NIOSH Firefighter Fatality Investigation Reports - Scene size-up and risk assessment
Arson Fire Kills Three Fire Fighters and Injures Four Fire Fighters Following a Floor Collapse in a Row House
Death in the Line of Duty…A summary of a NIOSH fire fighter fatality investigation
F2016-18 Date Release : November 9, 2018
Executive Summary
On September 24, 2016, a 41-year-old lieutenant and a 51-year-old senior fire fighter died due to a floor collapse in a row house at a structure fire. Two other fire fighters were critically injured. One of the injured fire fighters, a 48-year-old female died on December 1, 2016, due to injuries sustained from the collapse and exposure to fire in the basement. Another fire fighter spent 40 days in a metropolitan hospital before being released. Two other fire fighters received burns during fireground operations and one fire fighter sustained an ankle injury. All three were treated and released from the hospital on the same day. At 0256 hours, Engine 1, Engine 5, Squad 4, Ladder 2, Battalion 2, and Battalion 1 were dispatched to a report of a residential structure fire with persons trapped. Ladder 2 arrived on-scene at 0301 hours and reported heavy fire showing from the rear of the structure. The Ladder 2 Officer requested a 4th engine be dispatched. Engine 1 and Engine 5 arrived and both laid supply lines from different directions. Battalion 2 arrived on-scene and assumed Command. Crews from Engine 1, Engine 5, and Ladder 2 went to the front door and entered the 1st floor at approximately 0307 hours. At approximately 0309 hours, the Ladder 2 Officer, a fire fighter from Engine 1, and a fire fighter from Engine 5 fell into the basement. At 0310 hours, a Mayday was transmitted for a floor collapse and fire fighters in the basement. Fire fighters were able to get the fire fighter from Engine 1 (Engine 1B) out of the basement at 0318 hours. Crews were able to get the fire fighter from Engine 5 (Engine 5B) to the base of an attic ladder placed in the basement. Crews in the basement were also searching for the Ladder 2 Officer, plus fire fighters were exiting and entering the basement. The injured fire fighter from Engine 5 moved away from the attic ladder and crews were unable to locate her. Two fire fighters from Squad 4 (Squad 4C and Squad 4D entered the basement from Side Charlie and found the lieutenant from Ladder 2 near the Side Alpha/Side Delta corner. The two fire fighters from Squad 4 pulled the Ladder 2 Officer toward the doorway on Side Charlie. They got 4 – 6 feet from the doorway when a second collapse of the 1st floor occurred at approximately 0320 hours. One fire fighter from Squad 4 (Squad 4C) and the lieutenant from Ladder 2 were covered by debris. Squad 4D was pushed toward the doorway and pulled out by a fire fighter from Engine 5 (Engine 5C). Squad 4C was removed from the structure at 0329 hours. He was transported to a trauma center and pronounced deceased. The fire fighter from Engine 5 (Engine 5B) was located and removed from the structure at 0348 hours and transported by air ambulance to a trauma center and then a medical burn center. At 0430 hours, the Ladder 2 Officer was located in the debris pile and pronounced deceased by a paramedic. He was removed from the structure and transported to a trauma center. The fire was declared under control at 0550 hours.
Contributing Factors
- Sliding glass door open on Side Charlie
- Lack of scene size-up and risk assessment
- Lack of incident management and Command Safety
- Lack of an incident action plan
- Inappropriate fireground tactics for below grade fire
- Lack of company/crew integrity
- Lack of personnel accountability system
- Lack of rapid intervention crew(s)
- Ineffective fireground communications
- Lack of professional development for fire officers and fire fighters
Key Recommendations
- As part of the strategy and incident action plan, the incident commander should ensure a detailed scene size-up and risk assessment occurs during initial fireground operations, including the deployment of resources to Side Charlie. Scene size-up and risk assessment should occur throughout the incident. (Source: NIOSH)
- As part of ongoing professional development and training, utilize the tools and resources on FreeFireSimulator.com to simulate real-world fireground scenarios. For enhanced incident command scene size-up, use the Structure Fire Simulations to practice risk assessment and resource allocation under dynamic fire conditions. Additionally, the Building Construction pages and Structural Loading in Firefighter Operations page offer crucial insights into factors affecting building integrity, which can be integrated into scenario-based training. Fire Officers can use the simulations to explore contributing factors such as fireground communications, tactical response to below-grade fires, and strategies for ensuring crew integrity and accountability in high-risk situations. Incorporating these digital simulations into drill sessions will help reinforce critical decision-making and improve overall fireground safety. (Source: FreeFireSimulator)