Maryland FF Fatality

October 10, 2006

Investigation

NIOSH General Engineer NIOSH Occupational Safety & Health

Specialist Fire Department Safety Chief City Arson Officers Union Representatives

Examination and Review

Victim’s PPE, SCBA and PASS Scene Photographs Interviews with on scene personnel Review of Standard Operating

Guidelines Arson Investigator’s Report Officer and Victim’s Training Records

Examination and Review

Witness Statements Dispatch transcriptions Coroner’s report Amateur Video of the incident

Incident Information

October 10, 2006 0222 hours Residential 2-story row house on a

basement Possible parties trapped

Apparatus Assigned

Battalion Chief 1 – 0225 hours E41 – 4 personnel – 0225 hours M20 – 2 personnel – 0225 hours Squad 11 – 4 personnel – 0226 hours Truck 20 – 4 personnel – 0226 hours E51 – 4 personnel – 0227 hours Truck 3 – 4 personnel - 0227

Apparatus Assigned

E5 – 4 personnel – 0228 hours Battalion Chief 2 – 0228 hours Medic 10 – 2 personnel – 0232 E50 – 4 personnel – 0237

28 personnel within 6 minutes 34 personnel within 15 minutes

Incident Timeline

0222 hours dispatch

0225- B1, E41, Sq11 on sceneB1 did drive-around, row house, middle of

block, heavy black smoke.

1 citizen jumper and 1 walking wounded

Incident Timeline

E41 – water supply E41-C & D with Sq 11-D advanced 1

3/4” hand line for an interior attack E41-A – Entered and requested

ventilation S11-A & C – Gearing up

Incident Timeline

0228 hours – B2 assigned side C Truck 3, E5 and E51 all to C side

Heavily involved basement fire moving to 1st and 2nd floor on C side

0231 hours – numerous electrical lines C side, IC request 2nd alarm and utility co

Truck 20 to roof for ventilation and ground ladder to 2nd floor side “A”

Incident Timeline

E41-C to top of stairs, E41-D and Sq11-D at base of stairs with hand line

No fire visible from interior attack team No apparent impingement to front of

structure Some skylights opened by Truck 20,

some already venting

Incident Timeline

0231 – Crew learned fire originated in basement and advised to back out

0232 – Conditions rapidly worsened, E41-C down stairs past E41-D landing on top of Sq11-D against metal front door

Hose line pinched in door with door closed

IC requested RIT (not established)

Incident Timeline

E41-A and other FF’s that had just exited began to force and remove door

0232 hours E41-D and Sq11-D removed from structure with severe burns

0235 hours door removed E41-C removed, SCBA mask off and hood missing

CPR immediately started 13 minutes from dispatch time to CPR

PPE Findings

Witnesses state upon entry victim had face piece on, clicked in and gloves on.

During Incident: cylinder valve shut off, right glove missing, mask dislodged, hood missing (unknown if on in beginning)

Side A

Side B

Recommendations

Ensure TIC’s are used in size up for information to locate seat of fire

Ensure ventilation is in coordination with fire attack. When and Where ?

Ensure exits are not blocked by inadvertent closing doors (wedges)

Recommendations

RIT teams should be available “Many firefighters who die from smoke

inhalation, from a flashover, or from being trapped by fire actually become disoriented first. They are lost in smoke and their SCBA’s run out of air, or they cannot find their way out through the smoke, become trapped, and then fire or smoke kills them. The primary contributing factor, however, is disorientation.”

Recommendations

Fire departments should ensure that department policies and procedures are followed. “Every department member should have a

copy of or easy access to SOP’s, and each member should sign a statement indicating that he/she has read, understands, and agrees to abide by them.”

Questions & Thoughts