death in the - centers for disease control and … death in the 12 line of duty... photo courtesy of...

Career Fire Fighter Dies and Two Career Fire Fighters Injured in aFlashover During a House Fire - Ohio

January 7, 2005A summary of a NIOSH fire fighter fatality investigation

SUMMARYOn March 21, 2003, a 25-year old male career firefighter (the victim) was fatally injured in a flashoverduring a house fire. The victim and two other firefighters were on an interior attack crew and had justgone through the front door of a single familyresidence. The hose line was uncharged and thecrew was calling for water when a flashover occurred.From the time the victim arrived on scene until theflashover was approximately four minutes. After theflashover, fire fighters on the front porch witnessedthe victim walk toward the front door then turn andretreat into the structure. The two other fire fighterson the interior crew exited through the front door.They were injured and transported to the hospitalwhere they were treated and released. The victimwas located and removed from the structure within10 minutes. He was transported via ambulance tothe hospital where he was pronounced dead.

NIOSH investigators concluded that, to minimize therisk of similar occurrences, fire departments should:

• review and revise existing standardoperating procedures (SOPs) for structuralfire fighting to ensure fire fighters enterburning structures with charged hose lines

• ensure that a Rapid Intervention Team(RIT) is established and in position prior toinitiating an interior attack

• ensure that ventilation is closelycoordinated with interior operations

• ensure that crew continuity is maintainedon the fireground

• ensure that fire command always maintainsclose accountability for all personneloperating on the fireground

Additionally, emergency dispatchers should:

• obtain as much information as possible fromthe caller and report it to the respondingfire fighters

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.Identification of causal and contributing factors enableresearchers and safety specialists to develop strategies forpreventing future similar incidents. The program does notseek to determine fault or place blame on fire departmentsor individual fire fighters. To request additional copies ofthis report (specify the case number shown in the shieldabove), other fatality investigation reports, or furtherinformation, visit the Program Website at

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

Fire Fighter Fatality Investigation and Prevention Program

F2003 Death in the line of duty...12

Photo Courtesy of Fire Department

Career Fire Fighter Dies and Two Career Fire Fighters Injured in a Flashover During aHouse Fire - Ohio

Investigative Report #F2003-12Fatality Assessment and Control Evaluation

Fire Fighter Fatality Investigation And Prevention Program

INTRODUCTIONOn March 21, 2003, a 25-year old male career firefighter (the victim) was fatally injured in a flashoverduring a house fire. On March 24, 2003, the U.S.Fire Administration (USFA) notified the NationalInstitute for Occupational Safety and Health(NIOSH) of this fatality. On April 14-17, 2003,three occupational safety and health specialists anda safety engineer from the NIOSH Fire FighterFatality Investigation and Prevention Programinvestigated the incident. The NIOSH team met withthe Chief and District Chiefs of the department,representatives from the local InternationalAssociation of Fire Fighters (IAFF), and interviewedall but one of the fire fighters and officers involved inthe incident. The incident site was visited andphotographed by the NIOSH team. Thedepartment’s standard operating procedures(SOPs), training records for the victim, 911 dispatchtranscripts, fire investigator reports and the medicalexaminer's report were reviewed.

As part of the NIOSH Fire Fighter FatalityInvestigation and Prevention Program, the RespiratorBranch, National Personal Protective TechnologyLaboratory (NPPTL) conducted an evaluation of oneself – contained breathing apparatus (SCBA) at therequest of the fire department. The SCBA wasreported to be last used during interior fire-fightingoperations at the structure fire on March 21, 2003by an injured fire fighter. The performance of thisSCBA did not play a role in this fatality and asummary of this report is available from NPPTL.1

DepartmentThe career fire department involved in this incidenthas 785 uniformed fire fighters that operate from 26fire stations. The department serves a metropolitanpopulation of approximately 350,000 within ageographic area of about 77 square miles.

TrainingThe fire department provides all new recruits with a20-week training program conducted at the city’sFire Academy. The victim had 3 years of experienceas a career fire fighter and was certified in the Stateof Ohio as a Fire Fighter Level II, Fire SafetyInspector, and Basic Emergency Medical Technician(EMT). The victim had successfully completednumerous other training courses such as: firstresponder operations, workplace violence, Haz-Matoperations, thermal imaging, defensive driving, andweapons of mass destruction – chemical &radiological emergencies.

Equipment and PersonnelThere were 4 apparatus on scene during the 1st alarmresponse prior to the flashover. Additional units weredispatched in 2nd and 3rd alarms; however, only thoseunits directly involved in operations preceding thefatal event are discussed in the investigation sectionof this report. The initial dispatch was at 0845 hours.Units and apparatus listed in order of arrival on thescene included:

• Staff vehicle with District Chief as the IncidentCommander

• Engine 9 with officer, fire apparatus operator(FAO), victim, and one fire fighter

• Ladder 2 with officer, FAO and two fire fighters• Engine 2 with officer, FAO and two fire fighters• Ladder 32 with officer, FAO and two fire fighters

Approximately 17 fire fighters were on scene whenthe flashover occurred at approximately 0852 hours.All firefighters were equipped with a full array ofbunker gear, SCBAs, portable radios and personalalert safety system (PASS) devices.

StructureThe incident structure was a two-story, single-familyresidence of ordinary construction built in the 1910s(Photo 1). The first and second floor hadapproximately 1,200 square feet of furnished livingarea, with an 825 square foot finished basement




below grade. The first floor consisted of a livingroom, dining room and kitchen (Diagram 1). Therewas a 150 square foot covered front porch and a 60square foot covered back porch at the rear of thestructure. The second floor had three bedrooms anda bathroom. Exterior construction was brick overwood framing with aluminum siding on the secondfloor. The roof consisted of asphalt shingles and thehouse set on a level corner lot. Interior constructionwas wood paneling and the ceilings were plaster overwood lathe on the first floor.

According to the fire investigators, the origin andcause of the fire was from unattended food left on anatural gas stove in the kitchen. The occupants ofthe home evacuated prior to arrival of fire fighters,but first responding units were unaware of their status.

WeatherAt the time the fire occurred the weather was overcastwith a temperature of approximately 50OF and a windspeed of about 8 mph from the west-southwest.

INVESTIGATIONOn March 21, 2003, at 0845 hours, fire fighters weredispatched to a residential house fire. The firstresponder to arrive on the scene was the DistrictChief at 0848 hours, who assumed incident command(IC) and immediately conducted a size-up of thestructure. He reported to dispatch heavy fire showingin the southeast rear corner with heavy smoke.(Note: It is department policy to dispatch adistrict chief, 2 engine companies and 2 truckcompanies on a residential house fire). Afterconfirming a structural fire, three additional units (aRapid Assistance Team, a Rescue unit and anadditional District Chief) were automaticallydispatched to the scene per department policy.(Note: These units did not arrive on the sceneuntil after the flashover). The IC was unawarethat the home was unoccupied and proceeded withaggressive interior operations.

Activity of the victim and his crew on thefireground prior to the flashoverEngine 9 arrived on the scene at 0849 hours andparked at the front of the structure near a hydrant(Diagram 2). The officer and the victim took a 1¾-inch hose line and headed to the front door. Theother fire fighter from Engine 9 stayed at the rear ofthe apparatus and unloaded the hosebed to the street.When the crew arrived at the front door, it was lockedso they went to the rear of the structure. The ICwas at the rear of the structure and ordered the crewto make a forceable entry through the front door.The FAO made the connection to the hydrant. Theofficer and victim brought the hose line back to thefront of the structure while the other fire fighterretrieved an axe from Engine 9. The officer, victim,another fire fighter from Engine 9 and a fire fighterfrom Engine 2 (who had just arrived) donned theirSCBA masks and prepared to enter the structure.The officer from Engine 9 radioed his FAO twice tocharge the hose line. Since the hose line was still notcharged, the officer from Engine 9 left the porch andproceeded to the apparatus to check on the watersupply. The FAO yelled out that the line wascharged. After checking the hose line, the officersaw the tangled hose in the yard (Photo 2). Theofficer immediately went to the hose and began toflake it out removing the kinks. While the officerwas attending to the hose, the victim and two firefighters on the front porch made forceable entrythrough the front door with the hose line stilluncharged. Conditions in the interior were heavysmoke and intense heat. The fire fighter from Engine9 came out of the structure to check on the watersupply. He saw his officer working on the hose line;he went back inside the structure assuming that theline would soon be charged.

Within seconds, a flashover occurred (0852 hours)fully engulfing the first floor in heavy flame. The twofire fighters on the interior crew exited out the frontdoor with their bunker gear smoldering. The victim




was seen by exterior crews still within the structure.He proceeded away from the exit into the fire. Theofficer on Engine 9 did not realize that a member ofhis crew was still inside the structure; he saw threefire fighters on the front porch and assumed that allthe interior crew had escaped the flashover.

Other critical apparatus and fire fighteractivities on the fireground prior to the flashoverLadder 2 arrived on the scene at 0850 hours. Uponarrival, fire fighters had trouble determining whichhouse was on fire since heavy smoke obscured thestreet. Ladder 2 passed in front of the house andsetup on the west side of the structure. After theapparatus was set up, a fire fighter climbed the ladderonto the roof and made a vertical ventilation hole inthe southeast corner directly over the fire (Photo 2).The FAO from Ladder 2 began to climb the ladderwith a pike pole when the flashover occurred. (Note:The vertical ventilation hole was cut through theroof but the second floor ceiling had not beenpenetrated). Flame burst out of the windows onthe west side of the structure. The IC immediatelyordered the Ladder 2 fire fighter off the roof andLadder 2 began to setup ladder pipe operations.Upon arrival, the officer and another fire fighter fromLadder 2 were venting some of the first floor windowson the southwest corner when they saw the tangledhose in the side yard. They assisted with removingthe kinks. After ventilating the ground windows, thesecond fire fighter from Ladder 2 assisted Engine 2in deploying a 1¾-inch hose line from Engine 9 andproceeded to the front of the structure. When theflashover occurred, the second fire fighter fromLadder 2 saw the victim running through the first floorand thought he was going to exit out a side window.When he did not observe his exit, he immediatelyprepared for search and rescue operations.

Engine 2 also arrived at 0850 hours, but Ladder 2was blocking the road on the west side of thestructure. The FAO drove the apparatus around the

block and secured a hydrant southwest of thestructure. The rest of the crew from Engine 2dismounted and assisted Engine 9. One fire fighterassisted the interior crew; the officer and second firefighter got a second 1¾-inch handline from Engine 9and proceeded to the rear of the structure. (Note:The officer from Engine 2 thought the rear porchwas on fire). At the back of the structure, the ICverbally ordered Engine 2 back to the front door toback up Engine 9. When they arrived at the frontdoor, the flashover occurred.

Ladder 32 arrived on the scene at 0851 hours andpositioned in the front of the building behind Engine9. The crew was setting up the truck and had onlybeen on the scene for a minute when the flashoveroccurred. The officer and fire fighter from Ladder32 also saw the victim still inside the structureimmediately after the flashover occurred.

Fire fighter activities on the fireground after theflashoverAfter the flashover, the IC ordered an evacuation,accountability, requested a second alarm, andinitiated defensive operations. The two injured firefighters now located in the front yard were given firstaid. Officers from Engine 2, Ladder 2, and a firefighter from Ladder 32 took a charged hose line andmade entry through the front door. The fire fighterfrom Ladder 32 performed a search of the first floor.Several other fire fighters assisted with the rescueeffort and additional handlines were used throughthe front and back door. The victim was located inthe dining room and lowered out of a window intothe side yard, where resuscitation was immediatelybegun. The victim’s bunker gear, SCBA, portableradio and PASS device were all heavily damagedfrom the fire. The victim was removed from thestructure within 10 minutes of the flashover andtransported via ambulance to an area hospital wherehe was pronounced dead. The two fire fighters onthe interior crew were both injured (the fire fighter




from Engine 2 injured his hip and the fire fighter fromEngine 9 received second degree burns to the ears).The injured fire fighters were treated and releasedfrom the emergency room.

CAUSE OF DEATHThe medical examiner's report listed the victim's causeof death as severe 3rd degree burns.

RECOMMENDATIONS/DISCUSSIONRecommendation #1: Fire departments shouldreview and revise existing standard operatingprocedures (SOPs) for structural fire fightingto ensure fire fighters enter burning structureswith charged hose lines.2-3

Discussion: It is department policy to initiate anaggressive interior attack (offensive strategy)whenever possible. The department SOPs forstructure fires state the first fire line will be a 1¾-inchhose line and that line will be backed-up with aminimum size line of 1¾-inch. In this incident, poorhose deployment resulted in a lack of water supplyfor the interior attack crew. The initial 1¾-inch hoseline from Engine 9 was 350 foot long (seven 50 footsections) which became severely kinked restrictingwater flow. The backup handline was also unchargedat the time of the flashover. Department SOPs didnot specifically state that a handline is to be chargedprior to advancing into a structure on an offensiveinterior attack. Essentials of Fire Fighting 4th Editionstates, “When advancing a hose line into a burningstructure, air should be bled from the line once it ischarged and before entering the building.”Firefighters should continually train in establishingwater supply, proper hose deployment, andadvancing and operating hose lines to ensuresuccessful interior attacks. Refresher training shouldbe provided to all fire fighters on a regular basis oras needed to ensure effective fire fighting skills aremaintained.

Recommendation #2: Fire departments shouldensure that a Rapid Intervention Team (RIT)is established and in position prior to initiatingan interior attack.4-5

Discussion: A rapid intervention team (RIT) shouldrespond to every major fire. The team should reportdirectly to the IC and should remain at an areadesignated by the IC until an intervention is requiredto rescue a fire fighter. The RIT should have all thetools necessary to complete the task in case a firefighter needs assistance. These teams can intervenequickly to rescue fire fighters who becomedisoriented, lost in smoke-filled environments,trapped by fire, involved in structural collapse, orrun out of breathing air. A RIT should be established,in position and ready for deployment during the initialstages of an incident and before interior fire fightingoperations begin. In this incident, a RIT respondedafter the working structural fire was confirmed, butdid not arrive until after the flashover had occurred.

Recommendation #3: Fire departments shouldensure that ventilation is closely coordinatedwith interior operations.3,6-7

Discussion: Ventilation must be closely coordinatedwith the interior fire attack. Fire can quickly spreadin a structure, causing problems such as a flashoverwhich occurred in this incident. Ventilation timing isextremely important and must be carefullycoordinated between interior operating crews andventilation crews. Ventilation is necessary to releaseheat, smoke, and fire which improve the interiorconditions so that fire fighters can perform such dutiesas advancing to the fire with a hose line forextinguishment and for conducting search and rescue.Incident command should determine if ventilation isneeded and where ventilation is needed. The typeof ventilation should be determined based onevaluation of the structure and the location of any




interior crews. In this incident, vertical ventilationwas not fully completed prior to crew entry andventilation might have helped prevent the flashover.

Recommendation #4: Fire departments shouldensure that crew continuity is maintained onthe fireground.3

Discussion: In this incident, the interior attack crewwas from two engine companies without an officer.Team continuity involves knowing who is on yourcrew and who is the leader, staying within visualcontact at all times (if visibility is obscured then teamsshould remain within touch or voice distance of eachother), communicating your needs and observationsto the team leader, rotating to rehab and staging as ateam, and watching out for other team members.These key factors help to reduce serious injury oreven death resulting from the risks involved in firefighting operations by providing personnel with theadded safety net of fellow team members. As crewsenter a hazardous environment together, they shouldleave together to ensure that crew continuity ismaintained.

Recommendation #5: Fire departments shouldensure that fire command always maintainsclose accountability for all personnel operatingon the fireground.8

Discussion: Although there is no evidence that thisrecommendation would have prevented this fatality,it is being provided as a reminder of a good safetypractice. There was some confusion immediatelyafter the flashover as to the victim’s location by hisofficer. Accountability on the fireground is paramountand may be accomplished by several methods. It isthe responsibility of all officers to account for everyfire fighter assigned to their company and relay thisinformation to the IC. A fire fighter shouldcommunicate with the supervising officer by portable

radio to ensure accountability and indicate completionof assignments and duties. One of the most importantaids for accountability at a fire is the IncidentCommand System (ICS). As a fire escalates andadditional fire companies respond, communicationassists the IC with accounting for all fire fightercompanies at the fire, at the staging area, and atrehabilitation. With an accountability system in place,the IC may readily identify the location of all firefighters on the fireground. Additionally, the IC wouldbe able to initiate rescue within seconds of realizinga fire fighter is trapped or missing.

Recommendation #6: Emergency dispatchersshould obtain as much information as possiblefrom the caller and report it to the respondingfire fighters.3

During this incident, the fire fighters were unawarethat the structure was unoccupied and the IC couldhave used this information to formulate a differentsuppression strategy. The building occupant whoreported the fire to 911 indicated that all occupantswere exiting the structure and this critical informationwas not reported to fire fighters. Emergencydispatchers should always try to obtain all informationavailable from the caller. This would include anyinformation regarding the type of structure,occupancy, injuries, the fire or emergency condition,the possible location of the fire, address of theincident, and call-back numbers.

REFERENCES1. NIOSH [2003]. Status investigation report of

one self-contained breathing apparatus submittedby an Ohio fire department. By KochenderferV. Pittsburgh, PA: U.S. Department of Healthand Human Services, Centers for DiseaseControl and Prevention, National Institute forOccupational Safety and Health, NIOSH TaskNo. TN-12892.




2. Ohio Fire Department [1989]. Written standardoperating procedures from procedures manual.

3. International Fire Service Training Association[1998]. Essentials of fire fighting. 4th ed.Stillwater, OK: Oklahoma State University, FireProtection Publications.

4. NFPA [2002]. NFPA 1500, standard on firedepartment occupational safety and healthprogram. Quincy, MA: National Fire ProtectionAssociation.

5. Klaene BJ and Sanders RE [2000]. Structuralfire fighting. Quincy, MA: National FireProtection Association.

6. Brunacini, AV [1985]. Fire command. Quincy,MA: National Fire Protection Association.

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

8. NFPA [1995]. NFPA 1561: standard on firedepartment incident management system. Quincy,MA: National Fire Protection Association.

INVESTIGATOR INFORMATIONThis investigation was conducted by SteveBerardinelli and Mark McFall, Safety andOccupational Health Specialists and Tim Merinar,Safety Engineer with the Fire Fighter FatalityInvestigation and Prevention Team, FatalityInvestigations Team, Surveillance and FieldInvestigations Branch, Division of Safety Research,NIOSH located in Morgantown, West Virginia. Alsoassisting in the investigation was Tommy Baldwin,Safety and Occupational Health Specialist with theNIOSH Fire Fighter Fatality Investigation andPrevention Program, Cardiovascular DiseaseComponent located in Cincinnati, Ohio.




Photo 1. Front of incident structure




Photo 2. Aerial view of structure after incident. Photo courtesy of fire department




Origin of fire

Diagram 1. Layout of 1st floor of incident structure




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Ladder 32

Engine 9

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ngine 2

NOT TO SCALE

1¾ hand linestangled in side

yard

No water pressureat either nozzle

Approximate location of victim at the time of the

flashover

Approximate location of injured fire fighters at the

time of the flashover

X

XX

X

Approximate location where victim was

located Victim was removed through

this window

Diagram 2. Aerial view of incident scene at the time of the flashover

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