fire fighter face report no. 2004-37, volunteer chief dies

Volunteer Chief Dies and Two Fire Fighters Are Injured by a Collapsing Church Facade - Tennessee

January 13, 2006A summary of a NIOSH fire fighter fatality investigation

The Fire Fighter Fatality Investigation and Prevention Program is conducted by the National Institute forOccupationalSafetyandHealth (NIOSH).Thepurposeoftheprogramistodeterminefactorsthatcauseorcontributetofire fighter deaths suffered in the line of duty. Identification of causalandcontributingfactorsenableresearchersandsafetyspecialiststodevelopstrategiesforpreventingfuturesimilarincidents.Theprogramdoesnotseektodeterminefaultorplace blame on fire departments or individual fire fighters. Torequestadditionalcopiesofthisreport(specifythecasenumbershownintheshieldabove),otherfatalityinvestigationreports,orfurtherinformation,visittheProgramWebsiteat

www.cdc.gov/niosh/firehome.htmlorcalltollfree 1-800-35-NIOSH

SUMMARYOnApril8,2004a71-year-oldmalevolunteerChief(thevictim)wasseriouslyinjuredduringa church fire when he was struck by bricks and burningdebristhatfellfromanoutwardcollapseof a brick façade. The victim died from hisinjuries four months later. He had arrived atthe scene of the fire one minute after the first alarm and approximately 15 minutes beforethecollapse. HeassumedIncidentCommand,performed a 360° size-up of the scene, andwas in frontof thechurchverballycalling forfire fighters to evacuate the structure when the collapseoccurred.ThevictimwastransportedbyhelicoptertoahospitalandlatertransferredtoarehabilitationcenterwhereheremaineduntilAugust1,2004whenhediedfromhisinjuries.NIOSHinvestigatorsconcludedthat,tominimizethe risk of similar occurrences, fire departments should:• ensure that Incident Command (IC)

continually evaluates the risk versusgainand establishes a strategic plan when

deciding on an offensive or defensive fire attack

• ensurethatacollapsezoneisestablished,clearlymarked,andmonitoredatstructurefires where there is a risk of collapse

• use evacuation signals when commandpersonnel decide that all fire fighters should be evacuated from a burning building orotherhazardousarea

• ensurethatprotectiveclothingandprotectiveequipment is used whenever fire fighters areexposed,orpotentiallyexposed,tothehazardsforwhichitisprovided

• establish and implement written standardoperating guidelines (SOGs) regardingemergency operations on the fireground and ensuretheyarefollowed

• developpre-incidentplanningprotocolsandconduct joint training throughout mutualaiddepartments

37F2004

Photo courtesy of the fire department

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VolunteerChiefDiesandTwoFireFightersAreInjuredbyaCollapsingChurchFacade-Tennessee

FatalityAssessmentandControlEvaluation2004InvestigativeReport#F2004-37

Additionally,municipalitiesshould:

• considerrequiring,andownersofcommercialbuildingsshouldconsidermodifying,olderstructurestomeetnewbuildingcodesandstandardstoimprovethesafetyofoccupantsand fire fighters

INTRODUCTIONOnAugust 1, 2004, four months after beinginjured,a71year-oldmalevolunteerChiefdied.The victim was struck by bricks and burningdebris that fell from an outward collapse of achurchfaçade.OnAugust3,2004,theUnitedStates Fire Administration notified the National Institute for Occupational Safety and Health(NIOSH)ofthefatality.OnSeptember22,2004,an investigator from the NIOSH Fire FighterFatality Investigation and Prevention Programinvestigated the incident. The investigatorvisited the fire scene and interviewed the officers and fire fighters who were on the scene at the timeoftheincident.Theinvestigatormetwithrepresentativesfromthepolicedepartmentandreviewed fire and police dispatch records. The incident was also investigated by the FederalBureauofAlcohol,Tobacco,andFirearms,theState Bomb andArson Squad, and the StateOccupationalSafetyandHealthAdministration.Their findings were reviewed by the NIOSH investigator.Copiesofthedepartment'sstandardoperating procedures (SOPs), the victim’straining records, and the death certificate were alsoreviewed.

DepartmentThe volunteer department is comprised of one fire stationandservesapopulationofabout2,250inanareaofaboutthreesquaremiles.Thereareapproximately 20 volunteer fire fighters in the department.

TrainingandExperienceThe 71 year-old victim had been with thedepartmentfor48yearsandhadservedasChieffor the last 12 years. During his 48 years ofservice,thevictimcompletedhundredsofhoursoftraining.Recordsfromthemostrecentthreeyearsdocument131hoursoftrainingincludingengine operator, hazardous materials, personalprotective equipment, and officer training.EquipmentandPersonnelThere were four fire apparatus (Engine 1 [E1], Engine 3 [E3], Engine 5 [E5] and Truck 2 [T2]) onthescenewhenthecollapseoccurredat1045hours. E1 with a fire fighter/driver arrived on the sceneat1033hours.T2arrivedonthesceneat1036hoursandwasdrivenbythevictim’sson(FF1) who was one of the fire fighters injured during the collapse. E3 and E5, each with afire fighter/driver, radioed that they were on the scene at 1036 hours. The victim and the other fire fighter who was injured during the collapse (FF2) arrivedviatheirpersonalvehicles.Bythetimethe fire was brought under control, there were 59 fire service personnel from three companies, seven apparatus, and one emergency medicalunitonsite.

StructureThestructurewasafunctioningchurchthatwasoriginally built in 1870. It was a single storybuildingofwood-frameconstructionandhadapartialbasementwithapproximately2,233totalsquare feetofuseable space. Thechurchwasrenovated in 1920 and exterior walls of brickveneer were constructed over the wood frameat that time. Thegabled roofwascoveredbywood and composition shingles. The interiorwallsweremadeofwoodpanels.Therewasasuspendedacoustic tileceiling in thevestibulearea where it is believed the fire originated.

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FatalityAssessmentandControlEvaluation


2004InvestigativeReport#F2004-37

Flooringconsistedofcarpetoverapre-existingwooden floor. Until the mid 1960’s, the church was heated by a free-standing coal stove. Achurch officer reported to arson investigators that coaldusthadaccumulatedwithinthewallsandabovetheceilingwhichmayhavecontributedtoarapid fire-spread. The building was not equipped withasprinklersystemorsmokedetectors.

WeatherTheweatherwasfairandsunnywithatemperatureofapproximately70ºF.Thewindwasblowingatabout5miles-per-hour.Thereisnoindicationthat weather was a contributory factor in thisfatality.

INVESTIGATIONOnthemorningofApril8,2004at1029hours,avolunteerdepartmentwasdispatchedtoaworkingchurch fire. At the time of the initial alarm, the victimwas leavingthe townhallwhichisoneblockfromthechurch.Hearrivedatthesceneof the fire via his personal vehicle at 1030 hours, assumed Incident Command and performed a360°size-upofthescene.Heradioedat1031hours that he saw no signs of fire, but following awalk-aroundofthestructure,radioedat1032hoursthatheavysmokewasshowing.

The scene of the fire was located two blocks from the fire station and the first apparatus arrived within four minutes of the initial alarm. E1manned by a fire fighter/driver radioed he was on thesceneat1033hours.T2,whichwasdrivenbythevictim’sson(FF1),radioedhewasonthesceneat1036hours.Alsoarrivingat1036hourswasE5fromthevictim’sdepartmentandE3fromamutualaiddepartment.

At approximately 1038 hours, FF1 and FF2donnedfullturnoutgearandmasked-upbeforeforciblyenteringthefrontofthestructure.They

carriedacharged1½”lineoffofE5.At1042hoursFF1radioedforapikepoletopullceilingtileintheABcornerofthevestibuleandcheckfor fire extension where it was believed the fire hadoriginated.Atapproximatelythesametime,two fire fighters had pulled a 2½” line off of E1 andsetupinthestreetneartheABcornerofthechurch. The fire fighters were directing a water streamontotheABroofcornertowardthefrontofthestructure(seeDiagram).

The victim had just completed a 360° walk-aroundofthestructure.Hewaswearingcivilianpantsandshoes,buthaddonnedhisturnoutcoatand helmet. Very quickly, thick gray smokebegantoappearneartheAsideroofapex,theABcorner,andoutofthefrontupperlevelwindow.FlameswerejustbeginningtoshowattheroofridgelineandappearedtobemovingtowardsideA(Photo1).Itisbelievedthatthevictimmadethedecision toevacuate thestructurewhenhewitnessed thequicklydeterioratingconditions.Hebeganwalkingtowardthefrontentranceofthe church while verbally calling for FF1 andFF2 to immediatelycomeoutof thestructure.At approximately 1045 hours, as the two fire fighters exited the structure through the front door, the entire roof collapsed inward and thebrickfaçadeabovethegutterlineontheAsidewallfelloutwardontothestreet(Photo2).Thevictim was in front of, and facing, theA sidewall.Thefallingburningdebrisstruckhimandtheimpactcausedhimtofallbackwardsintothestreet.Hewasremovedfromthedebrisinlessthanaminute,butsufferedburnsandmultiplebody traumas. FF1 and FF2 were also struckbythedebrisastheyexitedthechurch.Atthetime of the collapse, both fire fighters were in, orverynear, thefrontdoorway. It isbelievedtheywereprotectedfrommoreseriousinjuriesduetotheirproximitytotheAsidewallandtheprotection of their turnout gear. The injured fire

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fighters were transported to a local hospital where theyweretreatedandreleased.ThevictimwasairliftedtoahospitalandlatertransferredtoarehabilitationcenterwhereheremaineduntilhisdeathonAugust1,2004.

CAUSE OF DEATHThe cause of death was identified by the medical examiner as multiple blunt force trauma andthermalinjuries.

RECOMMENDATIONS AND DISCUSSIONRecommendation#1:FiredepartmentsshouldensurethatIncidentCommand(IC)continuallyevaluatestheriskversusgainandestablishesastrategicplanwhendecidingonanoffensiveordefensive fire attack.

Discussion: According to NFPA 15001, theIncident Commander shall integrate riskmanagementintotheregularfunctionsofIncidentCommand. The concept of risk managementshall be utilized on the basis of the followingprinciples:• Activities that present a significant risk to

the safety of members shall be limited tosituationswherethereisapotentialtosaveendangeredlives.

• Activities that are routinely employed toprotect property shall be recognized asinherentriskstothesafetyofmembers,andactionsshallbetakentoreduceoravoidtheserisks.

• No risk to the safety of members shall beacceptable when there is no possibility tosavelivesorproperty.

• TheIncidentCommandershallevaluatetherisktomemberswithrespecttothepurposeandpotentialresultsoftheiractionsineachsituation.

• Riskmanagementprinciplesshallberoutinelyemployed by supervisory personnel at alllevels of the incident management systemto define the limits of acceptable andunacceptablepositionsandfunctionsforallmembersattheincident.

The offensive versus defensive commanddecisionisanongoingonethatrequirescontinualevaluationofthesemajorfactorsthroughouttheattack.

KlaeneandSanders2statethatstructuralconditionsbear heavily on, and the entire operation isgoverned by, the offensive/defensive decision. An operation that begins as an offensiveattacksometimeschangestodefensive,buttheactions being taken during either attack mustbe coordinated as offensive or defensive; theymustneverbeboth.Brunacini3statesthat“theoffensiveanddefensivemodesareindependentevents. Effective fire operations (safe, sane, and predictable)areconductedeitherontheinsideortheoutsideofthebuilding.Anymixtureofthetwobasicmodesbeginstosetthestageforlossoflifeandproperty.”

In this incident, fire fighters set up a 2½” handline inthestreettothenorthoftheABcornerofthechurch. They directed the stream toward flames beginning toshownear the roofapexat theAwall. During this same period of time, two fire fighters entered the front of the church with a charged 1½” line to check for fire extension in thefrontvestibulearea.Thecollapseoccurredapproximately fifteen minutes after the firstalarm and just as fire fighters were evacuating thestructure.

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Recommendation#�:Firedepartmentsshouldensurethatacollapsezoneisestablished,clearlymarked, and monitored at structure fires where there is a risk of collapse.Discussion: Upon arrival, and at any timeduring a structure fire, if size-up determines that structural integrity is questionable, a collapsezonemustbeestablished.Acollapsezoneisanareaaroundandawayfromastructureinwhichdebrismightlandifthestructurefails.Thisareashouldbeequaltotheheightofthebuildingplusanadditionalallowancefordebrisscatter,andataminimumshouldbeequalto1½timestheheightofthebuilding.4Forexample,ifthewallwere20feethigh,thecollapsezoneboundaryshouldbeestablishedatleast30feetawayfromthewall.

Knowledge of building construction and howfire reacts in a building can assist in making determinations of structural stability. Dodsonoutlines the following seven-steps to assist fire scene personnel in analyzing the potential forstructurecollapse.5

1. Classifythetypeofconstruction.2. D e t e r m i n e t h e d e g r e e o f f i r e

involvement.3. Visualize load imposition and load

resistance.4. Evaluatetimeasafactor.5. Determinetheweaklink.6. Predictthecollapsesequence.7. Proclaimacollapsezone.

Immediate safety precautions must be takenif factors indicate the potential for a buildingcollapse.All persons operating inside thestructure must be evacuated immediately anda collapse zone should be established aroundthe perimeter. Once a collapse zone has beenestablished,theareashouldbeclearlymarkedand

monitored, to make certain that no fire fighters enterthedangerzone.

According to Dunn, structural collapse duringfirefighting can be expected to increase and one factorcontributingtotheincreaseistheageofbuildings.6Olderbuildingscanbeweakenedduetoage.Structuresmaybecomebadlydeterioratedaswood shrinks and rots, andmortar loses itsadhesive qualities. One estimate identifies 75 to 100 years as the age at which buildings begintodeteriorateandconditionsmaycontributetocollapse. In this incident, the original churchstructurehadbeenbuiltapproximately130yearsago.

Itisbelievedthevictimhadrecognizedthequicklydeterioratingconditionsandthepossibilityofacollapse when he decided to call for the fire fighters to evacuate the church. Neither the victim nor the two fire fighters had time to escape from the collapse zone and were struck by fallingdebris.

Recommendation#�:Firedepartmentsshoulduseevacuationsignalswhencommandpersonneldecide that all fire fighters should be evacuated from a burning building or other hazardousarea.

Discussion: Evacuation signals are used whencommand personnel decide that all fire fighters shouldbeevacuatedfromaburningbuildingorother hazardous area because conditions havedeteriorated beyond the point of reasonablesafety. All fire fighters should be familiar with their department’s method of sounding anevacuationsignal.Thereareseveralways thiscommunication can be done. The two mostcommon methods are to (1) broadcast a radiomessage ordering all fire fighters to evacuate, and (2)soundanaudiblewarningdevice(airhorn)

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on the apparatus at the fire scene for an extended periodoftime.7Themessageshouldbebroadcastseveraltimestomakesureeveryonehearsit.

In this incident, the victim walked toward thestructure to personally call to the fire fighters whowereworkingjustinsidethefrontdoor.Thisdepartment’sevacuationsignalisthreesustainedblastsfromtheairhorn.Thecollapseoccurredbeforetheorderforthesignalwasgiven.

Recommendation#�:Firedepartmentsshouldensure thatprotectiveclothingandprotectiveequipment is used whenever fire fighters are exposed,orpotentiallyexposed,tothehazardsfor which it is provided.

Discussion:AccordingtoNFPA1500Chapter7,“The fire department shall provide each member with the appropriate protective clothing andprotectiveequipmenttoprovideprotectionfromthehazardstowhichthememberisorislikelyto be exposed. Such protective clothing andprotective equipment shall be suitable for thetasks that the member is expected to perform.Protective clothing and protective equipmentshallbeusedwheneverthememberisexposedorpotentiallyexposedtothehazardsforwhichitisprovided.”1

The victim in this incident was wearing hisbunkercoatandhelmet.However,hewasnotwearingbunkerpantsorbootswhichmayhavecontributedtothegravityofhisinjuries.

Recommendation#�:Firedepartmentsshouldestablish and implement written standardoperating guidelines (SOGs) regardingemergency operations on the fireground and ensure they are followed.

Discussion: SOGs are a set of organizationaldirectives that establish a standard courseof action on the fireground to increase theeffectiveness of the fire fighting team. SOGs are characterized as being written and official. Theyareappliedtoallsituations,enforced,andintegrated into the management model.Theygenerallyincludesuchareasas:basiccommandfunctions; communications and dispatching;fireground safety including discussions on risk management and establishing a collapse zone;guidelines that establish and describe tacticalprioritiesandrelatedsupportfunctions;methodof initial resource deployment; and an outlineof responsibilities and functions for variousindividualsandunits.8Unwrittendirectivesmaybe difficult to learn, remember, and apply. One approach to establishing SOGs is to have officers and fire fighters decide how all operations will beconductedandthencommittothosedecisionsinwriting.

It is imperative that companies perform theirdutiesasdescribedintheirSOGsunlessdirectedorapprovedbytheIncidentCommander(IC)todootherwise.Dunnstates“Astandardoperatingprocedure(orguideline)providesaccountabilityandcontrol.Itisageneralplanofwhodoeswhatandwhen. It lets companiesknowwhere theyshould be operating and what they should bedoing.Astandardoperatingprocedureshouldbecreated for the most frequent type of fire to which acompanyresponds.”9

An example of pertinent interior/exterior fire-groundoperationguidelinesarelistedbelow:10

• useextremecautionwhenaninteriorattackistobeperformedinstructuresexhibitingsignsofburningthroughtheroof

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• interior fire attack operations are not to be performedwithinstructures thathavebeenidentified as unsafe

• whenconductinganexteriorattack,exterioractivities must be watchful of both fallingdebrisandinterioractivities

• shouldan interiorcrewbeapproaching,orwithinanexteriorattackarea,exteriorcrewsmust shut down water streams to assureinteriorcrewsafety

• when conducting exterior attack, constantexaminationofroofandwallintegritymustbeperformedtopreventinjurytocrews

The department SOGs should declare that fire extinguishment and control must consider fire fighter safety first.

At the time of the incident, this departmenthad administrative SOPs but no documentedspecific and detailed procedures for fireground operations.

Recommendation#�:Firedepartmentsshoulddevelop pre-incident planning protocols andconduct joint trainingthroughoutmutualaiddepartments.

Discussion: NFPA 1620 provides guidance toassist departments in establishing pre-incidentplans. Pre-incident planning that includesagreementsformedbyacoalitionofallinvolvedparties including mutual aid fire departments, EMS companies, and police, will present acoordinated response to emergency situations,and may save valuable time by a more rapidimplementationofpre-determinedprotocols.11

Mutualaidcompaniesshouldtraintogetherandnotwait until an incidentoccurs to attempt tointegrate the participating departments into afunctional team.Differences inequipmentandprocedures need to be identified and resolved

before an emergency where lives may be atstake.Proceduresandprotocolsthatarejointlydeveloped,andhavethesupportofthemajorityofparticipatingdepartments,willgreatlyenhanceoverall safety and efficiency on the fireground. Once methods and procedures are agreedupon, training protocols must be developedand joint-training sessions conducted to relayappropriateinformationtoallaffecteddepartmentmembers.12

By the time the fire was brought under control, there were 59 fire service personnel from three companies,sevenapparatusandoneemergencymedicalunitonsite.Coordination of fireground effortsmayhavebeenenhancedifpre-incidentplanningandjointtraininghadtakenplaceamongmutualaiddepartments.

Additionally, municipalities should considerrequiring,andownersofcommercialbuildingsshould consider modifying, older structuresto meet new building codes and standardsto improve the safety of occupants and fire fighters.

Discussion: Building codes and standards arecurrentlyusedasguidelinesforpreservingnewlyconstructed buildings and improving occupantsafety.However,beforemunicipalitiesadoptedor enforced specific codes and standards, many buildingsweredesignedandconstructedwithoutincorporatingsuchstandards.NFPA909,CodefortheProtectionofCulturalResourceProperties–Museums,Libraries,andPlacesofWorship,13statesthataccordingtoarecentNFPAstudyoffires that occurred in houses of worship, from 1987 to 1998 an average of 1,580 places ofworshipwereseriouslydamagedordestroyedbyfire each year. This equated to four properties per daywithanannualaveragefordirectpropertydamagetotaling$44.2milliondollars.

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NFPA 909 B.4.2.3 states that “a properlydesignedautomaticsprinklersystemisthemosteffective single means of preventing seriousfires. Automatic sprinklers combined with good building design and fire-resistive construction, finishes, and furnishings are the best way to ensuresaferplacesofworship.” Thereisalsoastrongpossibilitythatsprinklerscouldreducefire fighter fatalities, since they contain, and even extinguish, fire prior to the arrival of the fire department. The structure involved in this incidentdidnothaveasprinklersystem.

REFERENCES1. NFPA [2002]. NFPA 1500, standard on

fire department occupational safety and health program. Quincy, MA: NationalFireProtectionAssociation.

2. Klaene B, Sanders R [2002]. Structural fire fighting. Quincy, MA: National Fire ProtectionAssociation.

3. Brunacini A [1985]. Fire command. Quincy, MA: National Fire ProtectionAssociation.

4. Fire Fighter’s Handbook [2000]. Essentials of fire fighting and emergency response. NewYork:DelmarPublishers.

5. Dodson D [1999]. Fire department incident safety officer. New York: Delmar Publishers.

6. Dunn V [1988]. Collapse of burning buildings, a guide to fireground safety. Saddlebrook,NJ:PennWell.

7. International Fire Service TrainingAssociation [1998]. Essentials of fire fighting, 3rd ed. Stillwater, OK: Fire

ProtectionPublications,OklahomaStateUniversity.

8. NFPA [1997]. Fire protection handbook. Quincy, MA: National Fire ProtectionAssociation.

9. Dunn V [2000]. Command and control of fires and emergencies. Saddle Brook, NJ: FireEngineeringBooksandVideos.

10. NIOSH [2003]. A summary of a NIOSH fire fighter fatality investigation: Structural collapse at residential fire claims lives of two volunteer fire chiefs and onecareer fire fighter. Morgantown, WV:U.S.DepartmentofHealthandHumanServices, Centers for Disease Controland Prevention, National Institute forOccupationalSafetyandHealth,DHHS(NIOSH)PublicationF2002-32.

11. NFPA [1998]. NFPA 1620, standard on recommended practice for pre-incidentplanning. Quincy, MA: National FireProtectionAssociation.

12. Sealy CL [2003]. Multi-company training: Part1.Firehouse,February2003Issue.

13. NFPA [2005]. NFPA 909, code for the protectionofculturalresourceproperties– museums, libraries, and places ofworship. Quincy, MA: National FireProtectionAssociation.

INVESTIGATOR INFORMATIONThis incident was investigated, and the reportwas authored, by Virginia Lutz, Safety andOccupationalHealthSpecialist,NIOSH,Divisionof Safety Research, Surveillance and FieldInvestigationBranch.

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Photo 1. Before collapse of roof and facade, photo courtesy of the fire department




Photo 2. After collapse of roof and facade, photo courtesy of the fire department

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fire fighter face report no. 2004-37, volunteer chief dies

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