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Operational Safety

Here are five (5) NIOSH Firefighter LODD Event report summaries for incidents that occurred in the March 4th through the 8th time frame in the years 1998, 2001, 2002, 2008.

Take the time to look over the event summaries, discuss and comment on the factors that lead to the events and the recommendations formulated from the subsequent investigations.

Take the opportunity to identify the common themes and apparent causes that were identified and discuss with your company, team or station, relevant considerations that may have a direct or indirect relationship to your organization, past incident calls or district risk profile.

What are your capabilities?

What are your gaps?

How can you prevent a similar situation from occurring?

Promote questions and dialog related to operational issues such as these;

  • Coordinated multi-company operations; how “coordinated” is your incident scene?
  • Do rapidly changing incident conditions get identified promptly and communicated to Command in rapid succession for actions?
  • How effective is the base line knowledge and skill set of company and command officers in “reading the building”?
  • What is the adequacy of your training for conducting operations above the fire floor?
  • When was the last time you “tested” the effectiveness of your RIT/FAST Team? Can they truly perform under the most demanding of incident conditions?
  • When was the last time you trained or drilled on Fire Behavior or on Building Construction?
  • Are you training on calling the mayday and personal survival techniques?
  • Have you implemented and trained on procedures for rapid and efficient transition in operational modes on the fireground?
  • Do you implement a 360 when applicable and delegate when needed?
  • What parameters are you operating under when assuming risk on the fireground?
  • What drives your incident operations: Are they Tactically Drive or Risk Managed?

Down load the complete NIOSH Reports and expand on the lessons learners and their applicably to your organization and capabilities.

Floor Collapse and Fire Conditions:
On March 7, 2002, a 28-year-old male volunteer fire fighter and a 41-year-old male career fire fighter died after becoming trapped in the basement. One firefighter manned the nozzle while second firefighter provided backup on the handline as they entered the house. After entering the structure, the floor collapsed, trapping both victims in the basement.

A career fire fighter captain joining the fire fighters near the time of the collapse was injured trying to rescue one of the fire fighters. Crew members responded immediately and attempted to rescue the victims; however, the heat and flames overcame both victims and eliminated any rescue efforts from the garage entrance.

NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should;

  • Ensure that the Incident Commander is clearly identified as the only individual responsible for the overall coordination and direction of all activities at an incident
  • Ensure that the Incident Commander conveys strategic decisions to all suppression crews on the fireground and continually reevaluates the fire condition
  • Ensure that Incident Command conducts an initial size-up of the incident before initiating fire fighting efforts and continually evaluates the risk versus gain during operations at an incident
  • Ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts
  • Ensure that fire fighters report conditions and hazards encountered to their team leader or Incident Commander
  • Ensure fire fighters are trained to recognize the danger of operating above a fire


Wall Collapse and Fire Conditions
On March 7, 2008, two male career fire fighters, aged 40 and 19 were killed when they were trapped by rapidly deteriorating fire conditions inside a millwork facility in North Carolina. The captain of the hose line crew was also injured, receiving serious burn injuries.

The victims were members of a crew of four fire fighters operating a hose line protecting a firewall in an attempt to contain the fire to the burning office area and keep it from spreading into the production and warehouse areas. The captain attempted to radio for assistance as the conditions deteriorated but fire fighters on the outside did not initially hear his Mayday. Once it was realized that the crew was in trouble, multiple rescue attempts were made into the burning warehouse in an effort to reach the trapped crew as conditions deteriorated further.

Three members of a rapid intervention team (RIT) were hurt rescuing the injured captain. One firefighter was located and removed during the fifth rescue attempt. The second firefighter could not be reached until the fire was brought under control.

The fourth crew member had safely exited the burning warehouse prior to the deteriorating conditions that trapped his fellow crew members. Key contributing factors identified in this investigation include radio communication problems (unintelligible transmissions in and out of the fire structure that may have led to misunderstanding of operational fireground communications), inadequate size up and incomplete pre-plan information, a deep-seated fire burning within the floor of the office area that was able to spread into the production and warehouse facility, the procedures used in which operational modes were repeatedly changed from offensive to defensive, lack of crew integrity at a critical moment in the event, and weather which restricted fireground visibility.

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

  • Ensure that detailed pre-incident plan information is collected and available when needed, especially in high risk structures
  • Limit interior offensive operations in well-involved structures that are not equipped with sprinkler systems and where there are no known civilians in need of rescue
  • Develop, implement, and enforce clear procedures for operational modes. Changes in modes must be coordinated between the Incident Command, the command staff and fire fighters
  • Ensure that Rapid Intervention Crews (RIC) / Rapid Intervention Teams (RIT) have at least one charged hose line in place before entering hazardous environments for rescue operations
  • Ensure that the incident commander establishes the incident command post in an area that provides a good visual view of the fire building and enhances overall fireground communication
  • Ensure that crew integrity is maintained during fire suppression operations
  • Encourage local building code authorities to adopt code requirements for automatic protection (sprinkler) systems in buildings with heavy fire loads.


Floor Collapse
On March 4, 2002, a 22-year-old male career fire fighter was injured and subsequently died and a 25-year-old male Captain was injured when the floor collapsed while they were fighting a residential fire.

The Captain was transported by ambulance to an area hospital where he was admitted overnight for first- and second-degree burns. The victim was conscious and was transported by medical helicopter to a State medical center where he died 2 days later.

NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should;

  • Ensure that each Incident Commander conducts a size-up of the incident before initiating fire-fighting efforts, after command is transferred, and continually evaluates the risk versus gain during operations at an incident
  • Ensure fire fighters are trained to recognize the dangers of searching above a fire
  • Ensure that an Incident Safety Officer, independent from the Incident Commander, is appointed
  • Ensure that ventilation is closely coordinated with fire attack
  • Ensure that a Rapid Intervention Team is established and in position immediately upon arrival
  • Ensure that adequate numbers of staff are available to operate safely and effectively




Floor Collapse
On March 8, 2001, a 38-year-old male career fire fighter fell through the floor while fighting a structure fire, and died 12 days later from his injuries. At 1231 hours, Central Dispatch notified the career department of a structure fire with reports of the occupants still inside. The Assistant Chief arrived on the scene along with Engine 70 and assumed Incident Command (IC).

The IC immediately called for the second alarm, began conducting the initial size-up of the structure, and confirmed heavy fire in the left front section. At that time, the neighbors approached the IC and informed him that the occupants were trapped inside. The IC ordered the fire fighters on scene to commence search and rescue efforts, and then verified the stability of the structure through radio and face-to-face communications.

Engine 68 arrived on the scene at approximately 1250 hours with an Assistant Chief and the victim. The Assistant Chief provided tactical command of the fire ground, and along with the victim, conducted search and rescue operations. Other crews conducted searches with a thermal imaging camera of the first floor and basement level of the residence with no sign of any occupants. During these searches the stability of the structure was diminishing due to the intense fire that was now venting through the roof.

Fire fighter #3 and the victim were at the front entrance conducting a defensive attack as the third emergency evacuation signal was sounded. The neighbors were still insisting to the IC and fire fighters that the occupants were trapped inside, and one of the occupants was handicapped. The victim and one other fire fighter conducted another search of the structure.

The heat and flames were now extending from the basement level to the first floor when the fire fighter’s low air alarm sounded. The victim and the fire fighter were backing out of the structure when the floor beneath the victim gave way, causing him to fall through the floor and become trapped in the basement.

Attempts were made from the first floor to rescue the victim by utilizing a handline and an attic ladder, but they were unsuccessful due to the intense heat and flames. Two Rapid Intervention Teams (RIT #1 & RIT #2) were deployed simultaneously from separate entrances into the basement to perform a search and rescue operation for the downed fire fighter. The RITs were able to locate and remove the victim on their initial entry. He sustained third degree burns to over half of his body and died 12 days later.

NIOSH investigators concluded that to minimize the risk of similar occurrences, fire departments should;

  • Ensure that Incident Command continually evaluates the risk versus gain during operations at an incident
  • Ensure that a separate Incident Safety Officer independent from the Incident Commander is appointed
  • Ensure that fire fighters are trained in the tactics of defensive search
  • Ensure that fire fighters performing fire fighting operations under or above trusses are evacuated as soon as it is determined that the trusses are exposed to fire
  • Ensure consistent use of Personal Alert Safety System (PASS) devices at all incidents and consider providing fire fighters with a PASS integrated into their Self-Contained Breathing Apparatus which provides for automatic operation
  • Ensure that personnel equipped with a radio, position the radio to receive and respond to radio transmissions


Roof Collapse and Fire Conditions
On March 8, 1998, one male fire fighter, the Captain on Engine 57, died while trying to exit a commercial structure after his egress was cut off by the wooden trussed roof that collapsed. Task Force 66 was the first on scene and reported light smoke showing from a one-story commercial building. A ventilation team from Truck 66 proceeded to the roof of the building and commenced roof ventilation. Forcible entry into the building required about 7 ½ to 9 ½ minutes from arrival on scene to force open the two metal security doors in the front. While fire companies waited for the security doors to be opened, fire conditions changed dramatically on the roof.

Fire was coming from the ventilation holes opened by the ventilation crew. As soon as the security doors were opened, three engine crews (Engine 66, Engine 57, and Engine 46) advanced hand lines through the front door in an attempt to determine the origin of the fire. Approximately 15 feet inside the front door, the fire fighters encountered heavy smoke with near zero visibility conditions. The engine crews advanced their hose lines approximately 30 to 40 feet inside the building.

As conditions continued to deteriorate inside the building, the members from the four engine companies involved in the fire attack began to withdraw. During this time the victim became separated from his crew and remained in the building. The victim was subsequently located by the Rapid Intervention Team and cardiopulmonary resuscitation was performed immediately and en-route to the hospital, where the victim was pronounced dead.

NIOSH investigators conclude that, to prevent similar occurrences, fire departments should:

  • Ensure that incident command conducts an initial size up of the incident before initiating fire fighting efforts, and continually evaluate the risk versus gain during operation at an incident
  • Ensure that incident command always maintains close accountability for all personnel at the fire scene
  • Ensure communications are established between the interior and exterior attack crews, e.g., the ventilation crew and the interior fire attack crew should communicate conditions among themselves and back to incident command
  • Ensure that Rapid Intervention Teams are in place before conditions become unsafe
  • Ensure that some type of tone or alert that is recognized by all fire fighters be transmitted immediately when conditions become unsafe for fire fighters
  • Ensure sufficient personnel are available and properly functioning communications equipment are available to adequately support the volume of radio traffic at multiple-responder fire scenes
  • Consider placing a bright, narrow-beamed light at the entry portal to a structure to assist lost or disoriented fire fighters in emergency egress.




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