department alongwith diagrams of the buildings, a video tape of theincident, and investigative information whichincluded a detailed time line. Figures, diagrams,and pictures used in this report were courtesy ofthe fire department.

The fire department involved in the incidentserves a population of 7.9 million in a geographicarea of 306 square miles. The fire department has230 firehouses and is comprised of approximately15,000 employees, including 11,000 fire fightersand officers, 3,000 emergency medical service(EMS personnel), and 1,000 civilians. The firedepartment provides all new fire fighters with thebasic 13 weeks of training at their fire academythat meet or exceed the National Fire ProtectionAssociation (NFPA) Fire Fighter Level I andLevel II. After graduating from the fire academy,




the recruit fire fighters go through a 3-yearrotation in which they are assigned to an A (highactivity level), B (moderate activity level), or C(light activity level) firehouse for 1 year. Theyare then rotated to a different activity andgeographic location for the second year, androtated again at the beginning of the third year.Refresher training continues on each shift andmulti-unit drills are conducted continually tomaintain hands-on proficiency. The firedepartment has extensive written standardoperating procedures. The Captain (Victim #1)had 20 years of fire fighting experience, and theLieutenant (Victim #2) had 21 years of firefighting experience.

Although many fire companies were involved inthis five-alarm incident, only those directlyinvolved up to the time of the fatal incident arediscussed in this report.

INVESTIGATIONOn June 5, 1998, at 2022 hours a call came intothe Dispatch Center reporting a boiler room fireat a residential/commercial complex. Thestructure was one of five attached, three-story,wood-frame residential/commercial units (seeFigure 1). Engine 332 (Lieutenant [Victim #2]and four fire fighters), Engine 231 (Lieutenantand four fire fighters), Engine 290 (Lieutenantand five fire fighters), Ladder l75 (Captain andfive fire fighters), and Battalion 44 responded. Engine 332 was the first unit to arrive at 2025hours, and reported a 1075 (working fire).Engine 332 and Engine 231 made hydrantconnections close to the building and stretchedhand lines to the front (see Figure 2). Firefighters from Ladder 175 (Captain and five firefighters) reported in at 2026 hours, and firefighters from Engine 231 reported in at 2027

hours and attempted to make an entry on the firstfloor of building #1. Battalion 44 arrived at 2027hours and was conducting a size-up, reportingheavy fire on the first floor of building #1, whenhe received a transmission from the fire fighterson the first floor of building #1 that the interiorhall had been closed off from the rest of thebuilding (the interior hall had been closed offduring one of the renovations of the building).Battalion 44 told the fire fighters on Ladder 175to breach the wall to gain access into the building.At that time, Battalion 44 called for an additionalEngine and Ladder to be dispatched.

At 2029 hours, Ladder 176 (Captain [Victim #1]and six fire fighters) was designated as theFirefighter Assist and Search Team (FAST)Truck. Note: A FAST Truck is similar to aRapid Intervention Crew/Team.

At 2029 hours Engine 290 arrived, followed byLadder 103 at 2030 hours. Engine 332 andEngine 231 pulled lines to the front of thestructure to prepare for making an interior attack.A woman who lived at building #2 reported toBattalion 44 that her mother was still in thebuilding (see Figure 3). The Lieutenant and twofire fighters on Ladder 103 responded to thereport that someone was trapped on the secondfloor. They were being assisted by the Lieutenantand three fire fighters on Engine 332.

At 2030 hours, dispatch notified Battalion 44 thatEngine 227 (Captain and five fire fighters) andLadder 111 (Lieutenant and five fire fighters)were the additional Engine and Ladder, and thatLadder 176 was the designated FAST Truck.

At 2030 hours, Engine 233 (Lieutenant and fourfire fighters) arrived at the rear of the building




and reported to Battalion 44 that heavy fire wasshowing in the rear. At 2031 hours, Ladder 175breached a hole in the first floor hallway ofbuilding #1 to gain entrance into the first floor ofthe building. At 2032 hours, Engine 231directed the line through the breached hole onthe first floor of building #1. At the same time,the team on Ladder 103 (Lieutenant and five firefighters) was at the rear entrance to the secondfloor apartment of building #2, and reported fire,heavy smoke, and heat on the second floor.Ladder 103 called Battalion 44 and requested aline. Battalion 44 ordered Engine 332 to pull aline to the second floor of building #2, and forthe FAST Truck (Ladder 176) to assist in thesearch for the missing woman.

At 2032 hours, Battalion 44 called for a secondalarm, which resulted in three more Engines, oneadditional Ladder, and the Maxi-water unit.

At 2034 hours Battalion 44 reported to thedispatcher that they were having trouble locatingthe fire, that people were trapped on the upperfloors, and that searches were in progress. TheLieutenant on Ladder 103, and the Lieutenant(Victim #2), the Nozzleman, and a fire fighter onEngine 332 were conducting a search in thekitchen area on the second floor of building #2.The Captain (Victim #1) on Ladder 176 wassearching the rear bedroom while a fire fighteron Ladder 176 went to the front of theapartment to search. The second floor was filledwith heavy black smoke and heat, with no visiblefire (fire fighters were unaware the fire wasbelow them). The fire fighter searching the frontarea of the second floor, experiencing extremeheat and heavy black smoke, was in a crawlingposition. He could hear yelling and screaming atthe rear of the hallway. Suddenly the heat

became intolerable, and he realized he must exitimmediately to survive. The fire fighter crawledto the railing along the stairwell and dove over itto escape the extreme heat, landing on firefighters in the stairwell. He was on fire when hewas removed from the building. At 2034 hours,Battalion 44 ordered everyone out of thebuilding.

At 2035 hours there was a major change inconditions, fire was now escalating in the front ofthe building. It is believed that at 2035 hours,when a major change in conditions occurred, therear area of the second floor (kitchen andbedroom area) collapsed, trapping five firefighters (see Figure 4) (the Captain on Ladder176 [Victim #1], the Lieutenant on 332 [Victim#2] and two fire fighters on Engine 332, and theLieutenant on Ladder 103). The collapsedsection allowed the fire to vent freely up throughthe floor and out the front and back of thebuilding, with flames leaping to the roof line.

At 2036 hours Battalion 44 received a Maydaythat was transmitted by the Ladder 103 IronsMan for the collapse, but there was noacknowledgment. A possible reason for this lackof acknowledgment was the fire fighters hadfallen through the floor into the store below andthe handie-talkie became damaged creating astuck mike condition.

Also at 2036 hours, Battalion 44 transmitted todispatch a request for a third alarm for the firecondition, unaware that a collapse had occurred.

At 2037 hours a fire fighter on Engine 332 exitedbuilding #2 and reported to another fire fighterthat a collapse had occurred. At 2038 hoursBattalion 38, now on the scene, went to the




second floor of building #2 and upon seeing thecollapsed area and a hand line extending downinto it, realized fire fighters had fallen to the firstfloor. Battalion 44 requested that the dispatcherhave EMS respond for possible fire fighterinjuries.

At 2039 hours, Engine 231 advanced theircharged line into the area of collapse on the firstfloor of building #2. At 2042 hours the Captain(Victim #1) and one of the fire fighters onEngine 332 were found in the collapsed area.Shortly after, the other three fire fighters werediscovered trapped in the debris. It tookapproximately 30 minutes to extricate the firefighters from the fallen and burning debris.All injured fire fighters were immediatelytransported to the hospital. The Lieutenant(Victim #2) on Engine 332 was pronounceddead on arrival. The Captain (Victim #1) onLadder 176 had 70% severe burns and diedapproximately one month later. One fire fighterwas hospitalized for three days and has returnedto duty. Three fire fighters were hospitalized forseveral weeks with severe burns, and have notreturned to active duty as of the date of thisreport.

CAUSE OF DEATHAccording to the medical examiner, the cause ofdeath for the Captain (Victim #1) was thermalburns, resulting in cardiac arrest. The cause ofdeath for the Lieutenant (Victim # 2) wascrushing trauma and burns resulting in cardiacarrest.

RECOMMENDATIONS/DISCUSSIONRecommendation #1: Fire departments shouldensure that Incident Command conducts aninitial size up of the incident before initiating

fire fighting efforts, and continually evaluatesthe risk versus gain during operations at anincident. [1-4, 8]

Discussion: One of the most important size-upduties of the first-in officers is locating the fireand determining its severity. This informationlays the foundation for the entire operation. First,it determines the number of fire fighters and theamount of apparatus and equipment needed tocontrol the blaze. Second, it assists indetermining the most effective point of fireextinguishment attack, and the most effectivemethod of venting heat and smoke. Severalfactors must be evaluated in conducting the size-up, e.g., type of structure, time of day, contentsof the structure, potential hazards, etc. The size-up should also include risk versus gain duringincident operations. The following generalfactors are important considerations: (1)occupancy type involved; (2) smoke conditions;(3) type of construction; (4) age of structure; (5)exposures; and (6) time considerations, such astime of incident, time fire was burning beforearrival, time fire was burning after arrival, andtype of attack.

Recommendation #2: Fire departments shouldensure that incident command alwaysmaintains close accountability for all personnelat the fire scene. [5-7]

Discussion: Accountability on the fireground isparamount and may be accomplished by severalmethods. It is the responsibility of every officerto account for every fire fighter assigned to his orher company and relay this information toIncident Command. Fire fighters should notwork beyond the sight or sound of thesupervising officer unless equipped with a




portable radio. This member shouldcommunicate with the supervising officer byportable radio to ensure accountability andindicate completion of assignments and duties.When the assigned duties are completed eachfire fighter should radio this information to thesupervisor then return to the supervisor foradditional duties. As a fire escalates andadditional fire companies respond, acommunication assistant with a command boardshould assist the Incident Commander withaccounting for all fire fighter companies at thefire, at the staging area, and at rehabilitation.One of the most important areas for

accountability at a fire is an Incident ManagementSystem.

Recommendation #3: Fire departments shouldensure that some type of tone or alert that isrecognized by all fire fighters be transmittedimmediately when conditions become unsafefor fire fighters. [7]

Discussion: There is a difference betweenwithdrawing fire fighters and calling for anemergency evacuation of fire fighters. A normalwithdraw action is ordered when a fire isspreading beyond the ability of fire fighters tocontrol it. An emergency evacuation is orderedwhen an extremely serious emergency hasoccurred or is about to happen, such as missingfire fighter(s), explosion, or collapse. In anemergency evacuation, unlike a withdraw, firedepartment tools and hose are left behind and aroll call or a head count must be conductedimmediately as there may be a missing fire fighter.An emergency evacuation is a rare occurrence inthe fire service, and because of its rarity,confusion and delay may occur when it isordered. For this reason, there should be aprearranged audible signal, to alert fire fighters ofan emergency withdraw; fire departments shouldtrain their members for an emergency evacuationupon receipt of the signal. Fire fighters shouldimmediately exit the structure upon receipt of theprearranged signal, leaving behind tools andequipment, which can be removed later. Incidentcommanders should use the prearrangedemergency evacuation signal whenever theydecide that conditions are unsafe for interior fire fighting or an accident oremergency involving a fire fighter(s).

Recommendation #4: Fire departments should




ensure that Rapid Intervention Crews/Teamsor Firefighter Assist and Search Teams (FASTTruck) are in place in the early stages of anincident [6]

Discussion: A Rapid Intervention Crew/Team orFirefighter Assist and Search Team (FASTTruck) should be positioned to respond to everymajor fire. The team should report to the officerin command and remain at the command post inthe event an intervention is required to rescue afire fighter(s). The Rapid InterventionCrew/Team or FAST Truck should have all thetools necessary to complete the job, e.g., asearch rope, rescue rope, first aid kit and aresuscitator to use if a fire fighter becomesinjured. These teams can intervene quickly torescue fire fighters who become disoriented, lostin smoke filled environments, trapped by fire,involved in a structural collapse, or run out ofbreathing air in their self-contained breathingapparatus.

Recommendation #5: Fire departments shouldensure that communication used on thefireground, e.g., handie-talkies, will remainoperational in the event that one unitmalfunctions. [6]

Discussion: Effective communication on thefireground between fire fighters, officers, andcommand is imperative. When there is acommunication breakdown, command becomesisolated from events occurring on the interior,rear, sides, and roof of the structure. In thisincident, when a Mayday call was transmitted bya fire fighter on the interior, it was neveracknowledged, possibly due to a handie-talkiemalfunction on the fireground.

Recommendation #6: Municipalities shouldensure that all modifications/renovations tobuildings are in compliance with currentbuilding codes, i.e., any renovation orremodeling does not decrease the structuralintegrity of supporting members.

Discussion: Modifications, renovations, andremodeling of buildings require building permitsto ensure all work done is in compliance withcurrent building codes and does not decrease thestructural integrity of supporting members. Thestructure involved in this fire incident had beenremodeled and renovated several times in thepast. For example, supporting structures hadbeen moved or removed without appropriaterestructuring or support, thereby, creating ahazard for the occupants and fire fighters in caseof a fire or other emergency. Specifically, arelieving wall had been installed on the first floorof building #2 (see Figure 5 ) that did notadequately support the rear of the second floorunder fire conditions and the added weight of thefire fighters.

REFERENCES 1. International Fire Service TrainingAssociation. Essentials of fire fighting, 3rd ed.Fire Protection Publications, March 1995.

2. Dunn V. Systems analysis, size-up: Part 1.Firehouse, October 1996.




3. Brunacini A [1985]. Fire command, Quincy,MA: National Fire Protection Association.

4. Dunn V [1988]. Collapse of burningbuildings, a guide to fireground safety. SaddleBrook, NJ: Fire Engineering Books and Videos.

5. Morris G, Gary P, Brunacini N, Whaley L[1994]. Fireground accountability: The PhoenixSystem, Fire Engineering, 147(4).

6. NFPA 1500: Standard on Fire DepartmentOccupational Safety and Health Program. 1997ed. Quincy, MA: National Fire ProtectionAssociation.

7. NFPA 1561: Standard on Fire DepartmentIncident Management System. 1995 ed. Quincy,MA: National Fire Protection Association.

8. Kipp JD, Loflin ME [1996]. Emergencyincident risk management: A safety & healthperspective. New York: Van Nostrand ReinholdPublishing.

INVESTIGATOR INFORMATIONTed A. Pettit, Chief of the TraumaInvestigations Section, Surveillance and FieldInvestigations Branch, Division of SafetyResearch.

death in the fire fighter fatality investigation line of dutyinvestigative report #98f-17 sudden...

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