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F2000 Death in the line of duty...04

Structure Fire Claims the Lives of Three Career Fire Fighters and ThreeChildren�Iowa

April 11, 2001A Summary of a NIOSH fire fighter fatality investigation

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. Identificationof causal and contributing factors enable researchers andsafety specialists to develop strategies for preventing futuresimilar incidents. The program does not seek to determinefault or place blame on fire departments or individual firefighters. To request additional copies of this report (specifythe case number shown in the shield above), other fatalityinvestigation reports, or further information, visit the programwebsite at

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

SUMMARYOn December 22, 1999, a 49-year-old ShiftCommander (Victim #1) and two EngineOperators, 39 and 29 years of age respectively(Victim #2 and Victim #3), lost their lives whileperforming search-and-rescue operations at aresidential structure fire. At approximately 0823hours, the three victims and two additional firefighters cleared the scene of a motor-vehicleincident. One of the fire fighters (Fire Fighter#1) riding on Engine 3, joined the ambulance crewto transport an injured patient to the hospital. Atapproximately 0824 hours, Central Dispatch wasnotified of a structure fire with three childrenpossibly trapped inside. At approximately 0825hours, Central Dispatch notified the firedepartment, and a Shift Commander and anEngine Operator (Victim #1 and Victim #2 ) were

dispatched to the scene in the Quint (Aerial Truck2). At 0827 hours, Engine 3 (Lieutenant andVictim #3) responded to the scene. At 0829 hoursas Aerial Truck 2 approached the scene, theyradioed Central Dispatch, reporting white to darkbrown smoke showing from the residence, andrequested six additional fire fighters. Aerial Truck2 arrived on the scene at 0830 hours. The crewof Aerial Truck 2 witnessed a woman and childtrapped on the porch roof, and they were informedthat three children were trapped inside the house.A police officer who was already on the scenepositioned a ladder to the roof and removed thewoman and child as Victim #1 proceeded into thehouse to perform a search-and-rescue operation.Engine 3 arrived on the scene shortly after, andthe Lieutenant connected a supply line to thehydrant as Victim #3 pulled the Engine intoposition. The Lieutenant and Victim #3 stretcheda 5-inch supply line and connected it to AerialTruck 2. At approximately 0831 hours, the Chiefand Fire Fighter #1 arrived on the scene, and theChief assumed Incident Command (IC). FireFighter #1 pulled a 1½-inch handline off Aerial

Incident Site

Photo courtesy of Cindy Iutzi,Daily Gate City, Iowa

Structure Fire Claims the Lives of Three Career Fire Fighters and Three Children�Iowa

Investigative Report #F2000-04Fatality Assessment and Control Evaluation


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Truck 2, through the front door and placed it inthe front room. The IC instructed Victim #2 andVictim #3 to don their protective gear and proceedinto the house to assist in the search-and-rescueoperations. Fire Fighter #1 went back to AerialTruck 2 to gear up. At this time, one of the victimsremoved the first of the three children from thestructure, handed the child to a police reserveofficer near the front entrance of the structure,and returned to the structure to continue search-and-rescue operations. The police reserve officertransported the child to a nearby hospital. TheIC charged the handline from Aerial Truck 2 andwent to the structure. At this time one of thevictims removed a second child. The IC grabbedthe child and began cardiopulmonary resuscitation(CPR). Due to limited personnel on thefireground, the IC directed a police officer on thescene to transport him and the child to the hospital.After donning her gear, Fire Fighter #1approached the front door and noticed that the1½-inch handline (previously stretched) had beenburned through and water was free-flowing. It isbelieved that the three victims were hit with athermal blast of heat before the handline burnedthrough. The three victims failed to exit as 12additional fire fighters arrived on the scenethrough a call-back method and began firesuppression and search-and-rescue operations.Victim #2 was located, removed, and transportedto a nearby hospital, where he was pronounceddead. Victim #1 and Victim #3 were later foundand pronounced dead on the scene. NIOSHinvestigators concluded that to minimize the riskof similar occurrences, fire departments should

� ensure that adequate numbers of staff areavailable to immediately respond toemergency incidents

� ensure that Incident Command conducts aninitial size-up of the incident before

initiating fire fighting efforts, andcontinually evaluates the risk versus gainduring operations at an incident

� ensure fire fighters are trained in the tacticsof defensive search

� ensure that fire command always maintainsclose accountability for all personnel at thefire scene

� ensure that fireground communication ispresent through both the use of portableradios and face-to-face communications

� ensure that a trained Rapid InterventionTeam (RIT) is established and in positionimmediately upon arrival

� ensure that fire fighters wear and use PASSdevices when involved in interior firefighting and other hazardous duties

INTRODUCTIONOn December 22, 1999, fire fighters from a careerfire department responded to a structural fire at alocal residence. The fire was started when a stoveturned on shortly after 0800 hours, ignited thematerials setting on the stove top. A 49-year-oldShift Commander (Victim #1), a 39-year-oldEngine Operator (Victim #2) assigned to driveAerial Truck 2, and a 29-year-old Engine Operator(Victim #3) assigned to drive Engine 3 lost theirlives while performing search-and-rescueoperations for three children who were trappedinside the burning structure. These fire fighterswere part of a five-person crew who were on dutyat the time of the alarm.

On December 22 and 23, 1999, the InternationalAssociation of Fire Fighters (IAFF) and the UnitedStates Fire Administration (USFA), respectively,





notified the National Institute for OccupationalSafety and Health (NIOSH) of this incident. OnJanuary 18-21, 1999, a Fire Protection Engineer,a Senior Investigator, an Occupational Safety andHealth Specialist, and the Chief of the Surveillanceand Field Investigations Branch, Division ofSafety Research, investigated this incident.Interviews and meetings were conducted with theChief of the department, fire fighters from thedepartment who were on the scene of this incident,a representative from the Local IAFF, and arepresentative from the State Fire Marshal�sOffice. Additionally, NIOSH held meetings withrepresentatives from the Bureau of AlcoholTobacco and Firearms (ATF), the NationalInstitute of Standards and Technology (NIST),and the National Fire Protection Association(NFPA), who were also conducting investigations.The incident site was visited and the fire scenewas photographed. Copies of witness statements,training records, standard operating procedures(SOPs), pathology reports, and a map of the firescene were reviewed. An inspection of thevictims� Self-Contained Breathing Apparatus(SCBA) and turnout gear was conducted.

On October 23, 2000, an Occupational Safety andHealth Specialist, the Chief of the Surveillanceand Field Investigations Branch, Division ofSafety Research, and an Engineer with theNational Institute of Standards and Technologymet with the Chief of the department to assist inthe development of a fire dynamics model for thisincident (see section titled FIRE MODELINFORMATION).

This career department consists of 18 uniformedfire fighters and a Chief. The department servesa population of 13,500 in an area of approximately10 square miles. The department operates on athree-shift rotation with five to six fire fightersper shift.

The incident occurred in a balloon-framedstructure built in the 1870s as a single-familyresidence. In the 1970s the structure wasremodeled and divided into three separateapartment units. The apartment in which theincident occurred was a single unit which occupiedboth floors of the structure. The attic andbasement did not receive fire damage. Minimalfire stops in the walls and ceiling cavities werecreated from heavy timber construction. The atticwas common to the entire area above the second-floor ceiling.

The State of Iowa requires all fire fighters to beNFPA Fire Fighter I certified. The departmentrequires all fire fighters to attain their certificationas Fire Fighter I 18 months from their date ofhire. All three victims were certified at the FireFighter I level. Regularly scheduled in-housetraining is conducted by shift officers anddocumented by certified instructors (State ofIowa) on the department�s staff. The firedepartment periodically sends fire fighters to theIowa State University Fire Service Institute forfire training. Victim #1 had 25 years of experience,Victim #2 had 4 years of experience, and Victim#3 had 5 years of experience.

At the time of the incident, all of the victims werewearing a full array of personal protective clothingand equipment, consisting of turnout gear (coatand pants), helmet, gloves, boots, Nomex® hoods,a Self-Contained Breathing Apparatus (SCBA)with an integrated Personal Alert Safety System(PASS) device, and a Manual Personal AlertSafety System (PASS) device secured to each firefighters� turnout coat. Note: The victims� manualPASS devices were checked and found to be severelydamaged, but in working condition. It is unknownif the PASS devices were turned off after the victims�removal from the structure or were never turned onbefore entering the structure.





INVESTIGATIONAt approximately 0823 hours, the three victimsand two additional fire fighters had cleared thescene of a motor-vehicle incident. One of the firefighters (Fire Fighter #1) riding on Engine 3 joinedthe ambulance crew to transport an injured patientto the hospital. At approximately 0824 hours,Central Dispatch received a call from a neighbor,about a structure fire with the possibility ofchildren trapped inside. Central Dispatch notifiedthe fire department and at approximately 0825hours dispatched Aerial Truck 2 with the ShiftCommander (Victim #1) and an Engine Operator(Victim #2). Aerial Truck 2 proceeded to thescene. At 0827 hours, Engine 3 was dispatchedand responded to the scene with a Lieutenant andan Engine Operator (Victim #3). The Chiefresponded by Car 5661 to the hospital to pick upFire Fighter #1 and continue to the scene. Atapproximately 0829 hours, the Shift Commander(Victim #1) radioed the hydrant position at thescene to Engine 3 who was approximately 1minute behind Aerial Truck 2. As Aerial Truck 2approached the location of the structure, the ShiftCommander (Victim #1) radioed Central Dispatchand requested that 6 additional fire fighters becalled in due to the severity of the situation. AerialTruck 2 reported white to dark brown smokeshowing from the residence.

Aerial Truck 2 arrived on the scene atapproximately 0830 hours. A woman and a childwere trapped on a porch roof at the front of theresidence. The fire fighters were informed thatthree children were trapped inside the house.Victim #1 proceeded into the house through thefront door to perform a search-and-rescueoperation (Photo 1). A police officer, who arrivedon the scene before Aerial Truck 2, positioned aladder to the porch roof and removed the motherand child. The Lieutenant from Engine 3connected a line (200 feet of a 5-inch supply line)

to the hydrant as the Engine Operator (Victim#3) pulled the engine into position. Afterconnecting the line, the Engine Operator (Victim#3) and the Lieutenant from Engine 3 connectedthe supply line to Aerial Truck 2.

At approximately 0831 hours, the Chief and FireFighter #1 arrived on the scene. The Chiefassumed duties as the Incident Commander (IC).Through face-to-face contact the IC instructedVictim #3 to finish hooking the supply line toAerial Truck 2, then �gear up� and proceed intothe house to assist in the search-and-rescueoperation. Note: In this incident only firegroundofficers were equipped with portable radios, thusonly certain members on the fireground receivetheir instructions over their portable radios.Other fireground personnel are forced to rely onface-to-face communications from the IC or theircrew leader. Fire Fighter #1 stretched 200 feetof a 1½-inch handline through the front door ofthe structure into the front downstairs room,noting smoky conditions with little heat. FireFighter #1 then went back to Engine 3 to finishdonning her protective gear.

At this time, one of the victims handed a child toa police reserve officer near the front door of thestructure. The police reserve officer transportedthe child to a nearby hospital. As the first childwas removed, the IC charged the handline andwent back up to the structure. At this time, asecond child was brought to the door. The ICran to the door and grabbed the child from one ofthe victims and began cardiopulmonaryresuscitation (CPR). The IC then looked forsomeone to give the child to; however, there wereno other fire fighters or emergency medical servicepersonnel on the scene. A second police officertransported the IC and the child to the hospital.Note: Both children removed from the structurewere pronounced dead at the hospital.





At approximately 0835 hours, Fire Fighter #1went up to the front of the structure to begin anactive fire fight and noticed that the hoseline wasfree-flowing. As Fire Fighter #1 continued towardthe structure she discovered that the hoseline hadburned through and flames were protruding fromthe entrance. Note: It is believed, throughinterviews conducted, evidence at the scene, anda fire model developed by NIST, that the diningroom flashed, causing secondary flashovers inthe living room, and ventilation conditionscreated a path of least resistance up the stairs,injuring and disorienting the three fire fightersenough to prevent their escape from the structure.Please see section titled FIRE MODELINFORMATION.

Noting that the hose was free-flowing, theLieutenant from Engine 3 shut the line down. Hethen charged a second line that was stretched intothe house for Fire Fighter #1 and proceeded tohis engine to �gear up.� At this time, Fire Fighter#1, standing inside the doorway of the structure,was yelling that they were out of water. TheLieutenant then proceeded to the pump panel ofAerial Truck 2 and opened the wheel valve,recharging the line for Fire Fighter #1. Fire Fighter#1 then initiated suppression activities in the livingroom (Figure 1). Note: Due to the extreme heatFire Fighter #1 would advance the hoseline intothe room and then retreat. This sequence wasrepeated several times.

At approximately 0839 hours, the Chief returnedto the scene and continued his role as IC. Shortlyafter the Chief returned to the scene, Engine 6arrived with an Assistant Chief (Assistant Chief#1) and a Lieutenant. As the Lieutenants fromEngines 3 and 6 and Assistant Chief #1 finisheddonning their protective gear, they were told byonlookers that there was the possibility of acivilian in the upstairs apartment on the non-fire

side of the building (Photo 2). Note: Theneighbor�s car was parked in front of the house,causing concern among onlookers that he wasstill inside the structure. At this time the ICordered the Lieutenant from Engine 3, theLieutenant from Engine 6, and Assistant Chief #1to form a three-man search-and-rescue team tosearch the apartment located on the top floor ofthe non-fire side.

The search-and-rescue team proceeded throughthe front door (non-fire side) to the upstairsapartment. As they reached the landing at thetop of the stairs, the search-and-rescue team splitup in their search efforts. Assistant Chief #1 wentoff to the left to search, the Lieutenant fromEngine 3 went straight ahead toward the back ofthe structure, while the Lieutenant from Engine 6stayed near the entrance of the structure. At thispoint, there was zero visibility in this side of thestructure due to thick smoke.

Note: Through interviews conducted it wasdetermined that the Fire Department had notcompleted any type of ventilation at this time.However, it is believed that horizontal ventilationtook place in the rear of the structure by a policeofficer. Both rear first floor windows of thestructure were cleared in both the fire and non-fire sides of the structure. Photographs reviewedby investigators show that the fire department waspossibly on the scene conducting search-and-rescue operations when the horizontal ventilationwas conducted; however, an exact time of thehorizontal ventilation could not be determined,due to insufficient fireground communicationbetween the fire department and the policeofficers on the scene. The window cleared on thefire side of the structure was the bathroom windownear the kitchen. ATF agents, who conducted apost-fire investigation of the structure, and theengineers from NIST, who developed the fire





model, concluded that the door leading from thebathroom to the kitchen area was closed andintact when the window was cleared.Consequently, it is believed that the clearing ofthis window had little impact on ventilation orfire growth.

After conducting their searches, the search-and-rescue team met on the upstairs landing to decidewhat their next move should be. At approximately0848 hours, they heard the IC yelling for Victim#1, so the search-and-rescue team exited thestructure and proceeded to the IC to get their nextassignment. Note: After returning from thehospital, the IC (Chief) regained command andstarted to account for all fire fighters on the scene.He realized that he was now missing three firefighters (Victims #1, #2, and #3). Atapproximately 0850 hours, Aerial Truck 1,consisting of a four-man crew (Lieutenant, EngineOperator, and Fire Fighters #2 and #3), arrivedon the scene. At the same time, an Assistant Chief(Assistant Chief #2) and a fire fighter (Fire Fighter#4) arrived on the scene in a privately ownedvehicle (POV). Assistant Chief #1 from Engine6, the Lieutenant from Engine 6, and the EngineOperator from Engine 3 were ordered to continueas a Rapid Intervention Team (RIT) and searchthe fire side of the structure (Photo 2). AssistantChief #2 and Fire Fighter #4 donned their SCBA,pulled an additional line off Aerial Truck 2, andwent into the structure to assist in suppressionactivities. Assistant Chief #2, the nozzleman, andFire Fighters #2 and #4 manned the hoseline insidethe doorway, spraying water into the living room.Fire Fighter #1 was also near the entrance of thestructure performing suppression activities. TheEngine Operator from Aerial Truck 1 went intothe hallway, then heard Assistant Chief #2 ask fora positive pressure ventilation fan (PPV) to beplaced in the front doorway. Fire Fighter #2 tookthe nozzle from Fire Fighter #4, and Assistant

Chief #2 acted as additional backup as theycontinued spraying water into the living room.At this time, Fire Fighter #2 noticed a helmet lyingon the floor in the front right room, then saw oneof the victims lying on the floor (Figure 1). Note:It is undetermined why the victims� integrated andmanual PASS devices were not heard soundingin this incident. The interior suppression crew�s(Fire Fighter #2, Fire Fighter #4, and AssistantChief #2) low-air alarms sounded, and they wereforced to exit the structure.

Fire Fighter #4 was ordered by the IC to go tothe rear of the structure and aid in suppressionactivities. Note: Two lines were taken to the rearof the structure; however, through interviewsconducted, it is undetermined who pulled theselines to the rear of the structure.

The interior suppression crew changed their airbottles and reentered. At this time the EngineOperator from Aerial Truck 1 placed a PPV fanin the front doorway. Upon entry, Assistant Chief#2, Fire Fighter #2, and the Engine Operator fromAerial Truck 1 removed who was thought to beVictim #1 from the structure. Upon exiting thestructure, they realized it was Victim #2. Victim#2 was transported to the hospital where he waspronounced dead.

Due to the extreme heat inside the structure, theIC made the call to switch from a search-and-rescue operation to a defensive attack. The ICassigned Assistant Chief #1 the responsibility ofkeeping fire fighters out of the structure until itwas deemed safe. At this time three additionalfire fighters (Fire Fighters #5, #6, and #7) weretransported to the scene by a police officer. FireFighter #7 was assigned to the rear of the structurewith the Lieutenant from Engine 6 and Fire Fighter#2, to control the fire extension from the rear ofthe structure (Photo 3). Fire Fighter #5 was





ordered to man a hoseline with the Lieutenantfrom Aerial Truck 1 on the side and rear of thestructure to control fire extension and assist insuppression activities. Fire Fighter #6 wasassigned with Assistant Chief #1 to man a hoselinefrom the main entrance of the structure to aid inthe cool down.

After approximately 4 minutes of defensive firefighting, search-and-rescue operations resumed.The Lieutenant from Engine 6 and Fire Fighter#3 formed a RIT and entered the fire side of thestructure to search for the two missing firefighters. However, they had to exit the structuredue to problems with Fire Fighter #3�s personalprotective equipment. At this time, Assistant Chief#1 and Fire Fighter #7 entered the structure tosearch for the two missing fire fighters and thethird child. Approximately 1030 hours, as crewscontinued to suppress the fire inside the structure,Assistant Chief #1 and Fire Fighter #7 locatedVictim #1 and the third child at the top of thestairs on the second-floor landing (Figure 2).Assistant Chief #1 radioed the IC asking EMSpersonnel to proceed to the front of the structureto aid in the removal of the third child from thestructure. After the third child was removed,Assistant Chief #1 and Fire Fighter #7 proceededback up the stairs to the landing, and with helpfrom Fire Fighter #6, they removed Victim #1from the structure. Assistant Chief #1 and FireFighter #7 then located Victim #3 in the masterbedroom and removed him from the structure.Fire Fighter #8 arrived on the scene by POV andassisted in fire suppression activities. Victims #1and #3 and the third child were pronounced deadat the scene.

Fire Fighters #5 and #8 and the Engine Operatorfrom Aerial Truck 1 received an order from thelocal Fire Marshal to ventilate the structure inpreparation for a post-fire investigation. Note:

At approximately 1012 hours the local FireMarshal arrived on the scene. At this time FireFighters #5 and #8 and the Engine Operator fromAerial Truck 1 ventilated the roof to aid insuppression activities. The remaining crews wererelieved from the scene at approximately 1530hours. At this time, mutual-aid companies arrivedon the scene and took over the suppression andoverhaul activities.

CAUSE OF DEATHThe pathology reports list the causes of death forthe victims as follows: Victim #1-Smokeinhalation (15% Carboxyhemoglobin level) andsudden exposure to intense heat, Victim #2-Smoke inhalation (25% Carboxyhemoglobinlevel) and sudden exposure to an extremely hotenvironment, and Victim #3-Sudden exposure tointense heat (1.0 % Carboxyhemoglobin level).

RECOMMENDATIONS AND DISCUSSIONRecommendation #1: Fire departments shouldensure that adequate numbers of staff areavailable to immediately respond to emergencyincidents.1

Discussion: As stated in NFPA 1500

�(6-4.3) Members operating in hazardous areasat emergency incidents shall operate in teams oftwo or more. Team members operating inhazardous areas shall be in communication witheach other through visual, audible, or physicalmeans or safety guide rope, in order to coordinatetheir activities. Team members shall be in closeproximity to each other to provide assistance incase of emergency.�

�(6-4.4) In the initial stages of an incident whereonly one team is operating in the hazardous areaat a working structural fire, a minimum of fourindividuals is required, consisting of two





individuals working as a team in the hazard areaand two individuals outside this hazard area forassistance or rescue at emergency operationswhere entry into the danger area is required. Thestaged members shall be responsible formaintaining a constant awareness of the numberand identity of members operating in thehazardous area, their location and function, andtime of entry. The standby members shall remainin radio, visual, voice, or signal linecommunications with the team.�

�(6-4.4.2) One standby member shall be permittedto perform other duties outside of the hazardousarea, such as apparatus operator, incidentcommander, or technician or aide, providedconstant communication is maintained betweenthe standby member and the members of the team.The assignment of any personnel, including theincident commander, the safety officer, oroperators of fire apparatus, shall not be permittedas standby personnel if by abandoning their criticaltask(s) to assist or, if necessary, perform rescue,they clearly jeopardize the safety and health ofany fire fighter working at the incident. No oneshall be permitted to serve as a standby memberof the fire-fighting team when the otheractivities in which he/she is engaged inhibit his/her ability to assist in or perform rescue, ifnecessary, or are of such importance that theycannot be abandoned without placing other firefighters in danger.�

Additionally, �when members are performingspecial operations, the highest available level ofemergency medical care shall be standing by atthe scene with medical equipment andtransportation capabilities. Basic life support shallbe the minimum level of emergency medical care.�

The small size of the initial responding crew couldnot appropriately and safely respond to the

necessary fireground operations�e.g. incidentcommand, scene size-up, search-and-rescue, astaged Rapid Intervention Team (RIT), hydrantconnections, ventilation, and medical aid andtransport.

Recommendation #2: Fire departments shouldensure that Incident Command conducts aninitial size-up of the incident before initiatingfire fighting efforts, and continually evaluatesthe risk versus gain during operations at anincident.2,3,4,5

Discussion: One of the most important size-upduties of the first-in officers is locating the fireand determining its severity. This information laysthe foundation for the entire operation. First, itdetermines the number of fire fighters and theamount of apparatus and equipment needed tocontrol the blaze. Second, it assists in determiningthe most effective point of fire extinguishmentattack and the most effective method of ventingheat and smoke.

A proper size-up begins from the moment thealarm is received, and it continues until theemergency is under control. Several factorsmust be evaluated in conducting the size-up�e.g., type of structure, time of day, contents ofthe structure, potential hazards, etc. The size-up should also include risk versus gain duringincident operations.

The following general factors are importantconsiderations:

Occupancy type involved. The type ofoccupancy can have a great effect on the aspectsof the fire attack. The type of occupancy couldassist in determining the structure�s layout,hazardous materials, and the possibility ofcivilians.





Smoke conditions. The smoke conditions canprovide the Incident Commander additionalinformation about the fire.

Type of construction. The type of constructionwill be one of the most important areas to identify.The type of structure could provide informationsuch as how the building will hold up under fireconditions or if the building is generally subjectto collapse under fire conditions.

Type of roof system. The roof system should beone of the first things that is determined beforefire fighters enter a burning structure.

Age of structure. The Incident Commandershould acknowledge the age of the building whendetermining strategy or tactics. The age of thestructure can provide the Incident Commanderwith information to determine the building�sintegrity or other areas previously mentioned.

Exposures. The Incident Commander shouldevaluate the whole picture. The protection ofexposures near or connected to a burning buildingshould be included in the strategic plan.

Time considerations. Information such as timeof incident, time fire was burning before arrival,time fire was burning after arrival, and type ofattack are some of the most important informationthe Incident Commander should have.

As the Chief (IC) arrived on the scene, whilepositioning his car, he drove on the road that thehouse faced, seeing primarily the front of thestructure. The IC could see a second side of thestructure when charging a handline. The IC wasthen handed a child from the structure whom hetransported to the hospital. A complete walk-around of the structure may have allowed theinitial responding crew and/or the IC to locate

the seat of the fire in the rear of the structure,assess the degree of the involvement of the fireand hazards to fire fighters, and to identify wherefire suppression activities should be initiated.

Additionally, fire departments should ensurethat the first officer or fire fighter insideevaluates interior conditions and reports themimmediately to the Incident Commander.

Interior size-up is just as important as exteriorsize-up. Since the IC is staged at the commandpost, the interior conditions should becommunicated to him or her. Interior conditionscould change the IC�s strategy or tactics. Forexample, if heavy smoke is emitting from theexterior roof system, but fire fighters cannot findany fire in the interior, it is a good possibility thatthe fire is above them in the roof system. It isimportant for the Incident Commander toimmediately obtain this type of information tomake the proper decisions.

Recommendation #3: Fire departments shouldensure fire fighters are trained in the tactics ofdefensive search.

6

As stated in Command and Control of Fires andEmergencies, �There are two warning signs thatmay precede flashover: heat mixed with smokeand rollover. When heat mixes with smoke, itforces a fire fighter to crouch down on his handsand knees. If you are forced down to the floor byintense heat, consider the possibility of flashover.As mentioned above, rollover presages flashover.�

Whenever one of these danger signs exists, youmust use defensive search tactics. Three defensivesearch tactics are as follows:

1. At a door to a burning room that may flashover,fire fighters should check behind the door to the





room and sweep the floor near the doorway. Firefighters should not enter the room until a hoselineis in position.

2. When there is a danger of flashover, fire fightersshould not go beyond the �point of no return.�The point of no return is the maximum distancethat a fully equipped fire fighter can crawl insidea superheated, smoke-filled room and still escapealive if a flashover occurs. The point of no returnis five feet inside a doorway or window.

3. �When searching from a ladder tip placed at awindow, look for signs of rollover if one of thepanes has been broken. If rollover is present, donot go through the window. Instead, crouchbelow the heat and sweep the interior area belowthe windowsill with a tool. If a victim hascollapsed there, you may be able to crouch belowthe heat enough to pull him to safety.�

6

Additionally, fire departments should ensure firefighters are trained to recognize the danger ofsearching above a fire.7

The danger of being trapped above a fire is greatlyinfluenced by the construction of the burningbuilding. Of the five basic building constructiontypes (fire resistive, noncombustible, ordinaryconstruction, heavy timber, and wood-frame)the greatest danger to a fire fighter who mustsearch above the fire is posed by wood frameconstruction. Vertical fire spread is more rapidin this type of structure. Flames may spreadvertically and trap fire fighters searching abovethe fire in four ways: up the interior stairs,through windows (autoexposure), withinconcealed spaces, or up the combustibleexterior siding.

Recommendation #4: Fire departments shouldensure that fire command always maintains

close accountability for all personnel at the firescene.8,9,10

Discussion: Accountability on the fireground isparamount and may be accomplished by severalmethods. It is the responsibility of every officerto account for every fire fighter assigned to his orher company and relay this information to theIncident Commander. Fire fighters should notwork beyond the sight or sound of the supervisingofficer unless equipped with a portable radio. Thecrew leader should communicate with thesupervising officer by portable radio to ensureaccountability and indicate completion ofassignments and duties. When the assigned dutiesare completed, the crew should radio thisinformation to the supervisor then return to thesupervisor for additional duties. As a fire escalatesand additional fire companies respond, acommunication assistant with a command boardshould assist the Incident Commander withaccounting for all fire fighter companies at thefire, at the staging area and at rehabilitation. Oneof the most important aids for accountability atan incident is an Incident Management System(IMS). The IMS is a management tool that definesthe roles and responsibilities of all units respondingto an incident. It enables one individual to havebetter control of the incident scene. This systemworks on an understanding among the crew thatthe person in charge will be �standing back� fromthe incident, focusing on the entire scene.

Recommendation #5: Fire departments shouldensure that fireground communication ispresent through both the use of portable radiosand face-to-face communications.3,9

Discussion: During the course of the firegroundoperations, the Incident Commander must beheard and also must hear everyone on the scene.All members should follow radio communications





guidelines, keeping transmissions short, specific,and clear. However, this cannot be achieved ifelectronic problems occur, or not all fire fightersare equipped with portable communicationequipment. Therefore, fire departments shouldimplement a backup communications plan to avoida communication breakdown on the fireground.The plan should include backup electronicequipment, additional channels, training, andconsideration of face-to-face communications, orthe utilization of runners to communicate animportant message if radio communication fails.

Recommendation #6: Fire departments shouldensure that a trained Rapid Intervention Teamis established and in position immediately uponarrival.1

Discussion: A Rapid Intervention Team (RIT)should respond to every major fire. The teamshould report to the officer in command andremain at the command post until an interventionis required to rescue a fire fighter(s) or civilians.The RIT should have all tools necessary tocomplete the job�e.g., a search rope, first-aid kit,and a resuscitator�to use if a fire fighter becomesinjured. Many fire fighters who die from smokeinhalation, from a flashover, or from being caughtor trapped by fire actually become disorientedfirst. They are lost in smoke and their SCBAsrun out of air, or they cannot find their way outthrough the smoke, become trapped, and then fireor smoke kills them. The primary contributingfactor, however, is disorientation. The RIT willbe ordered by the IC to complete any emergencysearches or rescues. They will provide thesuppression companies the opportunity to regroupand take a roll call instead of performing rescueoperations. When the RIT enters to perform asearch-and-rescue, they should have full cylinderson their SCBAs and be physically prepared. Whena RIT team is used in an emergency situation, an

additional RIT team should be put into place incase an additional emergency situation arises. Thisadditional RIT team should be comprised of fresh,well-rested fire fighters. The limited size of thedepartment made it difficult to establish a RapidIntervention Team (RIT) with the initialresponding crews, and to establish additional RITscomprised of fresh, well-rested fire fighters.

Recommendation #7: Fire departments shouldensure that fire fighters wear and use PASSdevices when involved in interior fire fightingand other hazardous duties. 1,3

Discussion: A PASS device should be part of everyfire fighter�s equipment. The PASS is an electronicdevice which will emit a loud and distinctiveaudible alarm if a fire fighter becomes motionlessafter a minimal period of time, frequently 30seconds. Fire fighters can also activate the alarmmanually if needed. Although the victims wereequipped with both PASS devices integrated intotheir SCBAs and a manual PASS device attachedto their turnout coats, none of the devices wereheard sounding in this incident. The victims�SCBAs were examined by the NIOSHinvestigators and were deemed to be unfit fortesting. Extreme heat and direct flameimpingement may have affected the operation ofthe integrated PASS devices.

REFERENCES1. NFPA [1997]. NFPA 1500; Standard on firedepartment occupational safety and healthprogram. 1997 ed. Quincy , MA: National FireProtection Association.

2. International Fire Service Training Association[1995]. Essentials of fire fighting. 3 rd ed.Stillwater, OK: Fire Protection Publications.

3. Dunn V [1988]. Collapse of burning buildings,





a guide to fireground safety. Saddle Brook, NJ: FireEngineering Books and Videos.

4. Kipp JD, Loflin ME [1996]. Emergencyincident risk management: A safety and healthperspective. New York: Van Nostrand ReinholdPublishing.

5. Norman [1998]. Fire officer�s handbook oftactics. Saddle Brook, NJ: Fire Engineering Booksand Videos.

6. Dunn V [1999]. Command and Control of Firesand Emergencies. Saddle Brook, NJ: FireEngineering Books and Videos, page 245.

7. Dunn V [1992]. Safety and Survival on theFire Ground. Saddle Brook, NJ: Fire EngineeringBooks and Videos. 97, 98.

8. Morris G, Gary P, Brunacini N, Whaley L.[1994]. Fireground accountability: The Phoenixsystem. Fire Engineering, 147(4): 45-61.

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

10. Coleman [1997]. Incident management for thestreet smart fire officer. Saddle Brook, NJ: FireEngineering Books and Videos.

INVESTIGATOR INFORMATIONThe lead investigator of this report is Thomas P.Mezzanotte, Safety and Occupational HealthSpecialist. The following NIOSH staffparticipated in the site visit: Eric Schmidt, FireProtection Engineer; Ted Pettit, SeniorInvestigator; and Dawn Castillo, Chief,Surveillance and Field Investigations Branch,Division of Safety Research.

Expert review was provided by the following:Vincent Dunn, Deputy Chief FDNY (ret); DanMadrzykowski, NIST; and Bob Duval, NFPA.

FIRE MODEL INFORMATIONUpon a request from NIOSH, the NationalInstitute of Standards and Technology (NIST)completed a fire model of this incident. The firemodel demonstrates growth and the fire�s reactionwhen different variables are introduced. Thecomplete fire model will be available for viewingonline in the Summer of 2001 atwww.fire.nist.gov.





Photo 1. Front of Structure Where Fire Fighters Entered

Photo courtesy of Cindy Iutzi, Daily Gate City, Iowa.





Photo 2. Doors in Which Fire Fighters Entered


Fire SideNon-Fire Side





Photo 3. Rear of Structure Note: Arrow indicates origin of the fire.






Figure 1. Overview of Incident Site: First Floor

First Floor

Aer

ial 1 3/4"

Engine 35"

1 3/4"

Victim #2

Non-Fire SideFire Side

Origin

Living Room

Kitchen

1 3/4"1 3/4"

1 3/4"

Dining Room





Figure 2. Overview of Incident Site: Second Floor

Second Floor

Aer

ial

Engine 35"

Victim #3

Non-Fire Side Fire Side

Master Bedroom

Landing

Victim #1

fire fighter face report no. f2000-04, structure fire ... · radioed central dispatch, reporting...

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