Expert answer:Fire Unit 4

Expert answer:Click on the following link to access the Centers for Disease Control and Prevention website: http://www.cdc.gov/ (1) use
the search box; (2) enter the following term: “Bowstring Roof Collapse at Theatre Fire – Wisconsin”; (3) once you get to
the resource list, click on the link posted on 2012-08.
Write an essay with a minimum of 500 words using APA format with proper citations. Discuss the incident and what
factors lead to the fatality.
unit_4_pdf.pdf

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2012
08
October 11, 2012
Volunteer Lieutenant Killed and Two Fire Fighters Injured
Following Bowstring Roof Collapse at Theatre Fire – Wisconsin
Revised on January 9, 2013 to edit the Training and Experience section
Executive Summary
On March 4, 2012, a 34-year-old male
volunteer lieutenant (the victim) lost his life
at a theatre fire after the roof collapsed,
trapping him within the theatre. At
approximately 1215 hours, an on-duty
patrol officer (also chief of the victim’s fire
department) radioed dispatch for a structure
fire (flames visible). The 1st due fire
department arrived on scene, set up
operations on the A-side of the structure,
and directed the incoming mutual aid
department (victim’s department) to the rear
of the structure. No fire was visible from
the rear. Both departments attacked the
theatre fire from opposite sides (A-side and
C-side) of the structure establishing their
Incident scene when fire was first discovered.
own incident commander/officer in charge,
(Photo courtesy of Julie Miklaszewicz.)
fireground operations, and accountability
systems. The 1st due fire department initially fought the fire defensively from the A-side, while the
victim and two additional fire fighters (FF1 and FF2) entered through the C-side, advancing a hoseline
until they met A-side fire fighters near the theatre’s lobby (area of origin). The 1st due fire department
eventually placed an elevated master stream into operation, directing it into the lobby and then onto the
roof while fire fighters were operating inside. Roof conditions deteriorated until the roof collapsed
into the structure trapping the victim, FF1, and FF2. FF1 and FF2 recalled speaking with the victim
immediately following the collapse, but nothing was heard from the victim following the activation of
a personal alert safety system device (PASS). All three were eventually located, removed from the
structure, and transported to a local hospital, but the victim had already succumbed to his injuries.
Contributing Factors
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Initial arriving units not establishing/performing/implementing an incident management
system, an overall incident commander, an incident action plan (IAP), and a 360-degree
situational size-up
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Risk management principles not effectively used
Page i
Report # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin

Fireground and suppression activities not coordinated
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Fire ground communications between departments not established
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Incident safety officer (ISO) role ineffective
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Rapid intervention crew (RIC) procedures not followed and/or implemented
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Bowstring roof truss construction not recognized by departments
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Fire burned undetected within the roof void space for unknown period of time
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Uncoordinated master stream operations
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Location of victim following roof collapse not immediately known.
Key Recommendations
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Fire departments should ensure that an effective incident management system is established
with a designated incident commander not involved with fire suppression activities
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Fire departments should ensure that a complete situational size-up is conducted on all
structure fires
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Fire departments should use risk management principles at all structure fires
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Fire departments should work together to develop mutual aid standard operating procedures
for fireground operations that support interagency operability and accountability and train on
those procedures

Fire departments should ensure that the incident safety officer (ISO) position, independent
from the incident commander, is appointed and effectively utilized at every structure fire
meeting the requirements within NFPA 1521 Standard for Fire Department Safety Officer

Fire departments should ensure that a rapid intervention crew (RIC) is readily available, on
scene, and prepared to respond to fire fighter emergencies.
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 # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin
Introduction
On March 4, 2012, a 34-year-old male volunteer lieutenant (the victim) lost his life at a theatre fire
after the roof collapsed, trapping him within the theatre. On March 5, 2012, the U.S. Fire
Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this
incident. On March 12 through March 17, 2012, two safety and occupational health specialists from
the NIOSH Fire Fighter Fatality Investigation and Prevention Program traveled to Wisconsin to
investigate this incident. The NIOSH investigators met with the two fire departments’ fire chiefs,
Wisconsin occupational safety and health inspectors, and a state fire prevention coordinator.
Interviews were conducted with the incident commanders (IC) for the 1st due department, the officers
in charge for the mutual aid department, fire department members directly involved with the incident,
and one of the theatre’s owner. The NIOSH investigators visited, documented, and photographed the
fire scene and structure. The NIOSH investigators reviewed photographs and video taken by law
enforcement, bystanders, and the theatre insurance adjuster. The NIOSH investigators also reviewed
available training records for the victim, the ICs, and fire fighters working with the victim at the time
of the collapse; dispatch radio transcripts; medical examiner’s cause of death; and individual
departmental standard operating guidelines (SOGs) for each department.
The NIOSH investigators documented the condition and took photographs of the victim’s personal
protective equipment (PPE) and self-contained breathing apparatus (SCBA). The victim’s PPE and
SCBA were sent to NIOSH’s National Personal Protective Technology Laboratory (NPPTL) for
further evaluation. The NIOSH investigators also reviewed available SCBA maintenance records for
both departments.
Fire Departments
At the time of this incident, the 1st due fire department was operating from a single fire station with 26
members serving a population of approximately 2,300 within an area of about 22 square miles. This
fire department had an engine, two tankers, a ladder truck (pump capable), a rescue truck, a brush
truck, and two ambulances. The department provided fire and EMS services within its jurisdiction,
responding to approximately 50 calls per year (approximately two structure fires per year). Members
within the department received an hourly rate per call and officers received a monthly stipend. At the
time of this incident, this fire department was rated as a Class 5 by the Insurances Services
Organization (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. This
department provided annual medical evaluations and respiratory fit testing for its members.
a
The Insurances Services Organization (ISO) is an independent commercial enterprise that 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. More information about ISO and
their Fire Suppression Rating Schedule can be found at http://www.isogov.com/about/.
Page 1
Report # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin
At the time of this incident, the mutual aid fire department (victim’s department) was operating from a
single fire station with 25 members serving a population of approximately 2,500 within an area of
about 99 square miles. The department also had a substation housing additional apparatus. This
department had two engines, two tanker/engines, three tankers, a brush truck, and two ambulances.
The department provided fire and EMS services within its jurisdiction, responding to approximately 40
calls per year (one or two structure fires per year). Members within this department received an hourly
rate per call and officers above the rank of lieutenant received a monthly stipend. In 2010, this fire
department received an ISO Class 5 rating. The victim’s department does not provide medical
evaluations or respirator fit testing.
Both departments had a designated safety officer who coordinated the departmental medical and safety
and health issues of their members. When available, this safety officer or a designated safety officer
would be utilized as an incident safety officer at emergency incidents.
The NIOSH investigators reviewed written standard operating guidelines for the 1st due fire
department and the suggested operations guide for the mutual aid fire department (victim’s
department). Most if not all procedures/guidelines included within these documents are listed below
and some procedures/guidelines were expanded upon within this report as it related to this incident.
The 1st due fire department’s SOGs1 (revised in 2008) contained the following information:
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Page 2
Fire department general requirements
Job descriptions
Officer duties
Member responsibilities
Orientation program
Protective clothing
SCBA units
Engine operations
Communications
o Plain language
o Provide size-up
o Advise incoming mutual aid departments of incident type
o Know radio frequencies
Auto accidents
Driver training program
Driving regulations
Training
Hazardous materials
Alarm guidelines
o Quadrant system
o Responding
o Size-up
Report # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin
o
o
o
o
o
o
Rescue
Vehicle fires
Auto accident with injuries
Chimney fires
Structure fires
General
 A single long horn blast and/or three pulses in water pressure on the hose
indicates to anyone inside the structure should exit immediately.
The mutual aid fire department’s (victim’s department) suggested operations guide2 contained the
following information:
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Page 3
Ordering equipment and supplies
Emergency/Nonemergency carbon monoxide response
Fire ground officer duties
Mutual aid incident commander (IC) (pertains to EMS incidents only)
Accountability
o Use a single identification tag
 Red – Attack Team
 Blue – Support Team
 Yellow – Truck Team
o Remove identification tag after arrival on scene
 Place in front seat of primary engine, rescue, or first truck on scene
o Mutual aid incidents
 Follow same procedure (above mentioned)
 Safety officer maintains communication with mutual aid department’s safety
officer so that information on member whereabouts can be shared
Receiving emergency calls
Ambulance response
Emergency equipment mutual aid response
Apparatus emergency response, safe operation, and placement
Incident commander (effective date 1995)
o Assigned at all emergency scenes
o Working knowledge of incident command system (ICS)
o Mutual aid incidents
 Primary jurisdiction will be the IC
Incident command system (effective date 1993)
o Establishing command and command post
o Command functions
o Initial report and size-up
o Responsibilities
o Command options
o Level I and II staging
Report # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin
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o Use of sectors
o Safety
Incident command system fireground safety (effective date 1993)
o Positioning of operating companies
 Opposing fire streams
 Combining interior/exterior fire attack, front/rear fire attack, and roof/interior
fire attack (utilize radio or face-to-face communications to coordinate)
 Under involved roof structures
 Where fire can move behind fire fighters
 Notify and evacuate interior crews before ladder pipe operations go into
operation
o Structural collapse
 Always a possibility when support members are exposed to fire and heat,
especially in peaked or domed roofs
 Age and type of building
o Search and Rescue
 Efficient, well planned procedure
 Personnel familiar with search and rescue plan before entering
 Accountability
Personal alert safety system (PASS) (effective date 1993)
SCBA (effective date 1993)
PPE (effective date 1993)
Live fire training (effective date 1993)
Safety officer (effective date 1993)
Emergency evacuation of hazardous areas (effective 1993)
o “Code Red Signal”
o “Code red, code red” transmitted over pa system
o Sound siren and horn of apparatus for 30 uninterrupted seconds
o Personnel respond to primary engine for accountability
Rapid intervention teams (RIT) (effective 2011)
o Follow National Fire Protection Association (NFPA) 1407 Standard for Fire Service
Rapid Intervention Crews3
o Shall be activated at all structure fires
o Personnel should be entry level fire fighters and participate in monthly RIT training
The two departments’ written SOGs and/or suggested guidelines that were reviewed were generic and
provided minimum guidance for fireground operations. The two departments had developed these
documents for their individual departments, but no mutual aid SOGs for emergency incidents (e.g.,
fireground operations/communications, evacuation, accountability) had been developed. Neither fire
department had policies, guidelines, or procedures related to a Mayday, engine/truck company
operations, building construction, fire behavior, or risk management principles; and neither department
was aware of NFPA 1500 Standard on Fire Department Occupational Safety and Health Program.4
Page 4
Report # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin
All fire and EMS departments within the county had signed a mutual aid agreement. Neither of the
departments’ safety officers (SO) had any formal incident safety officer training.
The Wisconsin Department of Safety and Professional Services standard SPS 330 Fire Department
Safety and Health Standards5 enforce safety and health standards for public sector fire department
employees. This document included the following subchapters:
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Page 5
Purpose and scope
Definitions
Administration and enforcement
Adopted standards
o NFPA 1001 Standard for Fire Fighter Professional Qualifications6 (1997 ed.)
o NFPA 1002 Standard for Fire Apparatus Driver/Operator Professional Qualifications7
(1998 ed.)
o NFPA 1021 Standard for Fire Officer Professional Qualifications8 (1997 ed.)
o NFPA 1403 Standard on Live Fire Training Evolutions in Structures9 (1997 ed.)
o NFPA 1901 Standard on Automotive Fire Apparatus10 (1999 ed.)
o NFPA 1911 Standard for Service Tests of Pump Systems on Fire Department
Apparatus11 (1997 ed.)
o NFPA 1914 Standard for Testing Fire Department Aerial Devices11 (1997 ed.)
o NFPA 1971 Standard on Protective Ensemble for Structural Fire Fighting12 (2000 ed.)
o NFPA 1981 Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire
Service13 (1997 ed.)
o NFPA 1982 Standard on Personal Alert Safety Systems14 (1998 ed.)
o NFPA 1983 Standard on Fire Service Life Safety Rope and System Components15 (2001
ed.)
Organization
Training and education
Vehicles and equipment
Protective clothing and protective equipment
Emergency operations
Facility safety
Medical
Member assistance referral program
Miscellaneous activities
o Hazardous materials
o Confined spaces
o Diving operations
o Miscellaneous hazardous situations
Report # F2012-08
Volunteer Lieutenant Killed and Two Fire Fighters Injured Following
Bowstring Roof Collapse at Theatre Fire – Wisconsin
Training and Experience
The victim had been with his department for approximately 10 years. He held certifications in Fire
Fighter I, meeting requirements of NFPA 1001 Standard for Fire Fighter Professional Qualifications,6
emergency medical technician, IS-700 National Incident Management System (Federal Emergency
Management Agency [FEMA]/Emergency Management Institute [EMI]), and LP gas emergencies. He
had held the rank of lieutenant within the department for the past year. He was also a detective in the
sheriff’s department of a neighboring county. From 2010, until the day of the incident, the victim had
attended approximately 30 training courses offered at the fire department and had responded to
approximately 17 fire/EMS calls.
The initial IC for the 1st due fire department had been with this department for approximately 15 years,
holding the rank of 2nd assistant chief for the past 2 years. He held certifications as a Wisconsin Entry
Level Firefighter in 1999 (60 hours), Incident Safety Officer in 2004 (FEMA/EMI), Wisconsin Entry
Level Driver Operator in 2003 (30 hours), OSHA 29 CFR 1910.120 Annual HAZWOPER,
environmental response training, and first responder. He had also completed documented courses on
the incident command system, such as IS-700 National Incident Management System in 2005
(FEMA/EMI); IS-100 Introduction to the Incident Command System in 2006 (FEMA/EMI); IS-800.a
National Response Plan (NRP), An Introduction in 2006 (FEMA/EMI); Intermediate Incident
Command System (ICS-300) in 2007 (Wisconsin Emergency Management); 12-hour Incident
Command Systems 400 course in 2008 (local technical college); IS-200.a ICS for Single Resources
and Initial Action Incidents in 2009 (FEMA/EMI).
The second IC for the 1st due fire department who assumed command of the scene during fire fighting
operations and was in command at the time of the collapse had been with this department for
approximately 22 years, holding the rank of fire chief for the past 2 years. He held certifications in
Fire Fighter I (1996), Wisconsin Entry Level Driver Operator in 2003 (30 hours), Incident Safety
Officer in 2004 (FEMA/EMI), and OSHA 29 CFR 1910.120 Annual HAZWOPER. He had also
completed documented courses on ICS such as IS-100 Introduction to the In …
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