fire fighter face report no. f2001-16, career fire … · on march 8, 2001, a 38-year-old male...

Fire Fighter Fatality Investigation and Prevention Program

F2001 Death in the line of duty...16

Career Fire Fighter Dies After Falling Through the Floor Fighting aStructure Fire at a Local Residence - Ohio

February 28, 2002A Summary of a NIOSH fire fighter fatality investigation

SUMMARYOn March 8, 2001, a 38-year-old male career firefighter (the victim) fell through the floor whilefighting a structure fire, and died 12 days laterfrom his injuries. At 1231 hours, Central Dispatchnotified the career department of a structure firewith reports of the occupants still inside. TheAssistant Chief arrived on the scene along withEngine 70 and assumed Incident Command (IC).The IC immediately called for the second alarm,began conducting the initial size-up of thestructure, and confirmed heavy fire in the left frontsection. At that time, the neighbors approachedthe IC and informed him that the occupants weretrapped inside. The IC ordered the fire fighterson scene to commence search and rescue efforts,and then verified the stability of the structurethrough radio and face-to-face communications.

Engine 68 arrived on the scene at approximately1250 hours with an Assistant Chief and the victim.The Assistant Chief provided tactical commandof the fire ground, and along with the victim,

conducted search and rescue operations. Othercrews conducted searches with a thermal imagingcamera of the first floor and basement level of theresidence with no sign of any occupants. Duringthese searches the stability of the structure wasdiminishing due to the intense fire that was nowventing through the roof.

Fire fighter #3 and the victim were at the frontentrance conducting a defensive attack as the thirdemergency evacuation signal was sounded. Theneighbors were still insisting to the IC and firefighters that the occupants were trapped inside,and one of the occupants was handicapped. Thevictim and one other fire fighter conductedanother search of the structure. The heat andflames were now extending from the basementlevel to the first floor when the fire fighter’s lowair alarm sounded. The victim and the fire fighterwere backing out of the structure when the floorbeneath the victim gave way, causing him to fallthrough the floor and become trapped in thebasement. Attempts were made from the firstfloor to rescue the victim by utilizing a handline

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. Identificationof causal and contributing factors enable researchers andsafety specialists to develop strategies for preventing futuresimilar incidents. The program does not seek to determinefault or place blame on fire departments or individual firefighters. To request additional copies of this report (specifythe case number shown in the shield above), other fatalityinvestigation reports, or further information, visit the ProgramWebsite at

www.cdc.gov/niosh/firehome.htmlor call toll free 1-800-35-NIOSH

Picture courtesy of Steve Claytor,Special County Arson Team

Career Fire Fighter Dies After Falling Through the Floor Fighting a Structure Fire at a LocalResidence - Ohio

Investigative Report #F2001-16Fatality Assessment and Control Evaluation

Fire Fighter Fatality Investigation And Prevention Program

and an attic ladder, but they were unsuccessful dueto the intense heat and flames. Two RapidIntervention Teams (RIT #1 & RIT #2) weredeployed simultaneously from separate entrancesinto the basement to perform a search and rescueoperation for the downed fire fighter. The RITswere able to locate and remove the victim on theirinitial entry. He sustained third degree burns toover half of his body and died 12 days later.

NIOSH investigators concluded that to minimizethe risk of similar occurrences, fire departmentsshould

• ensure that Incident Commandcontinually evaluates the risk versusgain during operations at an incident

• ensure that a separate Incident SafetyOfficer independent from the IncidentCommander is appointed

• ensure that fire fighters are trained inthe tactics of defensive search

• ensure that fire fighters performing firefighting operations under or abovetrusses are evacuated as soon as it isdetermined that the trusses are exposedto fire

• ensure consistent use of Personal AlertSafety System (PASS) devices at allincidents and consider providing firefighters with a PASS integrated into theirSelf-Contained Breathing Apparatuswhich provides for automatic operation

• ensure that personnel equipped with aradio, position the radio to receive andrespond to radio transmissions

INTRODUCTIONOn March 8, 2001, a 38-year-old male career firefighter responded to a structure fire at a localresidence with a report from the neighbors thatthe occupants were still inside. After severalsearch and rescue attempts the occupants couldnot be located. The victim, who was operatingthe nozzle, entered the first floor of the structurewith a fire fighter to conduct a search for theoccupants. The floor beneath the victim gave way,causing him to fall through the floor and becometrapped in the basement. The victim was removedfrom the structure approximately 1 hour and 10minutes from the time the department was notifiedof the incident. The victim died 12 days later as aresult of his injuries. On March 21, 2001, theUnited States Fire Administration notified theNational Institute for Occupational Safety andHealth (NIOSH) of the incident. On March 23-26, 2001, two Safety and Occupational HealthSpecialists from NIOSH, Division of SafetyResearch, investigated the incident. Interviewswere conducted with the Chief, the AssistantChiefs, and members of the departments whoresponded to the fire. The incident site wasvisited, and photographs were obtained. Copiesof the standard operating procedures, trainingrecords, dispatch records and the notes of thecounty arson team’s investigation were reviewed.The site was a single-family home built in 1991,consisting of a one-story brick ranch structurewith a finished walk-out basement and an attachedtwo-stall garage. The roof was constructed oflayered asphalt shingles over plywood sheeting.

The fire department involved in this incidentoperates from four stations, and is comprised of65 uniformed fire fighters. The department servesa population of 13, 000 in a geographic area of30 square miles. The victim was certified throughthe State of Ohio as Fire Fighter Level II, Engine




Operator, Para-Medic, Haz-Mat and FirstResponder. The victim had over 20 years ofexperience and received additional trainingthrough the department on first aid, search andrescue, apparatus operation, live fire training andcardiopulmonary resuscitation.

INVESTIGATIONOn March 8, 2001, at 1230 hours, CentralDispatch received a call from a local resident abouta structure fire with the occupants trapped inside.Central Dispatch notified the department at 1231hours and dispatched Engine 70 with a fire fighteracting as the officer in charge (E70 OIC ), EngineOperator, and Fire fighter #1. The Assistant Chiefresponded in Car 02 to the scene. As Car 02 wasen route to the structure, heavy black smoke couldbe seen from over 3 miles away. Car 02 andEngine 70 arrived on the scene at approximately1239 hours, and the Assistant Chief assumedIncident Command (IC). The IC immediatelyordered the second alarm for mutual aid due tothe involvement of the structure. The structurewas located at the end of a private drive thatextended approximately 2000 feet from the countyroad and the nearest hydrant (See Drawing #1).Engine 70 stopped on the driveway for Fire fighter#1 to pull approximately 700 feet of 5-inch supplyline off the back of the Engine. Fire fighter #1staged the 5-inch supply line on the driveway tobe attached by Engine 105 for water relay. Firefighter #1 then proceeded to the structure to assistthe E-70 OIC on stretching a 1 3/4 inch handlineto the front door. Engine 105 was the first toarrive on the scene at approximately 1244 hoursfor mutual aid and responded with a Lieutenant,Engine Operator and Fire fighter #2. Fire fighter#3 responded via a privately owned vehicle (POV)at approximately 1245 hours. Engine 69 also arrivedat approximately 1245 hours with a Lieutenant andFire fighter #4. Engine 105 obtained assignmentsfrom the IC to set up water relay. Engine 69 stopped

at the hydrant and pumped to Engine 105, which inturned hooked up to the 5-inch supply line andrelayed water to Engine 70. Engine 68 arrived onthe scene at approximately 1250 hours with anAssistant Chief and the victim. They picked up theLieutenant from Engine 69 and proceeded to driveup the driveway to the structure.

The IC did an initial size-up of the structure andnoticed heavy fire in the left front of the structure.Neighbors approached the fire fighters and theIC stating that two or three people were trappedinside the structure. One of the residents wasreported to be confined to a wheelchair. The ICconducted another size-up, determining that allthe windows were intact and that fire was ventingthrough the roof. He then ordered a crew fromEngine 70 to conduct a search of the structure tolocate and remove any occupants. The front andside entrances were locked so the E-70 OIC madeforced entry through the front door. The E-70OIC (equipped with a thermal imaging camera),Fire fighter #1 (Nozzleman) and Fire fighter #3(backup) advanced a 1 3/4 inch handline throughthe front door. The E-70 OIC took the thermalimaging camera inside the structure to assist inthe search. The crew turned to the left andproceeded through the foyer and conducted asearch of the living room and dining room. Theythen proceeded back through the foyer and downa hallway to the bedrooms located in the back ofthe structure. Heavy smoke was encountered inthe hallway, making visibility near zero. At theend of the hallway they searched the bathroomand ventilated the bathroom window. The E-70OIC, Fire fighter #1 and Fire fighter #3 thenconducted a left-hand search of the bedrooms andlocated a hospital bed and wheelchair, but foundno occupants. They became low on air and exitedthe structure to refill their air bottles. The secondcrew to enter the structure was from Engine 105and consisted of a Lieutenant operating the nozzle




and Fire fighter #2 providing back-up on the 1 3/4inch handline. They too entered and turned left,proceeding through the foyer. The dining roomand living room were fully involved and the firehad vented through the roof at this time. TheLieutenant and Fire fighter #2 proceeded backthrough the foyer and began an aggressivesuppression effort by pulling the ceiling andattacking the fire in the kitchen (See Drawing #2).They then moved back through the hallway, intothe back bedrooms and bathroom, conductingaggressive suppression efforts.

After changing their air bottles, the E-70 OICreentered the structure with Fire fighter #1, whowas on the nozzle of the 1 3/4 inch handline. Theyproceeded to the left of the foyer where they couldsee the exposed brick wall of the west side of thestructure. The roof trusses that were not yetconsumed by the fire were also exposed. Downthe hallway and to the east side of the structure,where the kitchen was located, the ceiling wasfalling and they could see the fire venting throughthe roof. As they pulled the ceiling to expose andsuppress the fire, the roof trusses were breakingdue to their fire exposure. At this time, the ICdetermined the structure to be unsafe due tointense heat and the possibility of a collapse. TheIC gave the order for an emergency evacuationover the radio and also sounded the engine’s airhorn for emergency evacuation per thedepartment’s standard operating procedures(SOPs). Note: Each crew had a radio to relaypertinent interior information to the IC.Information was also given to the IC throughface-to-face communications as the crews exitedthe structure to exchange air bottles. After theevacuation the neighbors were still insisting thatthe owners were trapped inside. The IC ordereda search of the basement area, and assigned theAssistant Chief from Engine 68 to oversee thetechnical operations of the fireground. The

Assistant Chief assembled a crew consisting ofhimself, the E-70 OIC, a Lieutenant from a mutualaid company and Fire fighter #6 to conduct thesearch of the basement. The rear entrance to thebasement was unlocked and did not show any fire(See Drawing #3). Since there was light smoke,the Assistant Chief did not don his SCBA and wasable to see across the basement. The search wascompleted very quickly and an “All Clear” wasradioed to the IC. The IC, unaware of the clearvisibility, ordered a second search. The AssistantChief and his crew entered again, taking a thermalimaging camera to conduct a more thoroughsearch. The “All Clear” was given for thebasement a second time and the crew exited. TheAssistant Chief directed his crew to the garage tolook for fire extension and provide suppression.The IC gave the second order for an emergencyevacuation over the radio and sounded severallong blasts on the air horn to signal the evacuation.A full personnel accountability report (PAR) wasreceived at this time and the operation was to bestrictly defensive. Neighbors were stillapproaching the fire fighters and screaming thatthere were occupants inside the structure. TheIC ordered another search of the structure, butinstructed the crews not to commit too far. TheAssistant Chief assembled a crew consisting ofE-70 OIC, a Lieutenant from Engine 105 and Firefighter #3 to enter the basement and conduct asearch for the occupants with the thermal imagingcamera. At this time, visibility for the crew in thebasement was very poor and the intense heat waslimiting the effectiveness of the thermal imagingcamera, causing the screen to “white out.” Thecrew radioed an “All Clear” to the IC and exitedthe structure. The third emergency evacuationsignal was sounded. At this time, Fire fighter #2and the Lieutenant from Engine 69 were takingturns operating the nozzle of a 1 3/4 inch handlineon an exterior attack through the front windows.The Lieutenant and Fire fighter #2 came to the




front door to make entry just as the thirdevacuation signal was sounded. The victim, whowas at the front entrance, informed Fire fighter#2 and the Lieutenant of heavy fire in the garagearea. A crew consisting of Captain #2 and theEngine Operator from Engine 95 were also at thefront door receiving instructions from the IC andE-70’s OIC to conduct a search of the first floorwith a thermal imaging camera for possibleentrapments. Note: No civilians were ever locatedin the residence. The Lieutenant and Fire fighter #2began to make entry when the Lieutenant becamelow on air and went to exchange bottles. The victimassisted the Lieutenant with his bottle then returnedto man the nozzle with Fire fighter #2. Fire fighter#2 and the victim made entry through the front doorto attack the fire in the garage area. They thenconducted another search of the living room area.In the hallway leading to the living room the firewas in the wall, extending through the switch coversand wall registers. The heat and flames were rollingfrom the basement area when Fire fighter #2’s lowair alarm sounded. The victim and Fire fighter #2were backing out of the living room when the floorin the hallway beneath the victim gave way, causinghim to fall through the floor into the basement withthe handline. Fire fighter #2 immediately lay proneand tried to pull the victim through the hole but couldnot. He then ran outside screaming “Fire fighterdown!”

Captain #2, the Engine Operator from Engine 95and Fire fighter #2 rushed back inside, followedby the Assistant Chief from Engine 68. Fire fighter#2 and the Engine Operator from Engine 95 bothhad their hands on the victim and were trying tohoist him up through the floor. The victim’s glovewas pulled off in the process. The handline wascaught on the hole in the floor and could not beused to extricate him. The Assistant Chief couldsee and hear the victim through the floor. Heordered a back-up line and attic ladder for the

first floor, and for rapid intervention teams (RIT)to enter the basement through the back door (RIT#1) and kitchen stairwell (RIT #2). The flameswere extending up and beyond the attic ladder,restricting its use and any rescue efforts throughthe hole in the first floor.

The Captain from Engine 95 was in charge of therear sector and staged Fire fighter #1 and aLieutenant from a mutual aid company as a RITfor rescue operations of the rear sector. Entryfor rescue was then made through the rear entryinto the basement by Captain #1, who operatedthe nozzle on a 1 3/4 inch handline, followed byFire fighter #8, the Captain from Quint 33, Firefighter #5, the Lieutenant from Engine 105 andFire fighter #3 with a thermal imaging camera(RIT #1). The crew moved straight into thestructure to the front wall and proceeded toconduct a right hand search, which led them intothe south hallway. The Lieutenant from Engine105 was unaware that his air tank was not turnedon forcing him to exit within a minute. Hereentered with E-70’s OIC. They met up withthe RIT #2 and proceeded down the north hallway.Fire fighter #6 and Fire fighter #7 entered the frontdoor and were instructed by the Assistant Chiefto be RIT #2. He instructed them to take thestairwell in the kitchen to the basement and conducta search for the victim. When they entered thebasement they proceeded straight back and passedanother crew (RIT #1) to their left, also searchingfor the victim. The west side of the basementconsisted of two separate parallel hallways leadingto bedrooms (See Drawing #3). They entered thehallway to the north and encountered intense heatfrom the bedroom areas which were fully involved.

RIT #1 was experiencing extreme heat with zerovisibility. Fire fighter #3 exited the structure torequest positive pressure ventilation (PPV). ThePPV fan was set in place and provided improved




visibility. RIT #1 found the victim in the furnaceroom between the two hallways. RIT #2 breacheda wall to reach the victim and assisted in removal.The victim was found between a wall and the hotwater heater, sitting on his hands in the uprightposition. The victims portable radio was in the offposition and located in the pants pocket of histurnouts. His hood, turnouts, SCBA and face-piecewere on with air remaining in his tank. His helmetand his gloves were not on at this time. Neither hislow air alarm nor his personal alert safety system(PASS) was sounding. The victim became semiresponsive while in transit to the emergency transporthelicopter. He sustained third degree burns to over halfof his body and died 12 days later from the injuries.

CAUSE OF DEATHThe cause of death was listed as complications ofthermal burns to 60% of total body surface.

RECOMMENDATIONS AND DISCUSSIONRecommendation #1: Fire departments shouldensure that Incident Command continuallyevaluates the risk versus gain during operationsat an incident. 1-6

Discussion: Considerations for rescue operationsof occupants include information such as time ofincident, time fire was burning before arrival, timefire was burning after arrival, time occupants havefor rescue (risk vs. gain) and type of attack are someof the most important pieces of information theIncident Commander should have. After it has beendetermined that the time frame for rescue hasexpired, the operation should become a recoveryand all tactical efforts should be defensive.

Recommendation #2: Fire departments shouldappoint an Incident Safety Officer. 1, 4, 7

Discussion: According to NFPA 1561, paragraph 4-1.1, “The Incident Commander shall be responsible

for the overall coordination and direction of allactivities at an incident. This shall include overallresponsibility for the safety and health of all personneland for other persons operating within the incidentmanagement system.” While the IncidentCommander (IC) is in overall command at the scene,certain functions must be delegated to ensureadequate scene management is accomplished.According to NFPA 1500, paragraph 6-1.3, “Asincidents escalate in size and complexity, the incidentcommander shall divide the incident into tactical-level management units and assign an incident safetyofficer to assess the incident scene for hazards orpotential hazards. “ The incident safety officer (ISO),by definition is “An individual appointed to respondto or assigned at an incident scene by the incidentcommander to perform the duties and responsibilitiesspecified in this standard. This individual can be thehealth and safety officer or it can be a separatefunction. “According to NFPA 1521, paragraph 2-1.4.1, “An incident safety officer shall be appointedwhen activities, size, or need occurs.” On-scenefire fighter health and safety is best preserved bydelegating the function of safety and health oversightto the ISO. The ISO is appointed by the IncidentCommander at each emergency scene. The dutiesof the ISO are to monitor the scene and report thestatus of conditions, hazards, and risks to the incidentcommander, ensure that fire fighter rehabilitationoccurs, that the personnel accountability system isbeing utilized, and to monitor radio communicationsto ensure all areas of the scene are capable ofcommunicating to incident command.

Recommendation #3: Fire departments shouldensure fire fighters are trained to recognize thedanger of searching above a fire.8

The danger of being trapped above a fire is greatlyinfluenced by the construction of the burningbuilding. Of the five basic building constructiontypes (fire resistive, noncombustible, ordinary




construction, heavy timber, and wood-frame) thegreatest danger to a fire fighter who must searchabove the fire is posed by wood frameconstruction. Vertical fire spread is more rapid inthis type of structure. Flames may spreadvertically and trap fire fighters searching abovethe fire, in four ways: up the interior stairs, throughwindows (autoexposure), within concealedspaces, or up the combustible exterior siding.Extreme caution must be used to determine if thestructural stability of the flooring system isadequate to facilitate the search.

Recommendation #4: Fire departments shouldensure that fire fighters performing fire fightingoperations under or above trusses are evacuatedas soon as it is determined that the trusses areexposed to fire.9

Discussion: There is no specific time limit on howlong fire fighters should operate under or on trussroofs that are exposed to fire. A time limit is oftenused by fire departments as a guide for operationunder or on truss roofs. Even though standardfire engineering calculations show that lightweighttrusses may be expected to collapse after about10 minutes in a fully developed fire, it is notrecommended to set a time limit. As stated inBuilding Construction For the Fire Service,13

“under fire conditions, truss failure isunpredictable.” When fire fighters arrive on thescene of a building with trusses exposed to fire, itis virtually impossible to identify how long thetrusses have been exposed to fire and set a timelimit for fire suppression. When it is determinedthat the building’s trusses have been exposed tofire, any fire fighters operating under or abovethem should be immediately evacuated. If it isnot clear that the building’s trusses have beenexposed to fire, a defensive attack should takeplace until the conditions can be verified. In thisincident, the decision was made early to evacuate

the structure due to the roof trusses collapsing.After the fire vented through the roof, the fireexpanded in the basement. The direct heat andflame impingement on the floor joists resulted inthe same type of failure as in the roof trusses.

Recommendation #5: Fire departments shouldensure consistent use of Personal Alert SafetySystem (PASS) devices at all incidents andconsider providing fire fighters with a PASSintegrated into their Self-Contained BreathingApparatus which provides for automaticactivation. 10

Discussion: PASS devices are electronic devicesworn by the fire fighter, which will emit a loudand distinctive alarm if the fire fighter becomesmotionless for more than 30 seconds. Fire fightersentering hazardous areas should be equipped witha PASS device. There are several types of PASSdevices available. One device that could be usedis a PASS that is integrated into the SCBA. “Suchautomatic activation shall be permitted to be, butnot limited to, linked to activation of SCBA, linkedto removal from storage or transportationpositions, by pull-away tether to a fixed position,or by remote activation.” Manual PASS devicesare also used throughout the fire service. Thesedevices require fire fighters to manually turn onthe device each time they use it.

Recommendation #6: Fire departments shouldensure that personnel equipped with a radio,position the radio to receive and respond to radiotransmissions.11

Discussion: The fireground communicationsprocess combines electronic communicationequipment, a set of Standard OperatingProcedures, and the fire personnel who will usethe equipment. To be effective, the communicationsnetwork must integrate the equipment and




procedures with the dynamic situation at theincident site, especially in terms of the humanfactors affecting its use. The ease of use andoperation may well determine how consistentlyfire fighters monitor and report over the radiowhile fighting fires. Fire departments shouldreview both operating procedures and humanfactors issues to determine the ease of use of radioequipment on the fireground to ensure that firefighters consistently monitor radio transmissionsfrom the IC and respond to radio calls.

REFERENCES1. Dunn V [1992]. Safety and survival on thefireground. Saddle Brook, NJ: Fire EngineeringBooks & Videos.

2. NIOSH [1999]. Preventing injuries and deathsof fire fighters due to structural collapse.Cincinnati, OH: U.S. Department of Health andHuman Services, Public Health Service, Centersfor Disease Control and Prevention, NationalInstitute for Occupational Safety and Health,DHHS (NIOSH), Publication No. 99-146.

3. International Fire Service Training Association[1995]. Essentials of fire fighting, 3rd ed. FireProtection Publications.

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

5. Norman J [1998]. Fire officer’s handbook oftactics. Saddle Brook, NJ: Fire Engineering Booksand Videos.

6. Dunn V [1988]. Collapse of burning buildings,a guide to fireground safety. Saddle Brook, NJ:Fire Engineering Books and Videos.

7. NFPA [1997]. NFPA 1500: standard on firedepartment occupational safety and healthprogram. Quincy, MA: National Fire ProtectionAssociation

8. Dunn V [1999]. Command and control of firesand emergencies. Saddle Brook, NJ: FireEngineering Books and Videos, p.245.

9. Brannigan FL [1999]. Building construction forthe fire service. Quincy, MA: National FireProtection Association.

10. NFPA [1998]. NFPA 1982: Personal AlertSafety System. Quincy, MA: National FireProtection Association.

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

INVESTIGATOR INFORMATIONThis investigation was conducted by Jay Tarleyand Tom Mezzanotte, Safety and OccupationalHealth Specialists, NIOSH, Surveillance and FieldInvestigations Branch, Division of SafetyResearch.




Photo: Courtesy of Steve Claytor, Special County Arson Team

(REAR OF STRUCTURE)




Photo: Courtesy of Steve Claytor, Special County Arson Team

(FRONT OF STRUCTURE)




Drawing Courtesy of: Steve Claytor, Special County Arson Team

F2001-16Overhead View

of Property

Drawing #1




F2001-16Aerial ViewFirst Floor


Drawing #2





Drawing #3

F2001-16Aerial ViewBasement

Victim

fire fighter face report no. f2001-16, career fire … · on march 8, 2001, a 38-year-old male...

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