Expert answer:Case Study Firefighting

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2011
30
June 25, 2012
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
Executive Summary
On December 8, 2011, a 43-year-old
male career fire fighter received fatal
injuries when he was trapped under
falling debris during a partial collapse at
the rear of a three-story residential
structure. The victim was part of a
rescue company that was conducting a
secondary interior search for a reported
missing resident. The secondary search
was initiated approximately 30 minutes
after the crews had arrived on-scene and
approximately 10 minutes after fire
fighters evacuated the building due to
deteriorating conditions within the
burning structure. The secondary
search was initiated after the missing
civilian’s roommate persisted in telling
Rear view of the “triple decker” residential structure
fire fighters that his friend was still
following partial cleanup of collapse debris. Search
inside, and most likely in a rear, secondcrews were on the second floor at the time of collapse.
floor bedroom. The collapse trapped the
(NIOSH Photo)
victim under debris on the first floor
while the injured fire fighter rode the second floor down to the basement. A total of 11 fire fighters
were inside the structure at the time of the collapse. Rescue operations took approximately 50 minutes
to free the victim who was unresponsive. Extensive shoring was required within the unstable collapse
area and crews had to breach the brick cellar wall to reach the injured fire fighter. Following the
extrication efforts, fire fighters continued to search for the missing civilian. It was later determined
that the missing civilian was not inside the structure at the time of the collapse. The civilian had left
prior to the arrival of the fire department.
Contributing Factors
 Civilian resident persistently stated another resident was still inside
 Fire burned well over 30 minutes before being brought under control
 Structure reacted to fire conditions in an unexpected manner
 1890 era balloon-frame wood structure in deteriorated condition
 Instability of cellar wall and surrounding soil due to age and weather conditions
Page i
Report # F2011-30
A summary of a NIOSH fire fighter fatality investigation
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
 Structural deficiencies not readily apparent
 Unusual cellar configuration for this type of residential structure
 Building inspection findings not readily available to fire department through city dispatch
system
Key Recommendations
 Fire departments and city building departments should
work together to ensure information on hazardous
buildings is readily available to both
 Authorities having jurisdiction should ensure that
hazardous building information is part of the information
contained in computerized automatic dispatch systems
 Fire Departments should train all firefighting personnel on
the risks and hazards related to structural collapse
 Fire Departments should use risk management principles
including occupant survivability profiling at all structure
fires
Hazardous building placard attached to exposure
structure located just south of the fire building.
(NIOSH Photo)
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 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the
NIOSH “Fire Fighter Fatality Investigation and Prevention Program” which examines line-of-duty-deaths or on duty deaths of fire
fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The
agency does not enforce compliance with State or Federal occupational safety and health standards and does not determine fault or
assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH
investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop
a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and
interviews are not recorded. The agency’s reports do not name the victim, the fire department or those interviewed. The NIOSH
report’s summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency’s
recommendations and is not intended to be definitive for purposes of determining any claim or benefit.
For further information, visit the program Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page ii
Report # F2011-30
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
Introduction
On December 8, 2011, a 43-year-old male career fire fighter received fatal injuries when he was
trapped under falling debris during a partial collapse at the rear of a three-story “triple decker”
residential structure. The U.S. Fire Administration notified the National Institute for Occupational
Safety and Health (NIOSH) of this incident the same day. NIOSH investigators with the Fire Fighter
Fatality Investigation and Prevention Program contacted the fire department involved in this incident
to arrange an investigation. At the request of the International Association of Fire Fighters (IAFF)
union and the fire department, the NIOSH investigation was initiated after the December holidays. On
January 4, 2012, a safety engineer, a general engineer, an occupational safety and health specialist and
an investigator with the NIOSH Fire Fighter Fatality Investigation and Prevention Program traveled to
Massachusetts to investigate this incident. During this investigation, the NIOSH representatives met
with fire department officials including the Fire Chief, the Deputy Chief of Operations, the Chief of
Safety and members of the Arson Unit. The NIOSH investigators also met with representatives of the
IAFF local and the Commonwealth of Massachusetts Assistant District Attorney representing the
county. The NIOSH investigators visited the city’s dispatch center and obtained a copy of the
fireground audio. The NIOSH investigators visited the incident site and photographed the structure as
well as an adjacent triple decker with a similar floor plan. The NIOSH investigators conducted
interviews with fire department officers and fire fighters directly involved in the fatal incident. On
January 11, 2012, the NIOSH safety engineer and one investigator returned to Massachusetts to
continue the investigation. Meetings were held with representatives of the U.S. Department of Justice,
Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF); Massachusetts State Police, Fire and
Explosion Investigation Section; the fire department’s Chief of Training; and the city’s Division of
Building and Zoning. Additional interviews were conducted with fire fighters directly involved in the
incident. The NIOSH investigators inspected and photographed the victim’s personal protective
clothing and self-contained breathing apparatus. The NIOSH investigators reviewed training records
and standard operating procedures at the fire department. Additional photographs and building
information were obtained with the assistance of the Assistant District Attorney.
Fire Department
The career fire department provides fire protection and life safety services to an area encompassing 39
square miles and a population of close to 181,000. The day time population increases to well over
200,000. The city encompasses a diverse range of structures from densely populated multi-family
dwellings to residential and office high rise buildings to a mixture of manufacturing and industrial
complexes. The city also contains 10 universities and colleges.1 A major east-west interstate highway
passes through the city, along with multiple rail systems. The fire department provides first responder
emergency medical care. Advanced life support and transportation is provided by a private health care
company.
The fire department operates 13 Engine Companies, 7 Ladder Companies, 1 Heavy Rescue, 1 Special
Operations unit, 1 Field Communications unit and 2 SCUBA (dive rescue operations) vehicles from 10
stations. Fire operations are divided into north and south divisions or districts with a District Chief
overseeing operations within each district. The fire department employs a total of 406 uniformed
personnel within the operations, fire prevention and support services divisions.
Page 1
A summary of a NIOSH fire fighter fatality investigation
Report # F2011-30
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
Fire fighters are assigned to work one of four operations shifts. Fire fighters work two 10-hour day
shifts on consecutive days (24 hours off) followed by two 14-hour night shifts on consecutive nights,
then are off for 3 consecutive days. A full shift roster includes 88 fire fighters with minimum staffing
at 72.
The fire department maintains a SCUBA Dive Rescue Team trained for swift water rescue and
recovery, under-water and under-ice rescue operations; and a Technical Rescue team trained for trench
rescue, confined space, collapse rescue and high-angle rescue
The fire department operates on an 800 megahertz trunked radio system managed by the city. Each
fire fighter is assigned a portable radio having 16 different talk groups. Emergency calls are
dispatched over an operations group. The fire department also has 3 operations groups to which an
incident can be assigned by the Incident Commander (per mandatory fire department procedures),
allowing fireground radio traffic to occur on its own channel. Fire Prevention, Training, and
Maintenance each have their own talk group. The city Emergency Communications Department
receives all 911 calls originating within the city. Calls are then transferred to the appropriate
dispatchers. Call receipt and dispatching are processed by a computer-aided-dispatch (CAD) system.
The fire department responded to a total of 28,150 incidents (1,435 fire and 26,715 non-fire) during
2010 and a total of 28,891 incidents (1,384 fire and 27,507 non-fire) during 2011. In 2007, the fire
department received a Class 2 rating from ISO.a In the ISO rating system, Class 1 represents
exemplary fire protection, and Class 10 indicates that the area’s fire-suppression program does not
meet ISO’s minimum criteria.
Training and Experience
The Commonwealth of Massachusetts does not have prerequisite training or education requirements
for an individual to become a fire fighter. Persons wanting to work as a fire fighter in Massachusetts
must pass the state’s civil service test and a physical abilities test.
This municipal fire department operates its own training center under the supervision of a Chief of
Training. The training center includes a burn building that allows for live-fire training using class A
fuels. The burn building can be configured for multiple training evolutions to simulate residential,
commercial, triple-decker and high-rise construction.
a
ISO is an independent commercial enterprise which helps customers identify and mitigate risk. ISO can provide
communities with information on fire protection, water systems, other critical infrastructure, building codes, and natural
and man-made catastrophes. ISO’s Public Protection Criteria program evaluates communities according to a uniform set of
criteria known as the Fire Suppression Rating Schedule (FSRS). More information about ISO and their Fire Suppression
Rating Schedule can be found at the website http://www.isogov.com/about/.
Page 2
A summary of a NIOSH fire fighter fatality investigation
Report # F2011-30
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
The training center provides recruit, proficiency and annual refresher training for the fire department.
Recruits are selected through the state’s civil service examination process. Potential candidates must
have a valid driver’s license and a high school diploma or a GED certificate. Selected candidates
attend a 16-week recruit training class at the department’s training center, regardless of whether they
have previous firefighting experience or not. The recruit class curriculum is equivalent to the
requirements of the National Fire Protection Association (NFPA) 1001 Standard on Professional
Qualifications for Fire Fighters, Fire Fighter I and Fire Fighter II.2 Recruit training is conducted at the
training center with the exception of flashover simulation training, gas-fueled fire and Hazardous
Materials Awareness training which is conducted at the Massachusetts Fire Academy. After
completing the 16-week recruit training class, new fire fighters are on probation for 9 months and
cannot work on a fire apparatus without an officer present. Recruits must pass the ProBoard
Certification requirements prior to receiving a permanent assignment. Note: Prior to 2010, fire
fighters completing the fire department’s recruit training class were not required to obtain ProBoard
certification for Firefighter I and Firefighter II.
The training center provides the resources for each station to conduct their own Company-level
proficiency training. Fire fighters are required to train at least 1-hour per work shift and must complete
8 training drills covering 8 different topics per month. Training records forms are submitted by the
company officer through the District Chief to the Chief of Training. The fire department has
maintained an electronic training record-keeping system since 2006. Note: Training records prior to
2006 are maintained by the fire department but were not reviewed by NIOSH investigators as part of
this investigation.
Special operations training is also handled through the training center. In addition to the Rescue 1
crews, the fire department maintains one engine company (Engine 5) and one ladder company (Ladder
4) specifically trained for technical rescue operations. Note: During the NIOSH interviews, a number
of fire fighters commented on the technical rescue training and how the training had enhanced the
rescue operations during this incident. This fire department suffered a multiple line-of-duty death
incident in 1999. The department’s training program was enhanced and the current training facility
built following the 1999 incident.
Internal promotions to all ranks are handled following the state’s civil service promotion test process.
Promotion examinations are given every two years. When promotions occur, the fire department
conducts a 40-hour officer development training program. In addition, company officers can take Fire
Officer I-IV training at the Massachusetts Fire Academy, although it is not a fire department
requirement.
The victim joined the fire department in April 1994. He had been assigned to Rescue 1 in May 2010.
Training records showed that the victim had completed numerous fire fighter and first responder
training such as live fire training, large diameter hose lines, positive pressure ventilation, and personal
protective equipment use. He had completed specialized technical rescue training in subjects such as
hazardous materials, use of hazardous materials detection equipment, dive rescue operations, rope
Page 3
A summary of a NIOSH fire fighter fatality investigation
Report # F2011-30
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
rescue operations, weapons of mass destruction/terrorism incidents, trench rescue and high angle
technical rescue operations.
The injured fire fighter joined the fire department in September 1997 and was assigned to Rescue 1 in
May 2005. The injured fire fighter completed numerous fire fighter and first responder training such
as live fire training, positive pressure ventilation, large diameter hose lines, and personal protective
equipment use. He also completed specialized training in a number of topics including rope rescue
operations, use of hazardous materials detection equipment, confined space rescue, trench rescue,
collapse rescue, dive rescue operations, and high angle technical rescue.
The Incident Commander joined the fire department in April 1977 and was promoted to District Chief
in December 2008. He had completed numerous fire fighter and first responder training.
Equipment and Personnel
The fire department responded to the initial alarm dispatch at 0421 hours with the following personnel
and apparatus:
Engine 12 – Lieutenant and 2 fire fighters
Engine 6 – Captain and 2 fire fighters
Engine 13 – Lieutenant and 2 fire fighters
Engine 2 – Lieutenant and 2 fire fighters
Ladder 1 – Lieutenant and 2 fire fighters
Ladder 3 – 3 fire fighters
Car 4 – District Chief and Incident Command Technician
Rescue 1 – Lieutenant and 5 fire fighters
Ladder 7 as the designated Rapid Intervention Team (RIT) – Lieutenant and 2 fire fighters
A second alarm was requested by the Incident Commander (Car 4) at 0425 hours which resulted in the
following personnel and apparatus being dispatched:
Engine 7 – Captain and 3 fire fighters
Engine 15 – Lieutenant and 2 fire fighters
Ladder 5 – Captain and 3 fire fighters
Car 3 – District Chief and Incident Command Technician
At 0501 hours, the IC requested an additional engine company to knock down a fire developing in a
garage behind Side C. The following personnel and apparatus were dispatched:
Engine 4 – Lieutenant and 2 fire fighters
A third alarm was requested by the IC at 0509 hours following the collapse which resulted in the
following personnel and apparatus being dispatched:
Engine 16 – 3 fire fighters
Engine 3 – Captain and 2 fire fighters
Ladder 2 – Lieutenant and 3 fire fighters.
Page 4
A summary of a NIOSH fire fighter fatality investigation
Report # F2011-30
Career Fire Fighter Dies and Another is Injured Following Structure
Collapse at a Triple Decker Residential Fire – Massachusetts
The Special Operations Task Force (SO1) was dispatched at approximately 0512 hours, which
consisted of crews from Engine 5 (Lieutenant and 2 fire fighters) and Ladder 4 (responding in the
Special Operations truck with a Lieutenant and 2 fire fighters).
Timeline
The following timeline is provided to set out, to the extent possible, the sequence of events as the fire
department responded to this incident. The times are approximate and were obtained from review of
the dispatch audio records, witness interviews, photographs of the scene and other available
information. In some cases the times may be rounded to the nearest minute, and some events may not
have been included. The timeline is not intended, nor should it be used, as a formal record of events.
Note: Per standard operating procedures, the dispatcher advised the Incident Commander after 10
minutes had elapsed and every 10 minutes thereafter, during the incident.

0421 Hours
Local fire department dispatched for a report of a fire in a “triple decker” residential structure.
E-12, E-13, E-2, E-6, L-1, L-3, R-1 and Car 4 dispatched. L-7 dispatched as the RIT. EMS
crews on-scene report pulling a civilian from the structure with more civilians still inside on the
second floor.

0422 Hours
Engine 12 on Scene. Reports heavy, heavy fire at Side B and C. Initially taking 2 1/2 –inch
line to rear, then E-12 radios Car …
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