Expert answer:Fire Case Study 3
Expert answer:Write a minimum of 500 words explaining the key issues that lead to this fatality. Make sure that you use sources to
support your main ideas. APA Format. Attach is the article
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2008
34
Fire Fighter Fatality Investigation
and Prevention Program
Death in the
line of duty…
A summary of a NIOSH fire fighter fatality investigation
June 11, 2008
Revised on June27, 2011 to include the attached Appendix.
Volunteer Fire Fighter Dies While Lost in Residential Structure FireAlabama
Incident Scene after Victim Removed
(Photo courtesy of sheriff’s office)
SUMMARY
On October 29, 2008, a 24-year old male volunteer fire fighter (the victim) was fatally injured while
fighting a residential structure fire. The victim, one of three fire fighters on scene, entered the
residential structure by himself through a carport door with a partially charged 1½-in hose line; he
The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease
Control and Prevention (CDC), is the federal agency responsible for conducting research and making
recommendations for the prevention of work-related injury and illness. In fiscal year 1998, the Congress appropriated
funds to NIOSH to conduct a fire fighter initiative. NIOSH initiated the Fire Fighter Fatality Investigation and
Prevention Program to examine deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire
service organizations, safety experts and researchers could learn from these incidents. The primary goal of these
investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations
are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking,
enforcement and inspection activities of any other federal or state agency. Under its program, NIOSH investigators
interview persons with knowledge of the incident and review available records to develop a description of the
conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations.
The NIOSH summary of these conditions and circumstances in its reports is not intended as a legal statement of facts.
This summary, as well as the conclusions and recommendations made by NIOSH, should not be used for the purpose
of litigation or the adjudication of any claim. For further information, visit the program website at
www.cdc.gov/niosh/fire or call toll free at 1-800-CDC-INFO (1-800-232-4643).
2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
became lost in thick black smoke. The victim radioed individuals on the fireground to get him out.
Fire fighters were unable to locate the victim after he entered the structure which became engulfed in
flames. The victim was caught in a flashover and was unable to escape the fire. Approximately an
hour after the victim entered the structure alone, a police officer looking through the kitchen window
noticed the victim’s hand resting on a kitchen counter; the victim was nine feet from the carport door
he had entered. The victim was removed from the structure and pronounced dead at the scene by
emergency medical services. Key contributing factors identified in this investigation include: fire
fighters entering a structure fire without adequate training, insufficient manpower, and lack of an
established incident command system.
NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments
should:
ensure that fire fighters receive essential training consistent with national consensus
standards on structural fire fighting before being allowed to operate at a fire incident
develop, implement, and enforce written standard operating procedures (SOPs) for
fireground operations
ensure that fire fighters are trained to follow the two-in/two-out rule and maintain crew
integrity at all times
ensure that adequate numbers of apparatus and fire fighters are on scene before initiating
an offensive fire attack in a structure fire
ensure that officers and fire fighters know how to evaluate risk versus gain and perform a
thorough scene size-up before initiating interior strategies and tactics
develop, implement, and enforce a written incident management system to be followed at all
emergency incident operations and ensure that officers and fire fighters are trained on how
to implement the incident management system
ensure fire fighters are trained in essential self-contained breathing apparatus (SCBA) and
emergency survival skills
ensure that protocols are developed on issuing a Mayday so that fire fighters and dispatch
centers know how to respond
ensure that a properly trained incident safety officer (ISO) is established at structure fires
ensure that a rapid intervention team (RIT) is established and available at structure fires
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2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
ensure that properly coordinated ventilation is conducted on structure fires
ensure that driver/pump operators receive adequate training to operate and maintain a
water supply to hoselines on the fireground
ensure that all fire fighters engaged in fireground activities wear the full array of personal
protective equipment (PPE) issued to them
ensure that fire fighters are trained to react to PASS and SCBA low air alarms, and that
procedures are developed to properly shut down and secure a SCBA and its PASS device
Additionally, states, municipalities, and authorities having jurisdiction
should consider requiring mandatory training for fire fighters
INTRODUCTION
On October 29, 2008, a 24-year-old male volunteer fire fighter (the victim) died in a residential
structure fire. On October 30, 2008, the U.S. Fire Administration notified the National Institute for
Occupational Safety and Health (NIOSH) of this incident. On November 3-7, 2008, two safety and
occupational health specialists from the NIOSH Fire Fighter Fatality Investigation and Prevention
Program investigated this incident. The NIOSH investigators interviewed the officers and fire
fighters of the volunteer departments involved in this incident and county EMS responders. The
investigators also spoke with representatives from the Alabama State Fire College and the Alabama
Association of Volunteer Fire Departments. The investigators met with the Deputy State Fire
Marshal, sheriff’s office investigator and the County 911 Dispatch Director. NIOSH investigators
also reviewed witness statements and photographs of the fireground and dispatch tapes, the victim’s
training records, and the coroner’s cause of death notification. The incident site was visited and
photographed.
Although the performance of the victim’s SCBA was not considered a factor in this incident, the
SCBA was examined by NIOSH’s National Personal Protective Technology Laboratory to determine
conformity to the NIOSH approved configuration. A summary of this evaluation is included at the
end of this report as an appendix. At the request of the fire department, NIOSH contracted with a
personal protective equipment (PPE) expert to evaluate the victim’s PPE.a The expert evaluation
concluded that the PPE was extensively damaged due to flame and heat exposures, most of which
likely occurred after the victim succumbed to either smoke inhalation or severe burn injuries. It was
a
The PPE evaluation report is available upon request to the NIOSH Division of Safety Research, Fire Fighter Fatality
Investigation and Prevention Program (Attention: Tim Merinar), 1095 Willowdale Road, MS H1808, Morgantown, WV,
26505, 304-285-5916, Tmerinar@cdc.gov.
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2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
not possible to identify if any of the PPE damage preceded the fatality, or if improper wearing of the
PPE contributed to the ultimately fatal injuries. Where it was possible to identify the manufacturer,
style of product, and manufacturing date, the gear appeared to be relatively new and compliant with
the latest editions of relevant standards. The expert noted that no protective clothing or equipment
would be expected to provide adequate protection in the circumstances of this event in which the
victim was possibly exposed to a flashover event and subject to flame and high heat for nearly an
hour.
FIRE DEPARTMENTS
Station “Alpha” – Victim’s Department. The victim’s volunteer department has one station
and is comprised of 21 fire fighters. The department serves a population of approximately
14,000 in a geographical area of 25 square miles.
Station “Bravo” – Mutual Aid Department. The volunteer department has one station and is
comprised of 20 fire fighters. The department serves a rural population in a geographical area
of 28 square miles.
Station “Charlie” – Mutual Aid Department. The volunteer department has one station and
is comprised of 18 fire fighters. The department serves a population of approximately 8,000
in an area of about 47 square miles. Note: Bravo Fire Department was dispatched before
Charlie Fire Department, but did not respond until after the victim was located.
The victim’s department had no verbal or written standard operating procedures for their members to
follow.
TRAINING and EXPERIENCE
The 24 year-old victim had been a volunteer fire fighter with this department for 2 years. The victim
had attended documented peer-led training on self-contained breathing apparatus (SCBA), pump
operations, water tactics, and general firefighting. The victim had also completed various online
training courses on the incident command system (ICS) and national incident management system
(NIMS).
The fire fighter initially operating with the victim had joined the fire department three months prior to
the incident with no previous experience. Other fire fighters on scene had completed the same online
courses in ICS and NIMS.
Alabama has no state training requirements for volunteer fire fighters. The Alabama State Fire
College has a non-mandatory 160-hour volunteer fire fighter certification course.1, 2 Alpha fire
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2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
department members on scene had not completed this training. The three responding members from
Charlie fire department had taken this training.
EQUIPMENT and PERSONNEL
Station “Alpha” – Victim’s Department
Alpha Rescue 1 (AR1) with one fire fighter (fire fighter #1)
Alpha Engine 2 (AE2) with two fire fighters (victim, fire fighter #2)
Alpha Truck 2 (AT2) with one fire fighter (fire fighter #3)
Alpha Engine 1 (AE1) with one fire fighter (fire fighter #4)
Station “Charlie” – Mutual Aid Department
Charlie Engine 3 (CE3) with fire chief (CFC) and one fire fighter (fire fighter #5)
Charlie Engine 1 (CE1) with one fire fighter (fire fighter #6)
Privately Owned Vehicle (POV) with one fire fighter
Water Supply on scene included:
AR1 300 gallons (used after last communication with victim)
AE1 1,000 gallons (arrived after last communication with victim)
AE2 1,000 gallons
AT2 1,200 gallons (not used)
CE1 1,000 gallons (arrived after last communication with victim)
CE3 3,000 gallons (arrived after last communication with victim)
TIMELINE
The timeline for this incident includes the initial call to the 911 dispatch center at 1301 hours. Only
the units directly involved in the operations preceding the incident are discussed in this report.
Certain key radio transmissions are summarized in the timeline. All times are approximate. The
response, listed in order of arrival, fire conditions and key events, includes:
1301 Hours
911 dispatch center receives a cellular 911 call for an attic fire in a house with all occupants
out
Alpha Fire Department dispatched
1310 Hours
AR1 en route
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2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
1316 Hours (thick black smoke from roof)
AR1 on scene and states, “smoke coming from roof”
AR1 driver requests Bravo Fire Department to be dispatched
Bravo Fire Department dispatched
1317 Hours
AE2, operated by the victim, on scene (no en route time available)
County EMS dispatched
1318 Hours
Bravo Fire Department dispatched again after no response
County EMS en route
Victim possibly requesting his hoseline to be charged
1319 Hours
AE1 en route
FF1 advises victim he is charging his line
1320 Hours
Sounds like victim states, “…fire getting away in here…”
1323 Hours
Charlie Fire Department dispatched after Bravo Fire Department was dispatched twice
with no response
Inaudible radio traffic by victim
1324 Hours
Sounds like victim yells “I’m hot…Come get me, come get me!”
1328 Hours (fire blowing out “A” side windows, front door, and carport entry)
AT2 on scene (no en route time available)
AE1 on scene
1330 Hours
CE1 and CE3 en route
County EMS on scene
1333 Hours
AR1 requested ambulance
911 dispatch center advised AR1 that ambulance may be on scene
AR1 requests second ambulance to be dispatched
911 dispatch center requested reason for a second ambulance, with no response
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2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
1338 Hours (fire visible from doors and “A” and “B” side windows)
CE3 on scene
1339 Hours
CE1 on scene
1356 Hours
AR1 requested local power company to be contacted
1418 Hours
911 dispatch center received cellular 911 call from police officer on scene requesting Bravo
and Delta Fire Departments be dispatched to the scene to help with a trapped fire fighter
1420 Hours
Victim found and removed from structure
PERSONAL PROTECTIVE EQUIPMENT
The victim was last seen wearing a full array of personal protective clothing and equipment,
consisting of turnout gear (coat and pants), helmet, Nomex® hood, gloves, boots, and a selfcontained breathing apparatus (SCBA) with an integrated personal alert safety system (PASS). The
structural fire fighting gear was compliant with the 2007 edition of NFPA 1971. The victim was
equipped with a portable radio, flashlight, and various fire fighter hand tools in his pockets. The heat
resistant outer shell, moisture barrier, and insulating thermal lining were all present during the
incident and documented during the investigation. The victim was found without his helmet and
Nomex® hood on. The victim was also missing a glove, boot, and assigned radio. The face piece
appeared to have been melted off of the victim.
STRUCTURE
The incident structure was a single-story brick ranch house built in 1969. The residential structure
had approximately 2,100 square feet of furnished living area and no basement. The interior
construction consisted of wood framing and possibly drywall. The exterior construction was brick
with an attached carport at the “A-D” corner (see Diagram). A tin roof had been placed overtop the
existing shingled roof.
The origin and cause of the fire was ruled accidental by the Deputy State Fire Marshal and believed
to have started in the chimney. The fireplace had been converted into a wood stove with a flue in or
around 1970 or 1971. Approximately 8-10 years prior to the incident, the brick chimney had begun
to pull away from the house. The owner had wrapped a steel cable around the chimney and placed a
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2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
turnbuckle to connect the cable ends; this supported the chimney while pulling it back against the
house (see Photo 1).
Photo 1. Steel cable used to support the chimney against the house with a turnbuckle.
(Photos courtesy of sheriff’s office)
After the chimney was repositioned, the owner noticed that bricks from the chimney’s flue had
cracked and shifted. The owner removed the damaged bricks and replaced them with hollow cinder
blocks. These blocks had been laid with the hollows horizontally positioned towards the attic space
(see Photo 2). The residents of the house were safely evacuated prior to the fire department’s arrival.
The structure was completely destroyed by a rekindle several days later.
Photo 2. The picture shows the area of the brick chimney flue that was replaced with cinder
blocks. The cinder blocks allowed heat and flame to impinge on the exterior wall allowing fire
to spread into the attic space.
(Photo courtesy of sheriff’s office)
Page 8
2008
Fire Fighter Fatality Investigation
and Prevention Program
Fatality Assessment and Control Evaluation
Investigation Report # F2008-34
Volunteer Fire Fighter Dies While Lost in Residential Structure Fire- Alabama
WEATHER
The weather at the time of the incident was clear with a temperature of 55°F and slight winds from
the west.
INVESTIGATION
On October 29, 2008, at 1301 hours, the 911 dispatch center received a cellular 911 call for an attic
fire. The initial dispatch included Station Alpha at 1301 hours, Station Bravo at 1316 hours (no
response), and Station Charlie at 1323 hours. Smoke was showing from the roof upon arrival of
Station Alpha’s first unit. Incident command was not established by arriving units.
Initial activities of AR1 and AE2
AR1 marked on scene at 1316 hours with thick, black smoke showing from the roof. Fire fighter #1
(FF1) exited the apparatus after he had positioned it in the street in front of the house. He then spoke
to several individuals in the yard that had appeared to be exiting away from the house. A female
advised him that there was no one left in the house. At 1317 hours the victim and fire fighter #2
(FF2) marked on scene in AE2 and positioned their apparatus behind AR1 (see Diagram). FF1 met
the victim and FF2 between their apparatus to put gear on. The victim and FF2 then walked around
the house to check on fire conditions. FF1 then flaked out cross-lay #1 (200-ft of 1½-in hose) from
AE2. FF2 returned to AE2 to retrieve the hoseline while the victim waited at the A-D corner under
the carport. It is believed that the victim and FF2 were on air. FF2 pulled the uncharged cross-lay #1
to the carport door and handed the nozzle to the victim, while FF1 charged the line. The victim
opened the bail and water trickled out of the nozzle. The victim yelled back to FF1 to give him more
pressure on the hoseline. FF2 recalls hearing the engine of AE2 get really loud, but could not
confirm the line being fully charged. The victim and FF2, on air, walked into the structure through
the carport door. They were approximately two feet inside the structure and were met by thick,
rolling black smoke, but no fire. Quickly, they exited through the carport door taking cross-lay #1
with them. The victim told FF2 to go and get a flashlight. FF2 reported that he told the victim to
wait for his return, and that the victim indicated that he would wait.
Activities of FF2
FF2 reported that he walked to the end of the driveway (approximately 75-ft) grabbed the flashlight
off of the apparatus, and returned to the carport doo …
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