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Deadly Delays: The Decline of Fire Response
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Staffing, response times in fires where firefighters died

To examine staffing levels and response times in fires where firefighters died, The Boston Globe compiled these facts from federal investigative reports on firefighters who died in structure fires from 1997-2004. Excluded were deaths from wildfires, motor vehicle accidents, heart attacks and other causes not directly involving a structure fire.

The newspaper found that most firefighters who die fighting a fire were working in substandard conditions, arriving too late with too few people. And most were going into buildings where there was no one to save. Out of 52 fires that killed 80 firefighters, in only 35 of the 52 fires could the department get even one firefighter to the scene within 6 minutes. In only 27 of the fires could four firefighters muster within 6 minutes, the minimum attack force recommended by the National Fire Protection Association. And in only 18 of the fires did a full force of 15 firefighters arrive within 10 minutes, the manpower standard for safe and effective work at a basic building fire.

This also stood out: the needlessness of the loss. In only 14 of the fires was there even a suspicion that someone might be inside. In all the rest, firefighters were let into a locked building by the owner or were told by occupants or first responders that the building was empty. In only six of the 52 fires was there actually anyone in the building.

The basic facts listed below on each fire come from the US Fire Administration's firefighter fatality database.

The staffing information comes from investigations by the CDC's National Institute for Occupational Safety and Health. In many cases the Globe looked up additional information on response times in the National Fire Incident Reporting System database, and telephoned fire departments for incident reports.

The recommended staffing levels here those used by the National Fire Protection Association. The NFPA applies these standards only to fire departments with primarily full-time firefighters, but the Globe applied the same measure to every fire response.

More information on the Globe's investigation of fire response times is at Boston.com/fires, including an Excel spreadsheet file with the information on this page.

Please send any questions to Bill Dedman, at Dedman@Globe.com.


Williams, Charles H


Age: 29
Sex: Male
Rank: Firefighter
Department: Lexington Fire Department, Lexington, Kentucky
Status: Career
Incident date: 02/17/97
Minutes to first responder arriving: 5
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 15
Firefighters arriving within 10 minutes (suggested 15): 15+
Any possible indication of anyone inside to save: No
Anyone in fact inside: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/17/97
Property type: Vacant Property

Summary by USFA: Firefighter Williams and a second firefighter became trapped after entering a residential fire and falling through a hole into the basement. Both received second and third degree burns. Efforts were made to revive Williams on the scene. The other firefighter was admitted to the hospital with serious burns.

NIOSH recommendations: "Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should ensure at least four fire fighters be on the scene before initiating interior fire fighting operations at a working structural fire. Fire departments should ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with two-way communications with incident command."

Click here for the NIOSH investigative report


Seguin, Michael L


Age: 31
Sex: Male
Rank: Firefighter
Department: Buffalo Fire Department, Buffalo, N.Y.
Status: Career
Incident date: 07/04/97
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 4
Firefighters arriving within 10 minutes (suggested 15): N/A
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Residence
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 07/04/97
Property type: Residential

Summary by USFA: Firefighter Seguin was killed when he became trapped by a roof collapse while fighting a residential structure fire. One other firefighter was injured and suffered second degree burns. The second firefighter was dragged to safety after becoming unconscious. Rescuers did not see Firefighter Seguin due to heavy smoke and he was not located until later that afternoon. Fire officials stated that there was a possibility that the fire was started by fireworks.

NIOSH recommendations: "Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should strictly enforce the wearing and use of PASS devices when fire fighters are involved in fire fighting, rescue, or other hazardous duties. Fire departments should develop and implement written maintenance procedures for the self-contained breathing apparatus (SCBA).

Click here for the NIOSH investigative report


Sammons, Jeffrey E


Age: 21
Sex: Male
Rank: Firefighter
Department: South Whitley Fire Department, South Whitley, Ind.
Status: Volunteer
Incident date: 08/19/97
Minutes to first responder arriving: 7
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): N/A
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Restaurant/tavern
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 08/19/97
Property type: Public Assembly

Summary by USFA: Firefighter Sammons was killed and two others were injured in a restaurant fire caused by cooking equipment that had been left on. Sammons and others were making an internal fire attack when the heat buildup became extreme. They started to exit the structure when a flashover occurred causing some of the ceiling tile to fall.

NIOSH recommendations: Fire departments should ensure that defensive (exterior operation) fire fighting tactics are suspended prior to switching the strategic mode of operation to an offensive strategy (interior fire attack with hand lines), and notify all affected personnel of the change in strategic modes. Fire departments should ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with two-way communications with incident command. Fire departments should establish and implement an incident-management system with written standard operating procedures for all fire fighters.

Click here for the NIOSH investigative report


Hynes, James E


Age: 27
Sex: Male
Rank: Firefighter
Department: Philadelphia Fire Department, Philadelphia, Pa.
Status: Career
Incident date: 10/27/97
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 3
Firefighters arriving within 10 minutes (suggested 15): 3
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Duplex
Cause of death: Exposure
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 10/27/97
Property type: Residential

Summary by USFA: Lt. McElveen and Firefighter Hynes died as a result of smoke inhalation at the scene of a residential structure fire. The fire was a result of wires that had come down on the roof during a heavy rain. The firefighters were operating in the interior of a two-story occupied dwelling with a fire in the basement. They both ran out of air, removed their SCBA masks,and remianed inside the dwelling. The two firefighters were found near the back door with their SCBA's on, but their masks off.

NIOSH recommendations: Fire departments should ensure that fire fighters advise dispatch on any change of conditions that would warrant a change in the status of unit(s) responding to a specific condition. Fire departments should strictly enforce the wearing and use of PASS devices when fire fighters are involved in fire fighting, rescue, and other hazardous duties.

Click here for the NIOSH investigative report


McElveen, Terry K


Age: 43
Sex: Male
Rank: Lieutenant
Department: Philadelphia Fire Department, Philadelphia, Pa.
Status: Career
Incident date: 10/27/97
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 3
Firefighters arriving within 10 minutes (suggested 15): 3
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Duplex
Cause of death: Exposure
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 10/27/97
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Carter, Gregory Scott


Age: 24
Sex: Male
Rank: Firefighter
Department: Fairlea Volunteer Fire Department, Fairlea, W.Va.
Status: Volunteer
Incident date: 01/21/98
Minutes to first responder arriving: 16
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 0
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Supermarket
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/21/98
Property type: Store/Office

Summary by USFA: Firefighter Carter responded to a report of smoke in a supermarket. The market was contained in a strip mall which also included a post office and a photo-processing store. Firefighter Carter had been employed at the supermarket in the past. Firefighter Carter and a Captain entered the front of the store in full protective clothing and SCBA to search for the fire. They became disoriented while trying to exit the store. The Captain alerted other firefighters by radio that he and Firefighter Carter were lost and in need of rescue. Firefighter Carter ran out of air and placed the breathing tube from his SCBA into his coat in an attempt to breathe. The Captain was able to escape without significant injury. Immediate attempts were made by on scene firefighters to rescue Firefighter Carter but rescuers were driven back by intense heat and smoke. Firefighter Carter was wearing a PASS device but it was not turned on. No hose line or search rope was used. The cause of death was smoke and soot inhalation, carbon monoxide poisoning, and complete body charring. This was an accidental fire caused by an electrical malfunction in a wall.

NIOSH recommendations: Fire departments should ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with safety lines or a hose line. Fire departments should strictly enforce the wearing and use of PASS devices when fire fighters are involved in fire fighting, rescue, and other hazardous duties. Fire departments should implement an incident management system with written procedures for all fire fighters. Fire departments should ensure that backup personnel are standing by with equipment, ready to provide assistance or rescue.

Click here for the NIOSH investigative report


Carletti, Stephen D.


Age: 43
Sex: Male
Rank: Firefighter
Department: Crooksville Volunteer Fire Department, Crooksville, Ohio
Status: Volunteer
Incident date: 02/05/98
Minutes to first responder arriving: 16
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 0
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/05/98
Property type: Residential

Summary by USFA: Firefighter Carletti and Firefighter Theisen responded to a report of a fire in the basement of a single story home. They entered the basement with other firefighters and extinguished fire in the ceiling. In the process of moving around the basement, the attack line was pinched off when it was caught in a folding chair. Firefighters were not aware that their water supply had been cut off. When they began to pull additional ceiling tiles, the room experienced a flashover. Of the five firefighters in the basement when the flashover occurred, two escaped, one was rescued, and two were killed. An adjacent room, which had not been discovered by the firefighters, was fully involved in fire and fire spread to the other room when tiles were removed. Repeated radio requests for help and water were received from the basement but rescuers were unable to reach the firefighters in distress due to severe heat and fire. Both firefighters were wearing their PASS devices, they were turned on, and they activated. The fire cause was determined to be accidental. Firefighter Carletti died as the result of a crushing injury and Firefighter Theisen died of asphyxiation and burns. Firefighter Theisen was also a career firefighter in Westerville. The Crooksville Fire Department suffered a firefighter fatality in 1997.

NIOSH recommendations: Fire departments should utilize the first arriving engine company as the command company and conduct an initial scene survey. Fire departments should implement an incident command system with written standard operating procedures for all fire fighters. Fire departments should provide a back-up hose crew. Fire departments should provide adequate on-scene communications including fireground tactical channels. Fire departments should train fire fighters in the various essentials of how to operate in smoke-filled environments, basement fire operations, dangers of ceiling collapse, ventilation practices, utilizing a second hoseline during fire attack, and identifying pre-backdraft, rollover, and flashover conditions. Fire departments should appoint an Incident Safety Officer.

Click here for the NIOSH investigative report


Theisen, David Paul


Age: 29
Sex: Male
Rank: Firefighter
Department: Crooksville Volunteer Fire Department, Crooksville, Ohio
Status: Volunteer
Incident date: 02/05/98
Minutes to first responder arriving: 16
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 0
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/05/98
Property type: Residential

Summary by USFA: (See above)

Click here for the NIOSH investigative report


King, Patrick Joseph


Age: 40
Sex: Male
Rank: Firefighter
Department: Chicago Fire Department, Chicago, Ill.
Status: Career
Incident date: 02/11/98
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 20+
Firefighters arriving within 10 minutes (suggested 15): 20+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Commercial tire service center
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/11/98
Property type: Store/Office

Summary by USFA: Firefighter King and Firefighter Lockhart responded on different companies to a report of a structural fire in a tire shop. No visible fire was encountered, there was no excessive heat, and only light smoke was found in most of the building with heavier smoke in the shop area. Ten firefighters were in the interior of the structure when an event that has been described as a flashover or backdraft occurred. The firefighters were disoriented by the effects of the backdraft. Some were able to escape but Firefighter King and Firefighter Lockhart were trapped in the structure. A garage door that self-operated due to fire exposure may have introduced oxygen into the fire area and may have been a factor in the backdraft. The exit efforts of firefighters were complicated by congestion in the building. Within minutes of the backdraft, the building was completely involved in fire and rescue efforts were impossible. Both firefighters died from carbon monoxide poisoning due to inhalation of smoke and soot.

NIOSH recommendations: Fire departments should ensure that command conducts an initial evaluation of the incident scene upon arrival at the fire scene. Fire departments should ensure command decision to ventilate a truss roof is based on conditions upon arrival. Fire departments should ensure that fire fighters do not enter structures during ventilation where there is a potential for built-up explosive gases to ignite and cause a backdraft or flashover as evidenced by smoke-stained windows at the rear of the building and puffing smoke at the roof vents and rear windows. Fire departments should ensure that fire fighters conducting ventilation on the roof are in communication with command. Fire departments should encourage municipalities to review and amend their building codes as applicable regarding exposed polystyrene insulation.

Click here for the NIOSH investigative report


Lockhart, Anthony Eddie


Age: 40
Sex: Male
Rank: Firefighter
Department: Chicago Fire Department, Chicago, Ill.
Status: Career
Incident date: 02/11/98
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 20+
Firefighters arriving within 10 minutes (suggested 15): 20+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Commercial tire service center
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/11/98
Property type: Store/Office

Summary by USFA: (See above)

Click here for the NIOSH investigative report


Dupee, Joseph Charles


Age: 38
Sex: Male
Rank: Captain
Department: Los Angeles Fire Department, Los Angeles. Calif.
Status: Career
Incident date: 03/08/98
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 20+
Firefighters arriving within 10 minutes (suggested 15): 20+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Dog treats preparation facility
Cause of death: Exposure
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/08/98
Property type: N/A

Summary by USFA: Captain Dupee and his company were dispatched to a structure fire in a pet food processing company and were assigned to backup interior crews. When fire conditions worsened, all firefighters exited the building with the exception of Captain Dupee who had somehow been separated from his crew. The situation was further complicated by the activation of an emergency signal by another firefighter that had become disoriented (he was rescued by his company officer). Shortly after firefighters left the building, a partial roof collapse occurred. When it was determined that Captain Dupee was missing, a rapid intervention crew forced entry in the rear of the structure and removed Captain Dupee. He was burned over 95% of his body, was provided with advanced life support care, and pronounced dead at the hospital. The cause of death was determined to be asphyxiation and burns. The fire was accidental and started as a grease fire in a convection oven.

NIOSH recommendations: Fire departments should ensure that 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. Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should 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 with Incident Command. Fire departments should ensure that Rapid Intervention Teams be established and in position immediately upon arrival at the fire scene. Fire departments should ensure that some type of tone or alert be transmitted immediately when conditions become unsafe for fire fighters. Fire departments should 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. Fire departments should consider placing a bright, narrow-beamed light at the entry portal to a structure to assist lost or disoriented fire fighters in emergency egress.

Click here for the NIOSH investigative report


Blackmore, James W


Age: 48
Sex: Male
Rank: Lieutenant
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 06/05/98
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 21
Firefighters arriving within 10 minutes (suggested 15): 27+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: residential complex
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 06/06/98
Property type: Residential

Summary by USFA: Along with other firefighters, Lieutenant Blackmore and Captain LaPiedra were conducting a search on the second floor of a commercial/residential structure. A civilian fire victim had been reported to be trapped in the area. Without warning, the second floor collapsed into the fire area on the first floor, trapping firefighters in a live fire on the first floor. Two firefighters died and four were seriously injured. The civilian fire victim had escaped through a back entrance. Lieutenant Blackmore was pronounced dead at the hospital after being recovered by other firefighters, the cause of death was crushing trauma and burns resulting in a heart attack. Captain LaPiedra suffered severe burns (70%) and died on July 4, 1998, the cause of death was thermal burns resulting in cardiac arrest.

NIOSH recommendations: Fire departments should 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. Fire departments should ensure that incident command always maintains close accountability for all personnel at the fire scene. Fire departments should 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. Fire departments should ensure that Rapid Intervention Crews/Teams or Firefighter Assist and Search Teams (FAST Truck) are in place in the early stages of an incident. Fire departments should ensure that communication used on the fireground, e.g., handie-talkies, will remain operational in the event that one unit malfunctions. Municipalities should ensure that all modifications/renovations to buildings are in compliance with current building codes, i.e., any renovation or remodeling does not decrease the structural integrity of supporting members.

Click here for the NIOSH investigative report


LaPiedra, Scott J


Age: 40
Sex: Male
Rank: Captain
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 06/05/98
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 21
Firefighters arriving within 10 minutes (suggested 15): 27+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: residential complex
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 07/04/98
Property type: Residential

Summary by USFA: (See above)

Click here for the NIOSH investigative report


Melton, Justin Allen


Age: 21
Sex: Male
Rank: Firefighter
Department: Marks Volunteer Fire Department, Marks, Miss.
Status: Volunteer
Incident date: 08/29/98
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 8+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Commercial building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 08/29/98
Property type: Store/Office

Summary by USFA: Firefighters Melton and Selby were working in different areas of a structure fire that involved a commercial building. A collapse occurred which trapped Firefighter Melton as he and other firefighters were advancing a hoseline on the fire. Firefighter Selby was on the roof of the fire structure attempting ventilation when he fell into the fire area and was killed. Both firefighters died of asphyxiation due to smoke inhalation.

NIOSH recommendations: Fire departments should use defensive firefighting tactics when they do not have adequate apparatus, equipment and training. Fire departments should ensure that accountability for all personnel at the fire scene is maintained. Fire departments should establish and implement an Incident Command System (ICS) with written standard operating procedures for all fire fighters. Fire departments should ensure those fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, are equipped with two-way communications with incident command. Fire departments should establish Standard Operating Procedures (SOPs) for fire fighters who conduct vertical ventilation. Fire departments should ensure that Rapid Intervention Teams be established and in position immediately upon arrival at the fire scene. Fire departments should strictly enforce the wearing and use of PASS devices when fire fighters are involved in fire fighting, rescue, and other hazardous duties. Fire departments should ensure adequate personal protective equipment is available while fire fighters are engaged in fire activity. Owners of commercial buildings should ensure that smoke alarms and sprinkler systems are installed and operable.

Click here for the NIOSH investigative report


Selby, Scott


Age: 35
Sex: Male
Rank: Firefighter
Department: Marks Volunteer Fire Department, Marks, Miss.
Status: Volunteer
Incident date: 08/29/98
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 8+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Commercial building
Cause of death: Fell or jumped
Nature of death: Asphyxiation
Activity: Ventilation
Death date: 08/29/98
Property type: Store/Office

Summary by USFA: (See above)

Click here for the NIOSH investigative report


McDonough, Eugene P


Age: 54
Sex: Male
Rank: Firefighter
Department: St. Johnsbury Fire Department, St. Johnsbury, Vt.
Status: Career
Incident date: 09/05/98
Minutes to first responder arriving: 5
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 9
Firefighters arriving within 10 minutes (suggested 15): 9
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: warehouse of recycled paper
Cause of death: Struck by or contact with object
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 09/05/98
Property type: Storage

Summary by USFA: Firefighter McDonough responded with other members of his Department to a mutual aid fire in a recycling facility. While opening a large door to allow a master stream attack, Firefighter McDonough was crushed when a parapet wall collapsed. The cause of the fire was arson.

NIOSH recommendations: Fire departments should ensure that pre-fire planning and inspections cover all structural building materials/components and exterior walls. Fire departments should establish a collapse zone around buildings that have parapet walls that could collapse.

Click here for the NIOSH investigative report


Blizzard, Robby Dean


Age: 24
Sex: Male
Rank: Lieutenant
Department: Arrington Volunteer Fire Department, Dudley, N.C.
Status: Volunteer
Incident date: 11/06/98
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 1
Firefighters arriving within 10 minutes (suggested 15): 5
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: auto salvage storage building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/06/98
Property type: Storage

Summary by USFA: Chief Jones and First Lieutenant Blizzard were killed as fought a fire in an automobile salvage yard storage building. Firefighters believed that they had found the seat of the fire and were applying water when a rapid change in conditions occurred. Chief Jones ran out of air while trying to escape. Lieutenant Blizzard entered the structure to search for Chief Jones. He ran out of air, became disoriented, and failed to exit the building. Lieutenant Blizzard was wearing a PASS device but it was not activated. Chief Jones was not equipped with a PASS device. The cause of death for Chief Jones was listed as carbon monoxide poisoning and smoke inhalation and the cause of death for Lieutenant Blizzard was listed as carbon monoxide poisoning. Lieutenant Blizzard was also a career firefighter in another community but was off duty at the time.

NIOSH recommendations: Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should ensure that vertical ventilation takes place to release any heat and smoke directly above the fire. Fire departments should ensure that Rapid Intervention Teams be established and in position. Fire departments should ensure that fire fighters wear and use PASS devices when involved in interior fire fighting and other hazardous duties.

Click here for the NIOSH investigative report


Jones, Hubert Sidney


Age: 29
Sex: Male
Rank: Volunteer
Department: Arrington Volunteer Fire Department, Dudley, N.C.
Status: Volunteer
Incident date: 11/06/98
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 1
Firefighters arriving within 10 minutes (suggested 15): 5
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: auto salvage storage building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/06/98
Property type: Storage

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Bohan, James E


Age: 25
Sex: Male
Rank: Firefighter
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 12/18/98
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 24+
Firefighters arriving within 10 minutes (suggested 15): 24+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: apartment building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 12/18/98
Property type: Residential

Summary by USFA: Firefighter Bohan, Firefighter Bopp, and Lieutenant Cavalieri were killed while fighting a residential high rise structure fire. As they rushed to the tenth floor to search for victims, they were overcome by a wave of heat and smoke that killed all three. The heat wave, or fireball, may have been propelled by a gust of wind coming through the fire apartment. The automatic closing device on the apartment door had been removed or had malfunctioned. The building's hallway sprinklers did not activate due to a closed valve. Six firefighters were injured in the fire.

NIOSH recommendations: Municipalities, city housing authorities, and building owners should ensure that buildings equipped with sprinkler systems are operational. Municipalities, city housing authorities, and building owners should consider early warning systems for timely notification of fire. Fire departments should ensure communications on the fireground are utilized and recorded, especially between fire fighters in IDLH situations and Incident Command. Fire departments should ensure that the standpipe hookup is on the floor below the fire.

Click here for the NIOSH investigative report


Bopp, Christopher Michael


Age: 27
Sex: Male
Rank: Firefighter
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 12/18/98
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 24+
Firefighters arriving within 10 minutes (suggested 15): 24+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: apartment building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 12/18/98
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Cavalieri, Joseph P


Age: 42
Sex: Male
Rank: Lieutenant
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 12/18/98
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 24+
Firefighters arriving within 10 minutes (suggested 15): 24+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: apartment building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 12/18/98
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Williams, Kennon Loy


Age: 27
Sex: Male
Rank: Captain
Department: Banks County Volunteer Fire Department, Homer, Ga.
Status: Volunteer
Incident date: 12/31/98
Minutes to first responder arriving: 10
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Church
Cause of death: Struck by or contact with object
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 12/31/98
Property type: Public Assembly

Summary by USFA: Captain Williams and other members of his Department were conducting an offensive attack on an arson fire of a church built around 1850. Captain Williams was caught under heavy timbers in a roof collapse.

NIOSH recommendations: Fire departments should ensure that pre-fire planning and inspections cover all structural building materials (type and age), components, and renovations so Incident Command at the fire scene will have necessary background information on the structure to make informed decisions and appropriate plan of attack. Fire departments should ensure that defensive fire fighting tactics are suspended prior to switching the strategic mode of operation to an offensive attack to avoid opposing streams, and notify all affected personnel of the change in strategic modes. Fire departments should ensure fire fighting tactics and operations do not increase hazards on the interior, e.g., hose streams being directed into concealed ceiling spaces which will add additional weight to the structure, possibly causing structural failure. Fire departments should ensure that all standard operating procedures (SOPs) are updated and adequate for incident command and fireground operations and that all officers and fire fighters are trained and knowledgeable in all SOPs. Fire departments should ensure that all officers and fire fighters wear and use a personal alert safety system (PASS) device that are involved in fire fighting, rescue, or other hazardous duty.

Click here for the NIOSH investigative report


Gouckenour, Jason A


Age: 22
Sex: Male
Rank: Firefighter
Department: Worthington-Jefferson Township Volunteer Fire Department, Worthington, Ind.
Status: Volunteer
Incident date: 01/09/99
Minutes to first responder arriving: 12
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 2
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/09/99
Property type: Residential

Summary by USFA: Firefighter Gouckenour entered a structural fire in a house alone with a hose line. He was equipped with full turnout gear and an SCBA but was not equipped with a PASS device. It is believed that he tripped over a coffee table and became entangled in a couch. He removed his SCBA to call for help and was overcome by extremely heavy heat and smoke conditions. Firefighters on the scene attempted a rescue but were driven back by intense heat and flames and finally by the collapse of the house's roof. Firefighter Gouckenour's body was found approximately ten feet inside the front door of the structure. The cause of death was asphyxiation due to smoke inhalation and carbon monoxide. Firefighter Gouckenour joined the fire department after his home burned two years previous to his death.

NIOSH recommendations: Fire departments should implement an incident command system (ICS) with written standard operating procedures for all fire fighters and ensure all fire fighters are trained on the system. Fire departments should ensure that command conducts an initial size-up of the incident before initiating fire fighting efforts and continually evaluates the risk versus gain during operation at an incident. Fire departments should ensure at least four fire fighters are on the scene before initiating interior fire fighting operations at a working structure fire. Fire departments should ensure that fire fighters wear and use Personal Alert Safety System (PASS) devices when involved in fire fighting, rescue, and other hazardous duties. Fire departments should ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with two-way communications with incident command. Fire departments should ensure automatic aid is established when known water pressure problems exist.

Click here for the NIOSH investigative report


Toomey, Tracy Dolan


Age: 52
Sex: Male
Rank: Firefighter
Department: Oakland Fire Department, Oakland. Calif.
Status: Career
Incident date: 01/10/99
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5+
Firefighters arriving within 10 minutes (suggested 15): 25+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: Nightclub
Cause of death: Caught or trapped
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/10/99
Property type: Residential

Summary by USFA: Firefighter Toomey was crushed and killed when the second floor of a turn of the century residential structure collapsed into the first floor. The fire eventually went to six alarms. A total of four firefighters were trapped by the collapse, including Firefighter Toomey.

NIOSH recommendations: Fire fighters should use extreme caution and recognize potential hazards that could exist when fighting a fire in a balloon-framed structure. Fire departments should implement an emergency notification system to rapidly warn all persons who might be in danger if an imminent hazard is identified or if a change in strategy is made. Fire Departments should ensure that fire fighters wear protective clothing whenever they are exposed or potentially exposed to hazards. Fire departments should ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed. Fire departments should ensure that when fire fighters are performing an interior attack with the possibility of a ceiling collapse, they should attempt to establish a collapse shelter. Fire departments should provide the Incident Commander with a Command Aide. Fire Departments should ensure that once a Rapid Intervention Team (RIT) is established that they remain the RIT throughout the operation. Fire departments should develop and implement a preventative maintenance program to ensure that all SCBA’s are adequately maintained. Building owners should ensure that all modifications/renovations to buildings are in compliance with current building codes (i.e., any renovation or remodeling does not decrease the structural integrity of supporting members).

Click here for the NIOSH investigative report


Matthews, Louis Jefferson


Age: 29
Sex: Male
Rank: Firefighter
Department: District of Columbia Fire Department ,Washington, D.C.
Status: Career
Incident date: 05/30/99
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 12
Firefighters arriving within 10 minutes (suggested 15): 15+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: townhouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 05/30/99
Property type: Residential

Summary by USFA: Firefighter Matthews and Firefighter Phillips were members of two different engine companies working on the first floor of a townhouse that was experiencing a fire. Both crews had entered the front door of the townhouse at street level. The fire was confined to the basement. The basement, at grade at the rear of the structure, was opened by a truck company and a small fire was observed. A company officer at the basement door requested permission to hit the fire but his request was denied by the incident commander since he knew that crews were in the building and he did not want to have an opposing hose stream situation. The fire grew rapidly and extended up the basement stairs into the living areas of the townhouse where Firefighter Matthews, Firefighter Phillips, and other firefighters were working. With the exception of Firefighter Matthews and Firefighter Phillips, all firefighters exited the building after the progress of the fire made the living area of the townhouse untenable. On the exterior of the building, firefighters realized that Firefighter Matthews was not accounted for. Firefighters reentered the building and followed the sound of a PASS device. They removed the firefighter with the activated PASS to the exterior of the building. Once outside, firefighters realized that the firefighter that had been rescued was not Firefighter Matthews but was in fact Firefighter Phillips. The search continued and Firefighter Matthews was discovered and removed approximately four minutes later. Firefighter Phillips' PASS device was of the type that is automatically activated when the SCBA is activated and it worked properly. Firefighter Matthews' PASS was a manually activated type and it was found in the off position. Both firefighters received immediate medical care on the scene and were rapidly transported to hospitals. Firefighter Phillips was pronounced dead upon arrival at the hospital and Firefighter Matthews died the following day on May 31, 1999. Firefighter Phillips died as the result of burns over 60% of his body surface area and his airway. Firefighter Matthews died as the result of burns over 90% of his body surface area and his airway. Two other firefighters were injured fighting the fire. One of these two firefighters, who suffered burns over 60% of his body surface area, survived and was released from the hospital in late August. At the time of his release, it was not clear if this firefighter would ever return to work.

NIOSH recommendations: Fire departments should ensure that the department’s Standard Operating Procedures (SOPs) are followed and refresher training is provided. Fire departments should consider providing the Incident Commander with a Command Aide. Fire departments should ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts. Fire departments should ensure that when a piece of equipment is taken out of service, appropriate backup equipment is identified and readily available. Fire departments should ensure that personnel equipped with a radio position the radio to receive and respond to radio transmissions. Fire departments should consider using a radio communication system that is equipped with an emergency signal button, is reliable, and does not produce interference. Fire departments should ensure that all companies responding are aware of any follow-up reports from dispatch. Fire departments should ensure that a Rapid Intervention Team is established and in position immediately upon arrival. Fire departments should ensure that any hose line taken into the structure remains inside until all crews have exited. Fire departments should consider providing all fire fighters with a Personal Alert Safety System (PASS) integrated into their Self-Contained Breathing Apparatus. Fire departments should develop and implement a preventive maintenance program to ensure that all SCBA’s are adequately maintained.

Click here for the NIOSH investigative report


Phillips, Anthony Sean


Age: 30
Sex: Male
Rank: Firefighter
Department: District of Columbia Fire Department, Washington, D.C.
Status: Career
Incident date: 05/30/99
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 12
Firefighters arriving within 10 minutes (suggested 15): 15+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: townhouse
Cause of death: Exposure
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 05/30/99
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Brotherton, Paul Arthur


Age: 41
Sex: Male
Rank: Firefighter
Department: Worcester Fire Department, Worcester, Mass.
Status: Career
Incident date: 12/03/99
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 28+
Firefighters arriving within 10 minutes (suggested 15): 28+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: warehouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/03/99
Property type: Vacant Property

Summary by USFA: Members of the Worcester Fire Department responded to a fire in the Worcester Cold Storage Warehouse. The building was a windowless six story structure. Upon arrival at the scene, firefighters found a large warehouse with light smoke conditions and a fire on the second floor. Search and rescue and fire attack operations were initiated. Within seconds, conditions in the fire building changed and thick black smoke reduced visibility to zero. All Fire Department personnel were ordered down from upper floors and a head count was taken. The head count revealed that two firefighters were not accounted for. A Mayday radio transmission was received from Firefighter Brotherton indicating that he and Firefighter Lucey, both of Rescue One, were lost and running out of air. A search for the trapped firefighters was initiated with eighteen firefighters searching for the two that were lost. Lieutenant Spencer, Firefighter Jackson, Firefighter McGuirk, and Firefighter Lyons entered the fifth floor to conduct a search. Contact with the team was lost and all six firefighters perished. The cause of the fire is believed to be accidental, the result of a knocked over candle during a domestic dispute by some transients living in the building. The transients were charged with manslaughter for failing to report the fire.

NIOSH recommendations: Fire departments should ensure that inspections of vacant buildings and pre-fire planning are conducted which cover all potential hazards, structural building materials (type and age), and renovations that may be encountered during a fire, so that the Incident Commander will have the necessary structural information to make informed decisions and implement an appropriate plan of attack. Fire Departments should ensure that the incident command system is fully implemented at the fire scene. Fire departments should ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed when activities, size of fire, or need occurs such as during multiple-alarm fires, or responds automatically to pre-designated fires. Fire departments should ensure that Standard Operating Procedures (SOPs) and equipment are adequate and sufficient to support the volume of radio traffic at multiple-alarm fires. Fire departments should ensure that Incident Command always maintains close accountability for all personnel at the fire scene. Fire departments should use guide ropes/tag lines securely attached to permanent objects at entry portals and place high-intensity floodlights at entry portals to assist lost or disoriented fire fighters in emergency escape. Fire departments should ensure that a Rapid Intervention Team is established and in position upon arrival. Implement an overall health and safety program such as the one recommended in NFPA 1500, Standard on Fire Department Occupational Safety and Health Program. Fire departments should consider using a marking system when conducting searches. Fire departments should identify dangerous vacant buildings by affixing warning placards to entrance doorways or other openings where fire fighters may enter. Fire departments should ensure that officers enforce and fire fighters follow the mandatory mask rule per administrative guidelines established by the department. Fire departments should explore the use of thermal imaging cameras to locate lost or downed fire fighters and civilians in fire environments. Manufacturers and research organizations should conduct research into refining existing and developing new technology to track the movement of fire fighters on the fireground.

Click here for the NIOSH investigative report


Jackson, Timothy P.


Age: 51
Sex: Male
Rank: Firefighter
Department: Worcester Fire Department, Worcester, Mass.
Status: Career
Incident date: 12/03/99
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 28+
Firefighters arriving within 10 minutes (suggested 15): 28+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: warehouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/03/99
Property type: Vacant Property

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Lucey, Jeremiah M


Age: 38
Sex: Male
Rank: Firefighter
Department: Worcester Fire Department, Worcester, Mass.
Status: Career
Incident date: 12/03/99
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 28+
Firefighters arriving within 10 minutes (suggested 15): 28+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: warehouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/03/99
Property type: Vacant Property

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Lyons, James F


Age: 34
Sex: Male
Rank: Firefighter
Department: Worcester Fire Department, Worcester, Mass.
Status: Career
Incident date: 12/03/99
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 28+
Firefighters arriving within 10 minutes (suggested 15): 28+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: warehouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/03/99
Property type: Vacant Property

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


McGuirk, Joseph T


Age: 38
Sex: Male
Rank: Firefighter
Department: Worcester Fire Department, Worcester, Mass.
Status: Career
Incident date: 12/03/99
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 28+
Firefighters arriving within 10 minutes (suggested 15): 28+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: warehouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/03/99
Property type: Vacant Property

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Spencer, Thomas Edward


Age: 42
Sex: Male
Rank: Lieutenant
Department: Worcester Fire Department, Worcester, Mass.
Status: Career
Incident date: 12/03/99
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 28+
Firefighters arriving within 10 minutes (suggested 15): 28+
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: warehouse
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/03/99
Property type: Vacant Property

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Tvedten, John H


Age: 47
Sex: Male
Rank: Battalion Chief

Kansas City Fire Department, Kansas City, Mo.
Status: Career
Incident date: 12/18/99
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 6
Firefighters arriving within 10 minutes (suggested 15): 27
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: paper warehouse
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Incident command
Death date: 12/18/99
Property type: Manufacturing

Summary by USFA: Chief Tvedten was a sector officer working inside of a warehouse that was involved in fire. Visibility in the warehouse was good and firefighters were putting water on the fire. About 45 minutes into the incident, interior conditions changed rapidly as thick black smoke enveloped the building. Command ordered the building to be evacuated and Chief Tvedten ordered firefighters to leave, the emergency evacuation signal was given over radios and by fire apparatus air horns at the scene. During the evacuation, Chief Tvedten became disoriented and lost. Chief Tvedten was in radio communication with Command. Six search teams swept the building but were not able to locate Chief Tvedten until it was too late.

NIOSH recommendations: Fire departments should ensure that the department’s Standard Operating Procedures (SOPs) are followed and refresher training is provided. Fire departments should ensure that all fire fighters performing fire fighting operations are accounted for. Fire departments should ensure that proper ventilation equipment is available and ventilation takes place when fire fighters are operating inside smoke-filled structures. Fire departments should ensure that one of the first-arriving engines be assigned to pump water into the building’s fire department sprinkler connection to reinforce the automatic sprinkler system. Fire departments should ensure that when entering or exiting a smoke-filled structure, fire fighters follow a hoseline, rope, or some other type of guide. Fire departments should ensure that fire fighters are equipped with a radio that does not bleedover, cause interference, or lose communication under field conditions. Fire departments should ensure that when fire fighters suspect that they have been exposed to carbon monoxide, they notify their officer or the IC and receive the proper medical care. Fire departments should ensure that a rehabilitation area is designated when needed. Fire departments should ensure that the assigned Rapid Intervention Team(s) (RIT) complete search and rescue operations and are properly trained and equipped. Fire departments should 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. Fire departments should develop and implement a preventative maintenance program to ensure that all SCBAs are adequately maintained. Building owners, supervisory staff, or employees should ensure that fires are reported to the fire department immediately.

Click here for the NIOSH investigative report


Bitting, Jason L


Age: 29
Sex: Male
Rank: Firefighter
Department: Keokuk Fire Department, Keokuk, Iowa
Status: Career
Incident date: 12/22/99
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 4
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: duplex
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 12/22/99
Property type: Residential

Summary by USFA: The Keokuk Fire Department was dispatched to a fire in a residential structure. The structure was a house built in 1910 that had been divided into three apartments. The Department responded with an engine, a quint, and a Chief's vehicle with a total of three Firefighters, a Lieutenant, an Assistant Chief, and the Fire Chief. The response of the Chief and one Firefighter was delayed since they were returning from a previous incident. Up arrival, Assistant Chief McNally, Firefighter Bitting, and Firefighter Tuck entered the building in full turnouts and SCBA for search and rescue. A mother and child were trapped on the roof above the porch and three other children were trapped inside. Firefighters rescued one infant child that was transported to the hospital by a police officer. Firefighters rescued a second infant child that was transported to the hospital by a police Captain and the Fire Chief, the Fire Chief was away from the scene for approximately three minutes. Firefighters were searching for the third child when a flashover occurred and trapped all three. An aggressive fire attack was mounted by firefighters that were arriving due to a callback of off-duty members but the effort was not able to save the lives of the three firefighters. All three firefighters were wearing PASS devices that were integrated with their SCBAs. The PASS devices failed to sound an alarm when the firefighters became incapacitated. The Fire Chief does not believe that the failure of the PASS devices contributed to the deaths. The SCBAs and PASS devices are undergoing testing to determine why they did not operate. Assistant Chief McNally was found on the second floor at the top of the stairs with the third child. The cause of death was listed as smoke inhalation and exposure to extreme heat. Chief McNally's carboxyhemoglobin level was 15%. Firefighter Bitting was found in the front bedroom on the second floor of the apartment. The cause of death was listed as exposure to intense heat. Firefighter Bitting's carboxyhemoglobin level was 1%. Firefighter Tuck was found on the first floor of the apartment in the living room area. The cause of death was listed as smoke inhalation and exposure to heat. Firefighter Tuck's carboxyhemoglobin level was 25%. In addition to the three firefighters killed in this incident, the two infant children and a seven year old child perished. The fire was caused by activation of a stove burner by a child. Two high chair trays that were stored on top of the stove were the initial objects involved in the fire. Smoke detectors in the home did not operate.

NIOSH recommendations: Fire departments should ensure that adequate numbers of staff are available to immediately respond to emergency incidents. Fire departments should 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. Fire departments should ensure fire fighters are trained in the tactics of defensive search. Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should ensure that fireground communication is present through both the use of portable radios and face-to-face communications. Fire departments should ensure that a trained Rapid Intervention Team is established and in position immediately upon arrival. Fire departments should ensure that fire fighters wear and use PASS devices when involved in interior fire fighting and other hazardous duties.

Click here for the NIOSH investigative report


McNally, Dave M


Age: 48
Sex: Male
Rank: Assistant Chief
Department:

Keokuk Fire Department, Keokuk, Iowa
Status: Career
Incident date: 12/22/99
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 4
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: duplex
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 12/22/99
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Tuck, Nathan R


Age: 39
Sex: Male
Rank: Firefighter
Department: Keokuk Fire Department, Keokuk, Iowa
Status: Career
Incident date: 12/22/99
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 4
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: duplex
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 12/22/99
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Gass, Walter Harvey


Age: 74
Sex: Male
Rank: Captain
Department: Sealy Volunteer Fire Department, Sealy, Texas
Status: Volunteer
Incident date: 01/27/00
Minutes to first responder arriving: 2
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 2
Firefighters arriving within 10 minutes (suggested 15): 10
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Exposure
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/27/00
Property type: Residential

Summary by USFA: Captain Gass and other members of his department were dispatched to a residential structure fire that was caused when lightning struck a house. The first two firefighters on the scene, the Assistant Chief and the Fire Chief, confirmed a working fire with dark smoke and fire visible from the attic and dormers. Captain Gass and his crew were the first fire company to arrive at the scene. Captain Gass and two firefighters entered the structure through the front door to perform an aggressive attack on the fire. Shortly after entering the structure, the two firefighters who were with Captain Gass were attempting to feed more hose into the structure. There was a rapid buildup of heat and the hoseline seemed to drop. The firefighters exited the building and reported this situation to the Chief. Two Rapid Intervention Teams (RIT) were formed and, after four attempts, the second team was successful in recovering Captain Gass. Captain Gass was equipped with full structural protective clothing and a manually activated PASS device. The PASS was found in the "off" position. Captain Gass was located about 18 feet inside the front door of the structure. Captain Gass was removed from the structure approximately 20 minutes after his arrival on the scene. The cause of death was listed as smoke and soot inhalation with greater than 80 percent total thermal injury.

NIOSH recommendations: Fire departments should ensure that the department’s Standard Operating Procedures (SOPs) are in place and refresher training is provided. Fire departments should ensure that a Rapid Intervention Team is established and in position immediately upon arrival. Fire departments should ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts.

Click here for the NIOSH investigative report


Mayo, Lewis Evans III


Age: 44
Sex: Male
Rank: Firefighter
Department: Houston Fire Department, Houston, Texas
Status: Career
Incident date: 02/14/00
Minutes to first responder arriving: 5
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 6
Firefighters arriving within 10 minutes (suggested 15): 12
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: restaurant
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 02/14/00
Property type: Store/Office

Summary by USFA: Firefighter Mayo and Firefighter Smith responded with Engine Company 76, three other engines, two ladder companies, two chief officers, an ambulance, and support staff to the report of a fire in a McDonald's restaurant. The fire was reported at 4:30 a.m. Engine Company 76 was comprised of a captain, a fire apparatus operator, and two firefighters. Engine 76 was the first fire fighting unit on the scene 8 minutes later and reported 6-foot flames visible from the roof. The flames appeared as if they might be venting from an exhaust fan, possibly indicating a grease fire. The captain ordered his firefighters to advance an attack line into the interior of the structure for fire control. No fire was visible in the interior of the restaurant. The firefighters from Engine 76 were joined by other firefighters who also advanced attack lines to the interior. At 4:52 a.m., the incident commander ordered all firefighters out of the building in order to transition to a defensive attack mode. The flames visible from the roof had grown to 30 feet in height, and fire had become visible in the kitchen area of the restaurant. Moments later, the captain from Engine 76 concluded that his firefighters were missing and notified the incident commander. A second alarm was requested at 5:02 a.m. and rescue attempts were begun. A number of rescue attempts were made. At 5:27 a.m., the incident commander struck a third alarm. Shortly thereafter, a ladder company opened the rear door of the restaurant and made access to the back of the kitchen area. A PASS device had been heard alarming in the kitchen area, and a firefighter was able to see a downed firefighter as he looked into the back door. Firefighter Mayo was discovered with his facepiece in-place, his regulator not connected to the facepiece, and with his SCBA partially removed and entangled in wires. He was removed, treated at the scene, in the ambulance, and at the hospital. Despite these efforts, he was pronounced dead at the hospital. Given the amount of time that had passed and the likelihood that Firefighter Smith was buried in debris, the search effort transitioned into a recovery mode. Firefighter Smith was found at approximately 7:13 a.m. within 6 feet of the rear door of the restaurant. She was entangled in wires and a pair of wire cutters were found near her body. She was wearing an SCBA but the status of her facepiece and regulator could not be determined. Both firefighters died of asphyxia due to smoke inhalation. Firefighter Mayo's carboxyhemoglobin level was found to be 26 percent and the level for Firefighter Smith was found to be 52 percent. The fire was intentionally set by a group of juveniles attempting to conceal a burglary attempt. Four individuals were convicted of crimes with sentences ranging from 2 to 35 years.

NIOSH recommendations: Fire departments should ensure that the department’s Standard Operating Procedures (SOPs) are followed. Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should 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. Fire departments should ensure that vertical ventilation takes place to release any heat, smoke, and fire. Fire departments should ensure that fire fighters are trained to identify truss roof systems. Fire departments should ensure that fire fighters use extreme caution when operating on or under a lightweight truss roof and should develop standard operating procedures for buildings constructed with lightweight roof trusses. Fire departments should 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. Fire departments should explore using a thermal imaging camera as a part of the exterior size-up. Fire departments should ensure that, whenever there is a change in personnel, all personnel are briefed and understand the procedures and operations required for that shift, station, or duty. Fire departments should ensure that, whenever a building is known to be on fire and is occupied, all exits are forced and blocked open. Fire departments should consider providing all fire fighters with portable radios or radios integrated into their face pieces. Fire departments should consider adding additional staff in accordance with NFPA standards. Fire departments should establish various written standard operating procedures, ensure record keeping, and conduct annual evaluations to monitor and evaluate the effectiveness of their overall SCBA respirator maintenance program. Utility suppliers should ensure that all exterior building utilities are accessible and in working condition. Building owners should consider placing specific building construction information on an exterior placard. Municipalities should upgrade or modify older structures to incorporate new codes and standards to improve occupancy and fire fighter safety.

Click here for the NIOSH investigative report


Smith, Kimberly Ann


Age: 30
Sex: Female
Rank: Firefighter
Department: Houston Fire Department, Houston, Texas
Status: Career
Incident date: 02/14/00
Minutes to first responder arriving: 5
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 6
Firefighters arriving within 10 minutes (suggested 15): 12
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: restaurant
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 02/14/00
Property type: Store/Office

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Sutton, David Paul


Age: 27
Sex: Male
Rank: Firefighter
Department: Fraser Department of Public Safety, Fraser, Mich.
Status: Volunteer
Incident date: 03/04/00
Minutes to first responder arriving: 17
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 4
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: apartment building
Cause of death: Exposure
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 03/04/00
Property type: Residential

Summary by USFA: Firefighter Sutton responded, along with other members of his public safety department, to a working apartment fire. While they were engaged in suppression of the first fire, another apartment fire was reported in a building across the street from the original fire. Since no fire apparatus was available to respond, Firefighter Sutton and other firefighters responded in a van to the scene. Police officers were in the process of evacuating the building. A resident in need of rescue had been spotted at a second story window. Mutual aid fire companies were responding but not yet on the scene. The smoke condition at the entrance to the apartment building was light, with heavier smoke and heat on the second floor. Fire at the top of the stairs was observed by one firefighter. Firefighter Sutton and another firefighter, equipped with full-protective clothing and SCBA, entered the building to effect the rescue. Witnesses outside the building reported that the resident disappeared from the window as if she had been reached by firefighters. Within seconds, a flashover occurred, trapping the resident and the two firefighters. Both firefighters managed to reach a bathroom at the rear of the apartment, but they were unable to get through the window with their SCBA in-place. Firefighter Sutton was observed by other firefighters at the window, and a rescue effort was mounted. Two firefighters shed their SCBA and entered the bathroom from ground ladders. Firefighter Sutton was removed after his SCBA was cut from him. The low pressure hose on his SCBA had burned through. The other firefighter was located in the bathtub and removed. Both firefighters were transported to the hospital. Firefighter Sutton was pronounced dead at the hospital. The cause of death was listed as asphyxiation. The injured firefighter sustained major burns and was hospitalized for 6 months. The resident of the apartment also died. The fire was caused when an arsonist(s) ignited combustibles on the first and second floors of the apartment building. This fire was one of six arson fires that occurred in the same general area over 2 days.

NIOSH recommendations: Fire departments should establish and implement an Incident Command System (ICS) with written standard operating procedures for all fire fighters. Fire departments should ensure that accountability for all personnel at the fire scene is maintained. Fire departments should ensure those fire fighters who enter hazardous areas–e.g., burning or suspected unsafe structures–are equipped with two-way communications with incident command. Fire departments should ensure that fire fighters preplan an escape route when entering a hazardous environment. Fire departments should ensure that adequate fire control forces and fire suppression equipment are on the scene and available for deployment for fire control activities. Fire departments should ensure that Rapid Intervention Teams are established and in position. Fire departments should consider providing fire fighters with a Personal Alert Safety System (PASS) integrated into their Self-Contained Breathing Apparatus (SCBA).

Click here for the NIOSH investigative report


Bryant, Kendall O.


Age: 36
Sex: Male
Rank: Firefighter/EMT
Department: Layton Fire Department, Layton, Utah
Status: Career
Incident date: 03/31/00
Minutes to first responder arriving: 7
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 7
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: residential garage
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/21/00
Property type: Residential

Summary by USFA: Firefighter/EMT Bryant and members of his department were dispatched to the report of a residential fire. Upon arrival, Firefighter/EMT Bryant's captain reported a working fire with flames and smoke visible from the garage. The captain ordered his firefighters to extinguish the fire in the garage, and the fire was knocked down within 5 minutes of their arrival on-scene. The captain then instructed Firefighter/EMT Bryant and another firefighter to enter the structure with a hoseline to search for victims, fire extension, and to begin to ventilate the structure. The firefighters were met with dark smoke but no visible flame when they entered the structure. They began a left hand search and proceeded to the second floor of the structure. The second floor contained bedrooms and was directly above the garage. A lieutenant joined the firefighters on the second floor by following the hoseline. As the firefighters searched the bedrooms, there was a rapid buildup of heat. A red glow was visible at the bottom of the stairs, cutting off the team's escape route. The decision was made to follow the hoseline back out of the structure since the firefighters were unsure about the presence of windows in the bedrooms and the stairway was small. Firefighter/EMT Bryant was the last in line as the firefighters made their way to safety. As the firefighters emerged from the house, the lieutenant removed his facepiece and told other firefighters that Firefighter/EMT Bryant was supposed to be right behind him but had not exited the structure with him. The incident commander ordered an accountability report and it was discovered that Firefighter/EMT Bryant was missing. A second crew of firefighters entered the residence through the front door but could not climb the stairs because they appeared to be collapsed and were heavily involved in fire. The incident commander ordered a ladder raised to provide firefighters with access to a roof area which led to the bedroom windows. Two firefighters entered the second floor of the structure and searched two bedrooms. A sound believed to be Firefighter/EMT Bryant's PASS device was located but turned out to be a smoke alarm. The firefighters saw a light in the bedroom across the hall and found that it was a flashlight that was carried by Firefighter/EMT Bryant. Firefighter/EMT Bryant was found on his knees on the floor with his facepiece removed. His SCBA cylinder was found to be empty and his protective hood was found over his mouth and nose, most likely in an attempt to filter air to breathe. His PASS device was found in the "off" position. Firefighter/EMT Bryant was removed by firefighters through a window and lowered to the ground into the care of waiting paramedics. Firefighter/EMT Bryant received aggressive resuscitation efforts at the scene, in the ambulance, and in a hospital emergency room, to no avail. Firefighter/EMT Bryant was pronounced dead in the emergency room. The cause of death was later listed as smoke and soot inhalation and acute carbon monoxide poisoning. Firefighter/EMT Bryant's blood carboxyhemoglobin level was found to be 25 percent at the time of his death. This level does not actually reflect the level that had been present in his blood since the level was reduced by resuscitation efforts. Firefighter/EMT Bryant was a career firefighter in Ogden, Utah. Two other firefighters were injured. The fire was caused by a droplight that had been hung near a cardboard box that was being used as part of a dog's bed.

NIOSH recommendations: Fire departments should establish and implement written standard operating procedures (SOPs) regarding emergency operations on the fireground. Fire departments should ensure that the Incident Command conducts a complete size-up of the incident before initiating fire fighting efforts, and continually evaluates the risk versus gain during operations at an incident. Fire departments should ensure that fire fighters conducting a search above a fire take safety precautions to reduce the risk of being trapped. Fire departments should ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed. Fire departments should ensure that Incident Command always maintains close accountability for all personnel at the fire scene. Fire departments should ensure that a Rapid Intervention Team (RIT) stand by with equipment, ready to provide assistance or rescue. Fire departments should consider providing fire fighters with a Personal Alert Safety System (PASS) integrated into their Self-Contained Breathing Apparatus (SCBA). Fire departments should ensure that the Incident Commander be clearly identified as the only individual responsible for the overall coordination and direction of all activities at an incident. Fire departments should ensure that the Incident Commander maintains the role of director and does not become involved as a laborer.

Click here for the NIOSH investigative report


Davis, Rickey Levi


Age: 33
Sex: Male
Rank: Firefighter/Paramedic
Department: Center Point Fire and Rescue, Center Point, Ala.
Status: Career
Incident date: 04/20/00
Minutes to first responder arriving: 2
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 9+
Firefighters arriving within 10 minutes (suggested 15): 13
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 04/20/00
Property type: Residential

Summary by USFA: Firefighter/Paramedic Davis and members of his department were dispatched to a report of a fire in a single-family residential structure that included a full basement. Upon arrival, firefighters found heavy smoke showing from the structure and found that the fire was in the basement. Firefighters attempted to reach the fire through the garage door (which opened into the basement) but were unsuccessful in locating the seat of the fire. A positive-pressure fan was placed at the garage door. Another team of three firefighters, including Firefighter/Paramedic Davis, advanced an attack line through the front door of the residence. On their initial entry into the residence, they were unable to locate any fire. The crew withdrew, found that a positive-pressure fan had been placed at the front door, and returned to explore another area of the house. Firefighter/Paramedic Davis was at the nozzle as the hoseline was advanced into the second entry on the main floor of the residence. As the line was advanced, Firefighter/Paramedic Davis fell through the floor into the area of the basement that was involved in fire. Other firefighters helped Firefighter/Paramedic Davis as he attempted to jump back to the first floor from the basement but his efforts were unsuccessful. Firefighters attempted to lower a scuttle hole ladder into the hole but the location of the hole and the sagging of the first floor into the basement prevented its use. Firefighters instructed Firefighter/Paramedic Davis to use the hoseline to protect himself as they attempted to rescue him through the basement. An attack team entered the basement and fought their way to the room that contained Firefighter/Paramedic Davis. He was removed from the basement and received ALS medical treatment immediately. He was transported by ground and air ambulances to a hospital in nearby Birmingham. He was treated in the emergency room but was pronounced dead. The cause of death was listed as hyperthermia (thermal injuries). The carboxyhemoglobin level that was found in Firefighter/Paramedic Davis' blood was less than 5 percent. He was burned over roughly one-third of his body. It is estimated that 12 to 15 minutes passed from the time Firefighter/Paramedic Davis fell into the basement until he was located and removed from the structure. Firefighter/Paramedic Davis was the first firefighter fatality for Center Point Fire/Rescue.

NIOSH recommendations: Fire departments should 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. Fire departments should ensure that a rapid intervention team is established and in position upon arrival. Fire departments should ensure that fireground communication is present through both the use of portable radios and face-to-face communications. Fire departments should ensure that exterior fire attack is at a minimum during search and rescue. Fire Departments should ensure fire fighters are trained to recognize the danger of searching above a fire. Fire departments should 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.

Click here for the NIOSH investigative report


Bartholomew, Marvin Maurice


Age: 30
Sex: Male
Rank: Firefighter II
Department: Pensacola Fire Department, Pensacola, Fla.
Status: Career
Incident date: 11/25/00
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 4
Firefighters arriving within 10 minutes (suggested 15): 13
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 11/25/00
Property type: Residential

Summary by USFA: Firefighter Bartholemew responded as a member of an engine company to a report of a residential fire. Upon arrival on the scene, the first company officer reported a working fire with approximately 50 percent of the building involved. Firefighter Bartholemew was assigned to join the crew of a rescue and perform a search of the structure. A handline was stretched by the search crew and carried into the structure. Five to ten minutes after arrival, the company officer from the rescue realized that fire was spreading behind them. He ordered his crew to abandon their efforts and leave the house. All three firefighters headed for the exit as the flashover occurred. The company officer and the firefighter from the rescue emerged from the structure, both were burned. Firefighter Bartholemew was not with them. The company officer reported Firefighter Bartholemew missing. At least four searches were completed before Firefighter Bartholemew was located. His body was located approximately an hour after the flashover. He had apparently become disoriented and ended up in the kitchen at the back of the house. The cause of death was listed as asphyxia due to smoke inhalation. The carboxyhemoglobin level in Firefighter Bartholemew's blood was 69.5 percent. The fire was caused when a pan caught fire on top of the kitchen stove and extended. The occupants of the house had evacuated prior to the arrival of the fire department.

NIOSH recommendations: Fire departments should ensure that the department’s standard operating procedures (SOPs) are followed. Fire departments should ensure that when entering or exiting a smoke-filled structure, fire fighters follow a hoseline, rope, or some other type of guide and refresher training is provided to reinforce the procedures. Fire departments should ensure that a rapid intervention team(s) (RIT) is established when fire fighters enter an immediately dangerous to life and health atmosphere, and the RIT be properly trained and equipped. Fire departments should consider providing all fire fighters with a personal alert safety system (PASS) integrated into their self-contained breathing apparatus. Fire departments should consider increasing the number of fire fighters on engine companies to perform in accordance with NFPA standards. Fire departments should consider providing all fire fighters with portable radios or radios integrated into their face pieces. Dispatchers or emergency call takers should obtain as much information as possible from the caller and report it to the responding companies.

Click here for the NIOSH investigative report


White, Andrew John


Age: 27
Sex: Male
Rank: Lieutenant
Department: Rocky Grove Volunteer Fire Department, Franklin, Pa.
Status: Volunteer
Incident date: 01/11/01
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 1
Firefighters arriving within 10 minutes (suggested 15): 1
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: mobile home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/11/01
Property type: Residential

Summary by USFA: Lieutenant White responded to a structure fire involving a manufactured home situated on top of a basement. Lieutenant White assisted firefighters operating a hoseline into the basement. When the line was withdrawn from the basement, Lieutenant White helped to reposition the line and then he and another firefighter advanced the line into the interior of the structure at the first floor. Conditions in the interior of the structure began to deteriorate, and the decision was made to back out. As the firefighters attempted to exit the structure, they became disoriented due to loops in the hoseline, heavy smoke, and heat conditions. The firefighters got off the line and crawled into a room that had been added to the structure. The firefighters became separated. The firefighter who had been with Lieutenant White broke through a window and made it to the outside. When he emerged from the structure, the injured firefighter was transported to the hospital. Unknown to firefighters on the scene, Lieutenant White remained in the addition. A firefighter from another fire department found Lieutenant White's helmet and gave it to a chief officer from Lieutenant White's fire department. A search for Lieutenant White was initiated. Firefighters searched the building, and a local hospital was contacted on the chance that Lieutenant White had left the scene. After 30 to 40 minutes of searching, Lieutenant White's boots were seen a few feet inside the doorway to the addition. Lieutenant White was found bent backwards over the top of a desk. Firefighters, including Lieutenant White's father, removed Lieutenant White from the structure. It was determined that Lieutenant White had expired. Lieutenant White's air supply had been depleted. He was wearing a PASS device, but it was found to be in the off position. Other firefighters had passed Lieutenant White's position several times during the search but were unable to see him due to smoke conditions. Lieutenant White carried a portable radio; it was found in a pocket in the off position. The cause of death was listed as asphyxiation due to oxygen depletion within the SCBA.

NIOSH recommendations: Fire departments should ensure that Incident Command conducts a complete size-up of the incident before initiating fire fighting efforts, and continually evaluates the risk versus gain during operations at an incident. Fire departments should ensure that fire command always maintains close accountability for all personnel at the fire scene. Fire departments should 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. Fire departments should ensure that a rapid intervention team is established and in position immediately upon arrival. Fire departments should ensure that a separate incident safety officer, independent from the incident commander, is appointed. Fire departments should ensure fire fighting tactics and operations do not increase hazards on the interior–e.g., opposing hose streams. Fire departments should ensure that any hoseline taken into the structure remains inside until all crews have exited. Fire departments should use evacuation signals when command personnel decide that all fire fighters should be pulled from a burning building or other hazardous area. Fire departments should ensure that personnel equipped with a radio, position the radio to receive and respond to radio transmissions. Fire departments should ensure that team continuity is maintained. Fire departments should ensure that ventilation is closely coordinated with the fire attack.

Click here for the NIOSH investigative report


McKean, Michael L


Age: 32
Sex: Male
Rank: Firefighter
Department: Ashton Fire Protection District, Ashton, Ill.
Status: Volunteer
Incident date: 02/17/01
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 7
Firefighters arriving within 10 minutes (suggested 15): 17
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/17/01
Property type: Residential

Summary by USFA: Lieutenant Talley and Firefighter McKean responded with members of their fire department to a report of a basement fire in a single-story residence. Upon their arrival on the scene, firefighters searched the basement for fire and found none. The search was continued on the first floor and again, nothing was found. Firefighters returned to the basement with a thermal-imaging camera and a hoseline. A small fire was discovered and firefighters began extinguishment. The basement ceiling was pulled and a wave of heat and smoke descended on the five firefighters in the basement, including Lieutenant Talley and Firefighter McKean. Fire had been burning for some time in the concealed space between the basement ceiling and the first floor and fire now spread rapidly to the basement. Three firefighters were able to escape the basement immediately but Lieutenant Talley and Firefighter McKean were trapped. Firefighter McKean was not heard from after the rapid fire progression. Lieutenant Talley was in communication with the incident commander and relayed the fact that he was low on air and that his exit path had been cut off by fire progress. Mutual aid companies and EMS resources were called to the scene. Firefighters cut a hole in the first floor in an attempt to make access to the basement for rescue but the conditions in the hole prevented their entry. After the fire was knocked down, both firefighters were removed and transported by medical helicopters to a hospital. Both were pronounced dead shortly after their arrival. The air supply in the SCBA worn by each firefighter was depleted. Both firefighters wore activated PASS devices. The cause of the fire was an electrical short at the panel. The cause of death for both firefighters was listed as asphyxiation. Lieutenant Talley's carboxyhemoglobin level was 58%, and Firefighter McKean's carboxyhemoglobin level was 59%.

NIOSH recommendations: Fire departments should ensure standard operating procedures (SOPs) addressing emergency scene operations, such as basement fires, are developed and followed on the fireground. Fire departments should ensure that Incident Command (IC) 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. Fire departments should ensure adequate ventilation is established when attacking basement fires. Fire departments should ensure that accountability for all personnel at the fire scene is maintained. Fire departments should ensure that a Rapid Intervention Team be in place before conditions become unsafe. Fire departments should ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed.

Click here for the NIOSH investigative report


Talley, Clint Anderson


Age: 27
Sex: Male
Rank: Lieutenant/EMT
Department: Ashton Fire Protection District, Ashton, Ill.
Status: Volunteer
Incident date: 02/17/01
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 7
Firefighters arriving within 10 minutes (suggested 15): 17
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/17/01
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Ellison, William A III


Age: 38
Sex: Male
Rank: Firefighter
Department: Miami Township Fire Department, Cleves, Ohio
Status: Career
Incident date: 03/08/01
Minutes to first responder arriving: 8
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 4
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Search and rescue
Death date: 03/20/01
Property type: Residential

Summary by USFA: Firefighter Ellison and members of his department were dispatched to a report of a structural fire in a residence with persons trapped. As firefighters approached the scene, smoke was visible. Upon their arrival, firefighters reported heavy black smoke and moderate fire coming through the left front side of the building. The first-arriving crew forced entry through the front door of the residence and found two bedrooms with fire involvement. The first floor of the structure was searched, and fire in the bedrooms was controlled with a handline. There was still a significant amount of fire in the attic, and the incident commander gave the order to evacuate the building. An exterior attack was made on the fire with handlines and a master stream. After the fire was knocked down, three firefighters, including Firefighter Ellison, made entry into the first floor. One firefighter was forced to leave due to difficulties with his SCBA. Firefighter Ellison was on the nozzle. As the firefighters pulled walls and applied water, they moved through a first-floor hallway. A soft spot in the floor was noted as firefighters worked their way down the hall. An additional group of firefighters were working to control a fire in the basement. Firefighter Ellison and the other firefighter working with him agreed that conditions were worsening on the first floor and that they needed to leave the structure. As they turned to exit, Firefighter Ellison fell through the soft spot in the floor into the basement. The firefighter that had been working with Firefighter Ellison attempted to reach down through the hole and pull Firefighter Ellison back to the first floor. After four unsuccessful attempts, the firefighter left the building and alerted other firefighters to the situation. Further attempts were made to pull Firefighter Ellison from the hole, but crews were unable to complete the task. A portable ladder was placed into the hole to facilitate rescue, but smoke and fire conditions would not allow it to be used. In the course of these attempts, Firefighter Ellison's gloves came off. Three crews entered the basement through the rear of the structure in an attempt to reach Firefighter Ellison. Two handlines were advanced, and the basement fire was knocked down. Firefighter Ellison was found in a seated position; his helmet was off and his hood was pulled back. Firefighter Ellison's facepiece was in-place and he was breathing. Firefighters removed him from the building, and his protective clothing was removed. Medical care was provided on-scene, and Firefighter Ellison was flown to a regional medical facility. Firefighter Ellison sustained second and third degree burns to 60% of his body, including his hands, head, chest, back, and legs. Intensive medical care was provided at the hospital, but he was not able to respond and died of complications from his thermal burns on March 20, 2001. Firefighter Ellison was a part-time firefighter with the Miami Township Fire Department and a full-time career firefighter with the Anderson Township Fire Department.

NIOSH recommendations: Fire departments should ensure that Incident Command continually evaluates the risk versus gain during operations at an incident. Fire departments should appoint an Incident Safety Officer. Fire departments should ensure fire fighters are trained to recognize the danger of searching above a fire. Fire departments should 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. Fire departments should 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 activation. Fire departments should ensure that personnel equipped with a radio, position the radio to receive and respond to radio transmissions.

Click here for the NIOSH investigative report


Tarver, Bret Richmond


Age: 40
Sex: Male
Rank: Firefighter/Paramedic
Department: Phoenix Fire Department, Phoenix, Ariz.
Status: Career
Incident date: 03/14/01
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 15
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: supermarket
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/04/01
Property type: Store/Office

Summary by USFA: On Wednesday, March 14, 2001, a report of a debris fire was received by the Phoenix Fire Department Regional Dispatch Center. The caller reported fire in a pile of debris at the rear of a hardware store. An engine company was dispatched to the fire reported by the caller. Based on the volume and nature of the smoke he was seeing as he drove through his district, Battalion 3 ordered additional fire department resources dispatched to assist. Battalion 3 also responded to the incident. The unit that is normally closest to the fire location is Engine 14. Engine 14 became available after the dispatch of the initial units. The captain of Engine 14 added his unit to the incident by computer and informed Battalion 3 of their arrival on the scene. Battalion 3 ordered Engine 14's crew to enter businesses that back up to the debris fire to evacuate occupants and to determine if fire had spread to the inside of these businesses. Engine 14's crew searched a barber shop that was adjacent to a supermarket, found it to be unoccupied and clear of fire, and moved on to the next business - the supermarket. When they entered the supermarket, Engine 14's crew found only light smoke at the ceiling of the main store. The crew moved through the building and entered a storage area. They found heavy smoke and moderate heat in the storage area. They reported this fact to Battalion 3 and went back to the front of the store to get a hoseline from another unit that had arrived at the front of the store. A hoseline was extended to the storage room, and water was applied to the fire. Visibility in the storage area was near zero and the ability to see in the supermarket deteriorated quickly. Firefighter Tarver, a member of the Engine 14 crew, told his captain that he was running low on air in his SCBA and needed to leave the building. The captain gathered his crew together and told them to follow the hoseline out to the exterior. As the two Engine 14 firefighters, including Firefighter Tarver, turned to leave, they became disoriented and ran into a wall. They got back up, turned in the direction that they thought was the correct way to go, and ran into another wall. Somehow both firefighters ended up in the rear portion of the main supermarket space. Firefighter Tarver called for help on his radio. The firefighter who was with Firefighter Tarver became separated from him and later exited the building with the assistance of other firefighters. The Engine 14 captain emerged from the building and looked for the other members of his crew, as well as the engineer of Engine 14. Battalion 3 could see that fire was developing in the supermarket and began to order crews out of the building. Firefighter Tarver heard these radio transmissions and repeated his call for help. The Engine 14 captain heard Firefighter Tarver's request for help and he notified Battalion 3 that he had two firefighters that were unaccounted for. The Engine 14 captain quickly spoke to the captain of another crew and told him to follow Engine 3's line to Firefighter Tarver's last known location. The captain and two firefighters entered the building immediately and followed the hoseline. Visibility in the supermarket had dropped to zero. They came upon Firefighter Tarver. He was lost, out of air, standing on his feet, and calling for help. The captain brought Firefighter Tarver down to the hose line and instructed him to follow it to the exterior. Firefighter Tarver had become incapacitated by the smoke and did not obey the instructions of the captain. Firefighter Tarver crawled a short distance, then stood up, turned, and disappeared in the smoke. The captain and his firefighters were low on air at this point and had to leave the building. When Battalion 3 heard that there were two Engine 14 firefighters missing, he immediately activated two Rapid Intervention Crews (RIC's). An engine crew and a ladder crew entered the supermarket with extra breathing air equipment to search for Firefighter Tarver and the other firefighter from Engine 14. While the RIC crews were unable to locate the Engine 14 firefighters, they did remove other firefighters from the building. As they left the supermarket, the interior of the supermarket became fully involved with fire. Further entry from their direction was impossible. After much effort, Firefighter Tarver was located and moved into a large storage room. The crew that discovered Firefighter Tarver was relieved by a series of other crews that moved Firefighter Tarver, with great difficulty, to the exit of the supermarket storage room. The movement of Firefighter Tarver was made extremely difficult by the smoke conditions in the storage room, the water that was falling as a result of fire suppression efforts, the heat of the fire, and obstacles that blocked the path to the exit and caught on Firefighter Tarver's clothing and protective equipment. His removal was further complicated by falling debris, the limited air supply in the firefighters' breathing apparatus, and Firefighter Tarver's physical size. Firefighter Tarver was transported to the hospital by ambulance but all efforts to revive him on the scene, in the ambulance, and at the hospital were futile. The cause of death was listed as thermal burns and smoke inhalation. Firefighter Tarver's carboxyhemoglobin level was 61%.

NIOSH recommendations: Fire departments should ensure that the department’s Standard Operating Procedures (SOPs) are followed and continuous refresher training is provided. Fire departments should ensure that a proper size-up, using common terminology, is conducted by all fire fighters responsible for reporting interior/exterior conditions to the Incident Commander (IC). Fire Departments should ensure that pre-incident plans are established and updated on mercantile occupancies in their district. Fire departments should ensure that fire fighters manage their air supplies as warranted by the size of the structure involved. Fire Departments should instruct and train fire fighters on initiating emergency traffic (Mayday-Mayday) and on the importance of activating their personal alert safety system (PASS) device when they become lost, disoriented, or trapped. Fire departments should ensure that multiple Rapid Intervention Crews (RIC) are in place when an interior attack is being performed in a large structure with multiple points of entry. Fire departments should consider placing fire fighter identification emblems on the fire fighters’ helmet and turnout gear. Fire departments should consider placing a bright, narrow-beamed light at all entry portals to a structure to assist lost or disoriented fire fighters in emergency egress. Building owners should consider upgrading or modifying structures to incorporate new codes and standards to improve occupancy and fire fighter safety. Fire departments should consider as part of their pre-incident planning, educating the public they serve on the importance of building owners, building personnel, or civilians immediately reporting any fire conditions to the first-arriving fire company on the scene. Manufacturers and research organizations should conduct research into refining existing and developing new technology to track the movement of fire fighters inside structures.

Click here for the NIOSH investigative report


Mullaney, Jonathon David


Age: 36
Sex: Male
Rank: Lieutenant
Department: Sac-Osage Fire Protection District, Osceola, Mo.
Status: Volunteer
Incident date: 03/18/01
Minutes to first responder arriving: 8
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/18/01
Property type: Residential

Summary by USFA: Firefighters were dispatched to a report of an electrical smell and smoke in the second story of a two-story residential occupancy. Upon their arrival, two firefighters entered the structure with a hoseline and extinguished a small fire on the stairwell that led from the first floor to the second floor. Smoke conditions worsened, and the firefighters who were not wearing SCBA were forced to leave the structure. Lieutenant Mullaney, Engineer Whitby, and a chief officer donned SCBA and reentered the structure on a hoseline to continue fire fighting efforts. As the team proceeded into the building, the low air alarms for Engineer Whitby and the chief officer began to sound. The chief instructed Lieutenant Mullaney to lead Engineer Whitby out of the structure by following the hoseline. The chief remained on the nozzle and continued to suppress fire. After about three minutes, the chief officer began to withdraw the hoseline from the structure. As he neared the exit, he was knocked down by falling debris. Unable to move on his own, he threw his helmet through the front door to get the attention of a firefighter on the exterior. Firefighters were able to remove the chief; he suffered second and third-degree burns to his head, face, and hands. Lieutenant Mullaney and Engineer Whitby had not exited the structure. No functional SCBA were available to mount a rescue effort until the arrival of mutual aid firefighters. Mutual aid firefighters arrived approximately one hour after the initial alarm and they assisted with fire fighting and rescue efforts. Lieutenant Mullaney and Engineer Whitby were discovered in a laundry room and removed from the structure. Both firefighters died from asphyxiation. It is unknown if either firefighter was equipped with a PASS device.

NIOSH recommendations: Fire departments should ensure that an adequate number of staff are available to immediately respond to emergency incidents. Fire departments should ensure that Incident Command conducts a complete size-up of the incident before initiating fire fighting efforts, and continually evaluates the risk versus gain during operations at an incident. Fire departments should ensure that officers enforce and fire fighters wear their SCBAs whenever there is a chance they might be exposed to a toxic or oxygen deficient atmosphere, including the initial assessment. Fire departments should 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 activation. Fire departments should ensure that vertical ventilation takes place to release any heat, smoke, and fire. Fire departments should ensure supervisors remain accountable for all who operate under their supervision and ensure that a team continuity of at least two fire fighters is maintained. Fire departments should provide adequate on-scene communications including fireground tactical channels. Fire departments should implement an emergency notification system to rapidly warn all persons who might be in danger if an imminent hazard is identified or if a change in strategy is made. Fire departments should ensure adequate personal protective equipment is available while fire fighters are engaged in fire activity. Fire departments should develop and implement a preventative maintenance program to ensure that all self-contained breathing apparatus (SCBAs) are adequately maintained.

Click here for the NIOSH investigative report


Whitby, Earl Franklin


Age: 39
Sex: Male
Rank: Engineer
Department: Sac-Osage Fire Protection District, Osceola, Mo.
Status: Volunteer
Incident date: 03/18/01
Minutes to first responder arriving: 8
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/18/01
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Tirado, Alberto


Age: 40
Sex: Male
Rank: Firefighter
Department: Passaic Fire Department, Passaic, N.J.
Status: Career
Incident date: 05/09/01
Minutes to first responder arriving: 2
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 10
Firefighters arriving within 10 minutes (suggested 15): 13
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: apartment building
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 05/09/01
Property type: Residential

Summary by USFA: Firefighter Tirado and members of his department were dispatched to a report of a fire in an occupied three-story apartment building. The first-arriving engine company reported a working fire and Firefighter Tirado responded as the tiller driver of the first-arriving ladder company. Firefighters on-scene received reports that children were trapped in the building. Firefighter Tirado and another firefighter from his company proceeded to the second floor of the building to conduct a search. A search of the second floor was conducted and all of the apartments on that floor were found to be clear. Firefighter Tirado and the other firefighter proceeded to the third floor to continue their search. On their way to the third floor, the team encountered heavy smoke and high heat. Both firefighters went back to the second-story landing. Firefighter Tirado's partner told Firefighter Tirado to wait on the landing while he retrieved additional lighting from the apparatus. A few minutes later, Firefighter Tirado called on the radio and said that he was trapped on the third floor. This transmission was not heard on the fireground and a second request for help was also not heard. He called a third time and reported that he was trapped on the third floor and needed help. Firefighter Tirado's exit path had been blocked by fire, and he was unable to find his way out. A defective throttle on the pumper supplying the initial attack line created water supply and pressure problems. Firefighters were unable to advance to the third floor to rescue Firefighter Tirado. The fire on the third floor grew to a point where it was impossible for firefighters to control it with handlines. An aerial master stream was used to darken down the fire and allow firefighters to access the third floor. After a number of attempts, Firefighter Tirado was discovered in a third-story bedroom. The cause of death was listed as asphyxiation. Firefighter Tirado's carboxyhemoglobin level was found to be 65%. The fire was caused by an unsupervised twelve-year-old girl that was attempting to light a stove. The children that were reported trapped were actually out of the building.

NIOSH recommendations: Fire departments should ensure that the department’s standard operating procedures (SOPs) regarding structure fires are followed unless otherwise directed by the Incident Commander. Fire departments should ensure that adequate fire control forces are on the scene and available for deployment for fire control activities. Fire departments should ensure that team continuity is maintained with two or more fire fighters per team. Fire departments should ensure that fire fighters notify their officer when they go above a fire. Fire departments should ensure that fire fighters, when operating on the floor above the fire, have a charged hoseline. Fire departments should ensure that fire fighters manually activate their PASS device after radioing Mayday. Fire departments should ensure that Incident Commanders size up the stretch of the first attack hose line. Fire departments should ensure that a fire fighter assist and search team (FAST) is established and in position. 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. Fire departments should establish and enforce standard operating procedures on the use of thermal imaging cameras for search and rescue operations. Municipalities should consider establishing and maintaining multiple operating frequencies for emergency services, allowing portable radios at incidents to be equipped with two frequencies, one channel for tactical messages and one channel for command.

Click here for the NIOSH investigative report


Chavis, Jeffrey Vaden


Age: 22
Sex: Male
Rank: Firefighter
Department: Lexington County Fire Service, outside city of Lexington, S.C.
Status: Career
Incident date: 06/16/01
Minutes to first responder arriving: 9
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 3
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 07/12/01
Property type: Residential

Summary by USFA: Firefighter Chavis and members of his department were dispatched to a report of a residential structure fire. When firefighters arrived on-scene, the patio style home was well involved and fire was extending to a second home. Firefighter Chavis relieved another firefighter who had run low on air. He entered an open garage with a charged hoseline and began to apply water to the fire. The garage was situated below the living area above. Five minutes after taking over the handline, Firefighter Chavis was knocked to the ground by a partial collapse of the floor/ceiling assembly above the garage. Firefighter Chavis began to crawl toward the garage door opening with burning debris on top of him. As he neared safety, the remainder of the garage floor/ceiling assembly and the garage door fell on top of him. Firefighter Chavis' SCBA high-pressure line burned through and he was exposed to direct flame contact for over a minute. Other firefighters and civilians on-scene came to Firefighter Chavis' aid. He was transported to the hospital by a medical helicopter. He suffered 2nd and 3rd degree burns over 50% of his body. Firefighter Chavis died of complications of his burns on July 12, 2001. The Lexington County Fire Service was fined $3,250 by the South Carolina State Occupational Safety and Health Administration for work safety violations that occurred at the fire where Firefighter Chavis was injured. The major violations included lack of supervision by a commander and lack of communications between the interior and exterior of the hazard zone. A lack of staffing was also cited, 30 minutes into the incident only 5 firefighters were on the scene.

NIOSH recommendations: Fire departments should ensure that adequate numbers of staff are available to immediately respond to emergency incidents. Fire departments should ensure that at least four fire fighters are on the scene before initiating interior fire fighting operations at a structural fire - two in, two out. Fire departments should ensure that Incident Command maintains the role of directing operations on the fire scene, and not become involved in fire fighting efforts. Fire departments should ensure that proper safety measures are implemented when accessing a structure through the garage door.

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Downing, John J


Age: 40
Sex: Male
Rank: Firefighter 1st Grade
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 06/17/01
Minutes to first responder arriving: 1
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 6
Firefighters arriving within 10 minutes (suggested 15): 31
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: hardware store
Cause of death: Struck by or contact with object
Nature of death: Internal trauma
Activity: Ventilation
Death date: 06/17/01
Property type: Store/Office

Summary by USFA: Fire companies were dispatched to a report of a fire in a hardware store. The first-arriving engine company, which had been flagged down by civilians in the area prior to the dispatch, reported a working fire with smoke venting from a second-story window. A bystander brought the company officer from the first-arriving engine company to the rear of the building where smoke was observed venting from around a steel basement door. The first-arriving command officer was also shown the door and ordered an engine company to stretch a line to the rear of the building. A ladder company was ordered to the rear to assist in opening the door; Firefighter Downing was a member of this company. The first-due rescue company, including Firefighters Fahey and Ford, searched the first floor of the hardware store and assisted with forcible entry on the exterior. The incident commander directed firefighters at the rear of the building to open the rear door and attack the basement fire. Firefighters on the first floor were directed to keep the interior basement stairwell door closed and prevent the fire from extending. The rear basement door was reinforced, and a hydraulic rescue tool was employed to open it. Once the first door was opened, a steel gate was found inside, further delaying fire attack. Firefighters Downing and Ford were attempting to open basement windows on the side of the building, and Firefighter Fahey was inside of the structure on the first floor. An explosion occurred and caused major structural damage to the hardware store. Three firefighters were trapped under debris from a wall that collapsed on the side of the hardware store; several firefighters were trapped on the second floor; firefighters who were on the roof prior to the explosion were blown upwards with several firefighters riding debris to the street below; and firefighters on the street were knocked over by the force of the explosion. The explosion trapped and killed Firefighters Downing and Ford under the collapsed wall; their deaths were immediate. Firefighter Fahey was blown into the basement of the structure. He called for help on his radio, but firefighters were unable to reach him in time. The cause of death for Firefighters Downing and Ford was internal trauma, and the cause of death for Firefighter Fahey was listed as asphyxiation. Firefighter Fahey's carboxyhemoglobin level was found to be 63%. In addition to the three fatalities, 99 firefighters were injured at this incident. The fire was caused when children - two boys, ages 13 and 15 - knocked over a gasoline can at the rear of the hardware store. The gasoline flowed under the rear doorway and was eventually ignited by the pilot flame on a hot water heater.

NIOSH recommendations: Fire Departments should ensure that pre-incident plans are updated and used on mercantile occupancies. Fire departments should ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts. Fire departments should ensure that fire fighters are trained to know the hazards associated with cellar fires and the precautions that can be taken to reduce serious injury. Municipalities and building owners should consider requiring and modifying older structures to meet new building codes and standards to improve safety of occupants and fire fighters. Building owners and/or fire departments should consider placing specific building construction information on an exterior placard. Building owners should follow guidelines of the local authority having jurisdiction regarding the storage of hazardous/flammable materials and ensure that all existing safeguards are operational.

Click here for the NIOSH investigative report


Fahey, Brian D


Age: 46
Sex: Male
Rank: Firefighter 1st Grade
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 06/17/01
Minutes to first responder arriving: 1
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 6
Firefighters arriving within 10 minutes (suggested 15): 31
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: hardware store
Cause of death: Struck by or contact with object
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 06/17/01
Property type: Store/Office

Summary by USFA: (See above)

NIOSH recommendations: (See above)


Click here for the NIOSH investigative report

Ford, Harry S


Age: 50
Sex: Male
Rank: Firefighter 1st Grade
Department: New York City Fire Department, New York, N.Y.
Status: Career
Incident date: 06/17/01
Minutes to first responder arriving: 1
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 6
Firefighters arriving within 10 minutes (suggested 15): 31
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: hardware store
Cause of death: Struck by or contact with object
Nature of death: Internal trauma
Activity: Ventilation
Death date: 06/17/01
Property type: Store/Office

Summary by USFA: (See above)

NIOSH recommendations: (See above)


Click here for the NIOSH investigative report

Jahnke, Jay Paul


Age: 40
Sex: Male
Rank: Captain
Department: Houston Fire Department, Houston, Texas
Status: Career
Incident date: 10/13/01
Minutes to first responder arriving: 10
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 3
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: high-rise apartment
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 10/13/01
Property type: Residential

Summary by USFA: Captain Jahnke and his engine company were dispatched to a report of a fire in a 40-story residential high-rise. Upon their arrival, Captain Jahnke reported a working fire on the fifth floor of the building and requested a second alarm. While Captain Jahnke's driver attached lines to the building's fire department connection, Captain Jahnke and his firefighter climbed the stairs to the fire floor. Upon their arrival on the fire floor, Captain Jahnke and his firefighter were joined by the captain and firefighter from a ladder company. The four firefighters entered the fire occupancy and began to apply water to the fire. The two firefighters ran low on air and exited to change their cylinders, leaving the two captains to fight the fire. When the firefighters opened the stairway door to exit, conditions in the fire occupancy worsened dramatically. The captains decided to leave the apartment by following their hoseline but soon became separated. Captain Jahnke became separated from the line and disoriented. The other captain was found in the stairwell by other firefighters and removed from the building. Captain Jahnke called for help on his portable radio. Firefighters responding to his request were guided to his location by the sound of his PASS device. Despite their efforts, Captain Jahnke died of asphyxiation due to smoke inhalation. There are a number of Jahnke's that serve the Houston Fire Department. The department's training academy is named for Captain Jahnke's uncle.

NIOSH recommendations: Fire departments should ensure that the department’s high-rise Standard Operating Procedures (SOPs) are followed and refresher training is provided. Fire departments should ensure that team continuity is maintained. Fire departments should ensure that personnel are in position to maintain an offensive attack. Fire departments should ensure that a lifeline is in place to guide fire fighters to an emergency stairwell. Fire departments should instruct and train fire fighters on initiating emergency traffic (Mayday-Mayday) when they become lost, disoriented, or trapped. Fire departments should ensure that a Rapid Intervention Team (RIT) is established and in position. Fire departments should ensure that a backup line is manned and in position to protect exit routes. Fire departments should ensure that adequate numbers of staff are available to immediately respond to emergency incidents. Fire departments should ensure that the Incident Commander (IC) continuously evaluates the present weather conditions (i.e., high winds) during high-rise fire operations. Fire departments should establish and enforce standard operating procedures on the use of thermal imaging cameras for search-and-rescue operations. The authority having jurisdiction shall ensure that the receipt and processing of alarms is completed in a timely manner.

Click here for the NIOSH investigative report


Davis, Vincent Llyonell


Age: 42
Sex: Male
Rank: Firefighter
Department: Dallas Fire-Rescue Department, Dallas, Texas
Status: Career
Incident date: 02/11/02
Minutes to first responder arriving: 2
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 13+
Firefighters arriving within 10 minutes (suggested 15): 20+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: apartment construction
Cause of death: Caught or trapped
Nature of death: Unknown
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/11/02
Property type: Residential

Summary by USFA: Firefighter Davis was assigned to fill in for a vacancy at Engine 33 on the day of the fatal incident. A fire was reported in a vacant apartment building that was undergoing renovation. Engine 33 was initially dispatched to move up to another fire station but was brought to the scene on the third alarm. Upon their arrival on the scene, Firefighter Davis and the members of his crew checked for fire extension on the second floor of the southwest wing. After confirming that the attic of the involved wing and the attic of the southwest wind were not connected, Firefighter Davis and his crew returned to the ground floor. The captain of Firefighter Davis' company conferred with other officers in the area and the decision was made to deploy an additional handline. Firefighter Davis and his crew began to walk through a breezeway to a nearby engine company apparatus. The captain was in the lead, Firefighter Davis and his driver were an arms length behind the captain, and a firefighter was an arms length behind Firefighter Davis and the driver. As the captain neared the end of the breezeway, a collapse occurred; Firefighter Davis and the driver were buried. Engine 33 had been on the scene for less than 8 minutes when the collapse occurred. The driver was freed from the rubble after some difficulty, but the whereabouts of Firefighter Davis could not be confirmed. A boot was found in the rubble, and the search for Firefighter Davis began. Firefighter Davis was found in a sitting position with his face down on his legs. He was wearing his SCBA but the unit was not activated. His Personal Alert Safety System (PASS) devices were also not activated. Firefighter Davis had no pulse. Debris was cleared and medical treatment began. CPR was initiated immediately and on-scene paramedic firefighters provided Advanced Life Support (ALS) care. Care continued en-route to the hospital. Firefighter Davis was pronounced dead at the hospital. The elapsed time from the collapse to the removal of Firefighter Davis from the rubble was approximately 28 minutes. The fire was caused by the careless use of a construction torch. The cause of death was listed as blunt force trauma and traumatic asphyxiation.

NIOSH recommendations: Fire departments should establish and monitor a collapse zone to ensure that no fire fighting operations take place within this area as part of defensive operations. Fire departments should ensure that an Incident Safety Officer, independent from the Incident Commander, is appointed and on scene early in the fire operation. Fire departments should ensure consistent use of personal alert safety system (PASS) devices at all incidents.

Click here for the NIOSH investigative report


Murray, Thomas Shane


Age: 21
Sex: Male
Rank: Firefighter
Department: Jefferson City Fire Department, Jefferson City, Tenn.
Status: Volunteer
Incident date: 03/01/02
Minutes to first responder arriving: 2
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 2
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/01/02
Property type: Residential

Summary by USFA: Firefighter Murray and members of his department were dispatched to a report of a structure fire in a single-family residence. A fire inspector had discovered the fire and was about to report it when the incident was dispatched. An engine company arrived on the scene, a water supply was established, and 2 attack lines were advanced. Firefighter Murray, who was a city employee, arrived in his city vehicle at this time. The fire chief and Firefighter Murray joined 2 other firefighters in the interior and completed a primary search of the structure. Finding an all-clear, the fire chief and Firefighter Murray retrieved a hoseline from the front entrance of the house for fire control. A positive-pressure fan was placed at the front entrance of the structure and windows were broken out for ventilation. A backup line from another engine company was advanced into the interior. The hoselines were not having much effect on the fire and the second hose line became useless when the booster tank on the second engine ran out of water. A third line was deployed but interior conditions continued to worsen. Based on his view of the exterior of the structure, the Incident Commander (IC )ordered an evacuation. Due to problems with the IC's radio, firefighters inside the structure did not hear the order. Conditions continued to worsen inside the structure, and the fire chief ordered everyone to exit the structure. A firefighter and a lieutenant were first out the door and made it to the front yard. The chief, however, had difficulty exiting and collapsed just after stepping outside the structure. He could not get up and was helped to safety by other firefighters. An accountability report was taken, and Firefighter Murray was found to be missing. The fire had progressed to the point that further entry into the structure was impossible. A deck gun was used to darken down the fire. Firefighters were able to see Firefighter Murray about 5 feet inside of the front door of the structure. He was removed to the street where EMS treatment was initiated. CPR was started and continued as Firefighter Murray was transported to the hospital. He was pronounced dead upon arrival. Firefighter Murray was wearing and using his SCBA and PASS device. The low air warning and PASS alert tone did not help in his discovery. The cause of death for Firefighter Murray was listed as asphyxiation with a carboxyhemoglobin level of 31.8 percent.

NIOSH recommendations: Fire departments should ensure that Incident Command (IC) conducts a complete size-up of the incident before initiating fire fighting efforts, and continually evaluates the risk versus gain during operations at an incident. Departments should also ensure that the first officer or fire fighter inside evaluates interior conditions and reports them immediately to Incident Command. Fire departments should ensure that adequate numbers of staff are available to operate safely and effectively. Fire departments should ensure that a Rapid Intervention Team is established and in position immediately upon arrival. Fire departments should use evacuation signals when command personnel decide that all fire fighters should be evacuated from a burning building or other hazardous area. Fire departments should ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed. Fire departments should ensure that team continuity is maintained. Fire departments should ensure that ventilation is closely coordinated with the fire attack. Fire departments should instruct and train fire fighters on initiating emergency traffic (Mayday-Mayday) when they become lost, disoriented, or trapped. Fire departments should ensure that backup lines are equal to or greater than the initial attack lines. Fire departments should ensure that fire fighters are equipped with a radio that does not bleed over, cause interference, or lose communication under field conditions.

Click here for the NIOSH investigative report


Earley, Joshua Brandon


Age: 22
Sex: Male
Rank: Firefighter
Department: Harrisburg Volunteer Fire Department & Rescue, Harrisburg, N.C.
Status: Career
Incident date: 03/04/02
Minutes to first responder arriving: 7
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 5
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Residence
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/06/02
Property type: Residential

Summary by USFA: Firefighter Earley and the members of his engine company responded to the report of a structure fire. Their response was an automatic mutual aid response into a neighboring fire district. When the first units arrived on the scene, they reported a working fire. Firefighters attempted to enter the structure but were driven back by intense heat. Firefighter Earley was the first firefighter through the door at another entry point. He had advanced a 1-¾ -inch hoseline 4-5 feet inside of the structure when the floor collapsed. Firefighter Earley fell into the fire-involved basement. The Captain backing him up on the line was able to avoid the fall by grabbing the door frame and was assisted by other firefighters to the exterior. Firefighter Earley was removed from the structure by other firefighters approximately 1 minute after he fell into the basement. Medical care was provided by firefighters and EMS workers on the scene. Firefighter Earley received second and third-degree burns over 87 percent of his body. Firefighter Earley was airlifted from the scene and was later transferred to a regional burn treatment facility. He expired due to complications from his burns on March 6, 2002. Firefighter Earley was also a career firefighter for the Charlotte Fire Department. The fire started due to ordinary combustibles being stored too close to a wood burning stove.

NIOSH recommendations: 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. Fire departments should ensure fire fighters are trained to recognize the danger of searching above a fire. Fire departments should ensure that an Incident Safety Officer independent from the Incident Commander is appointed. Fire departments should ensure that ventilation is closely coordinated with the fire attack. Fire departments should ensure that a Rapid Intervention Team is established and in position immediately upon arrival. Fire departments should ensure that adequate numbers of staff are available to operate safely and effectively.

Click here for the NIOSH investigative report


Ginocchetti, John Evo


Age: 41
Sex: Male
Rank: Firefighter/Paramedic
Department: Manlius Fire Department, Manlius, N.Y.
Status: Career
Incident date: 03/07/02
Minutes to first responder arriving: 8
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/07/02
Property type: Residential

Summary by USFA: Firefighter/Paramedic Ginocchetti and Firefighter/Paramedic Lynch responded with 2 other firefighters in a ladder truck to a mutual aid structure fire. Fire was reported in the basement of a house. Upon their arrival at the scene, the Manlius truck company was ordered to the roof to ventilate. The hole produced heavy smoke and heat. After returning to the ground, the crew was directed to relieve a crew operating a handline in the garage area of the home. Firefighter/Paramedic Lynch took the nozzle and Firefighter/Paramedic Ginocchetti backed him up. The line was advanced from the garage into the mudroom of the house. As soon as the firefighters made entry into the structure, the floor beneath them failed and they fell into the fire area. An officer entered the mudroom and encountered heavy smoke and heat. He was unaware that a collapse had occurred until he heard Firefighter/Paramedic Ginocchetti calling for help. The officer tried to grab hold and help Firefighter/Paramedic Ginocchetti back into the mudroom, but he was driven back by intense heat and fire. The officer received burns to his hands and face after his SCBA facepiece was pulled off during the rescue attempt. Other firefighters also attempted to rescue Firefighter/Paramedic Ginocchetti but they too were driven back by fire progress. The collapse made access to the firefighters impossible through any existing entrances. A hole was breached into the back basement wall and firefighters were able to remove debris and locate both firefighters. They were removed from the basement and transported to the hospital where they were pronounced dead. The cause of death for both firefighters was asphyxiation. Firefighter/Paramedic Ginocchetti had a carboxyhemoglobin level of 15 percent and the level in Firefighter/Paramedic Lynch's blood was not detected. The total time that had passed from the collapse to the removal of both firefighters was approximately 3 hours. The fire was caused by sparks from a grinder being operated by the homeowner. Firefighter Lynch was a career member of the Village of Fayetteville Fire Department.

NIOSH recommendations: 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. Fire departments should ensure that the Incident Commander conveys strategic decisions to all suppression crews on the fireground and continually reevaluates the fire condition. Fire departments should 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. Fire departments should ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts. Fire departments should ensure that fire fighters report conditions and hazards encountered to their team leader or Incident Commander. Fire departments should ensure fire fighters are trained to recognize the danger of operating above a fire.

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Lynch, Timothy John


Age: 28
Sex: Male
Rank: Firefighter/Paramedic
Department: Manlius Fire Department, Manlius, N.Y.
Status: Volunteer
Incident date: 03/07/02
Minutes to first responder arriving: 8
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/07/02
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Martin, Derek Duval


Age: 38
Sex: Male
Rank: Firefighter
Department: St. Louis Fire Department, St. Louis, Mo.
Status: Career
Incident date: 05/03/02
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 20+
Firefighters arriving within 10 minutes (suggested 15): 20+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Refrigeration plant
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 05/03/02
Property type: Industry

Summary by USFA: Firefighter Martin and Firefighter Morrison responded as a part of a rescue company crew to the report of a fire in a 2-story commercial building. First-arriving firefighters found light smoke showing and a fire on the first floor. While other firefighters opened up the building, engine company firefighters advanced a hoseline into the first floor area and knocked down the fire. As the ceiling on the first floor was pulled, fire was noted in the space between the first and second floors. Fire extension into the second floor was suspected. The handline was removed from the first floor and advanced to the second floor. An engine company captain became separated from his crew at the rear of the first floor of the building. He opened a roll-up door for egress. The fresh air supplied by the open door allowed the remaining fire on the first floor to progress rapidly. A metal security gate at the base of the roll-up door prevented his escape. The captain was able to escape when firefighters and civilians at the rear of the structure moved the gate to permit his exit. While he was trapped, the captain made a number of requests for assistance on the radio. At the same time, firefighters from the rescue company were opening up the second floor. An engine company firefighter came upon Firefighter Morrison as they worked on the second floor. Firefighter Morrison appeared to be lost and conditions in the area were worsening. The firefighter attempted to lead Firefighter Morrison to the exit but almost became disoriented himself. As he worked his way to the exit, he came upon Firefighter Morrison lying face down and unresponsive. The firefighter was unable to move Firefighter Morrison and, running out of air himself, he was forced to leave the structure. As soon as he exited the building, the firefighter notified a chief officer that Firefighter Morrison was down. A search party was organized, including Firefighter Martin. The search party entered the building and located Firefighter Morrison. Firefighter Morrison was removed from the building and provided with emergency medical aid. The captain of the rescue company did another head count and realized that Firefighter Martin was now missing. A second search party entered the building and was aided in the discovery of Firefighter Martin by the sound of his PASS device. Firefighter Martin was removed from the structure and emergency medical care was provided. Firefighter Morrison was missing for approximately 20 minutes and Firefighter Martin was missing for approximately 29 minutes. Firefighter Morrison had a blood carboxyhemoglobin level of 47.9 percent and third-degree burns over 18 percent of his body. Firefighter Martin had a carboxyhemoglobin level of less than 10 percent and suffered third-degree burns over 40 percent of his body. Firefighter Martin was pronounced dead upon his arrival at the hospital. Firefighter Morrison died the next day. Both firefighters were promoted to Captain posthumously.

NIOSH recommendations: Fire Departments should ensure that team continuity is maintained. Fire departments should ensure that a rapid intervention team is established and in position immediately upon arrival. Fire Departments should ensure that the incident command system is fully implemented at the fire scene. Fire departments should ensure that fire fighters, when operating on the floor above the fire, have a charged hoseline. Fire departments should instruct and train fire fighters on manually activating their PASS device when they become lost, disoriented, or trapped. Fire departments should ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed. Fire departments should ensure that Standard Operating Procedures (SOPs) and equipment are adequate and sufficient to support the volume of radio traffic at multiple-alarm fires. Fire departments should ensure that self contained breathing apparatus (SCBAs) are properly inspected, used, and maintained to ensure they function properly when needed.

Click here for the NIOSH investigative report


Morrison, Robert Bruce


Age: 38
Sex: Male
Rank: Firefighter
Department: St. Louis Fire Department, St. Louis, Mo.
Status: Career
Incident date: 05/03/02
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 20+
Firefighters arriving within 10 minutes (suggested 15): 20+
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Refrigeration plant
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Search and rescue
Death date: 05/04/02
Property type: Industry

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Stewart, Thomas G III


Age: 30
Sex: Male
Rank: Firefighter/EMT
Department: Gloucester City Fire Department, Gloucester, N.J.
Status: Career
Incident date: 07/04/02
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 11
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: Single-family residence
Cause of death: Caught or trapped
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 07/04/02
Property type: Residential

Summary by USFA: The Gloucester City Fire Department was dispatched to a structure fire in a residential building. While units were responding, dispatch advised units of a working fire with people trapped. When firefighters arrived on the scene, they found a well-involved fire in a 3-story wood-frame structure with fire threatening a connected exposure building of the same size. Heavy smoke was showing from the exposure. Mount Ephraim Fire Department's rescue company was also dispatched upon the report of a working fire. The amount of fire in the building of origin prohibited an interior attack. The initial arriving officer saw movement in a window on the second floor of the exposure. Firefighters were directed to stretch an attack line into the exposure for search and rescue and fire control. Firefighters found that fire had extended into the second floor of the exposure and conducted suppression efforts but were unable to locate any occupants. Facing heavy fire in the original structure and extension into the exposure, master streams were applied into the original structure. The bulk of the fire was knocked down in the original fire building while crews continued to operate in the exposure. An occupant (mother) was found in the rear portion of the first floor of the exposure by interior crews and was removed from the structure. An interior crew reported a missing firefighter and the structure was evacuated to conduct an accountability of operating personnel. The firefighter was almost immediately accounted for yet there were still 3 building occupants (children) that had not been located. A crew of 8 firefighters and chief officers, including Firefighter Stewart, Chief Sylvester, and Deputy Fire Marshal West, entered the front of the exposure structure to conduct a search. At the 30-minute mark since the dispatch of the incident, the interior crews reported that they were leaving the structure due to conditions. Within seconds of these reports, both the original fire-involved structure and the exposure structure experienced a catastrophic collapse. The collapse occurred approximately 34 minutes after the initial alarm of fire. Two firefighters freed themselves after the collapse. Four firefighters were trapped in the collapse. Rescue efforts began immediately and 2 of the firefighters were freed, with the first taking approximately 25 minutes and the last removed almost 1-1/2 hours after the collapse. After an extensive recovery and rescue effort, the bodies of Firefighter Stewart, Chief Sylvester, and Deputy Fire Marshal West were found and removed from the rubble. Three children, who resided in the original fire structure, were also killed in the incident. The cause of death for all 3 firefighters was fixed compression as the result of being crushed by the collapse. Deputy Fire Marshal West was also a deputy chief with the Mount Ephraim Fire Department.

NIOSH recommendations: Fire departments should ensure that the department's structural fire fighting standard operating guidelines (SOGs) are followed and refresher training is provided. Fire departments should ensure that the Incident Commander (IC) formulates and establishes a strategic plan for offensive and defensive operations. Fire departments should ensure that the incident commander (IC) continuously evaluates the risk versus gain during operations at an incident. Fire departments should ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed. Fire departments should ensure that fire fighters conducting interior operations (e.g., search and rescue, initial attack, etc.) provide periodic progress reports to the IC. Fire departments should ensure that accountability for all personnel at the fire scene is maintained. Fire departments should ensure that a Rapid Intervention Team (RIT) is established and in position. Fire departments should ensure that the officer in charge of an incident recognize factors (e.g., structural defects, large body of fire in an old structure, etc.) when analyzing potential building collapse. Fire departments should ensure, when feasible, that fire fighters should respond together, in one emergency vehicle, as a crew. Municipalities should consider establishing and maintaining regional mutual-aid radio channels to coordinate and communicate activities involving units from multiple jurisdictions.

Click here for the NIOSH investigative report


Sylvester, James E


Age: 31
Sex: Male
Rank: Chief
Department: Gloucester City Fire Department, Gloucester, N.J.
Status: Volunteer
Incident date: 07/04/02
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 11
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: Single-family residence
Cause of death: Caught or trapped
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 07/04/02
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


West, John D


Age: 40
Sex: Male
Rank: Deputy Fire Marshal
Department: Gloucester City Fire Department, Gloucester, N.J.
Status: Career
Incident date: 07/04/02
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 11
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: Yes
Type of building: Single-family residence
Cause of death: Caught or trapped
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 07/04/02
Property type: Residential

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Kruse, Michael Raymond


Age: 53
Sex: Male
Rank: Firefighter
Department: Muscatine Fire Department, Muscatine, Iowa
Status: Career
Incident date: 09/14/02
Minutes to first responder arriving: 2
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 7
Firefighters arriving within 10 minutes (suggested 15): 7
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family residence
Cause of death: Caught or trapped
Nature of death: Unknown
Activity: Advancing Hose Lines / Fire Attack
Death date: 09/14/02
Property type: Residential

Summary by USFA: Firefighter Kruse and members of his department were dispatched to a report of a structure fire in a 3-story multifamily residence. Firefighter Kruse and another firefighter responded in the department's aerial tower. The first firefighters on the scene reported light smoke showing. The first and second floors were clear but firefighters encountered heavy heat and smoke conditions that prevented their entry to the third floor. The order to ventilate the roof was given. Firefighter Kruse and the other firefighter ascended to the roof of the structure in the platform of the aerial tower. Firefighter Kruse was not wearing an SCBA, the second firefighter was wearing an SCBA. When they arrived at the roof, both firefighters got off the platform. The other firefighter completed the roof cut with a chain saw but did not open up the roof. Due to the smoke conditions on the roof, Firefighter Kruse had been covering his face with his hands. When the roof cut was complete, Firefighter Kruse pulled on the other firefighter's arm and indicated that they urgently needed to get off the roof. As both firefighters headed for the aerial tower platform, Firefighter Kruse fell to his hands and knees. The other firefighter attempted to grab Firefighter Kruse and lead him to the platform but he was unsuccessful. At this point, Firefighter Kruse turned on his back and fell through the roof into the fire area. Firefighters in the interior of the structure heard radio transmissions indicating that Firefighter Kruse had fallen through the roof. They fought their way into the third floor of the structure. Firefighter Kruse was located and removed from the fire area. He was then brought outside the structure approximately 9 minutes after falling through the roof. He was immediately transported to the hospital. The cause of death was listed as smoke inhalation. The carboxyhemoglobin level in Firefighter Kruse's blood was 30.3 percent.

NIOSH recommendations: Fire departments should enforce existing standard operating procedures (SOPs) for structural fire fighting, including the use of self-contained breathing apparatus (SCBA), Incident Command System, Truck Company Operations, and Transfer of Command. Fire departments should ensure that the Incident Commander evaluates resource requirements during the initial size-up and continuously evaluates the risk versus benefit when determining whether the operation will be offensive or defensive. Fire departments should develop, implement and enforce SOPs regarding vertical ventilation procedures. Fire departments should review dispatch/alarm response procedures with appropriate personnel to ensure that the processing of alarms is completed in a timely manner and that all appropriate units respond according to existing SOPs. Fire departments should ensure that Incident Command maintains the role of director of fireground operations and does not become involved in fire-fighting efforts. Fire departments should ensure that adequate numbers of staff are available to immediately respond to emergency incidents. They should consider doing only defensive operations until sufficient resources are on the scene. Fire departments should consider using a thermal imaging camera (TIC) as part of the exterior size-up.

Click here for the NIOSH investigative report


Stott, Ralph Jr.


Age: 50
Sex: Male
Rank: Captain
Department: Terre Haute Fire Department, Terre Haute, Ind.
Status: Career
Incident date: 09/30/02
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 8
Firefighters arriving within 10 minutes (suggested 15): 16
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: auto body shop
Cause of death: Caught or trapped
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 09/30/02
Property type: Store/Office

Summary by USFA: Captain Stott and other members of his department responded to the report of a structure fire in a automobile body shop. Captain Stott was in command of an engine company. The first engine company to arrive reported a working fire with heavy smoke showing. Upon their arrival, Captain Stott and his crew deployed a 1-¾ inch handline into the front door of the structure. The on-duty battalion chief arrived on the scene and conducted a size-up of the building. The chief decided to switch to a defensive mode of operations. The IC attempted to contact Captain Stott and the other firefighter on the handline but was unsuccessful. A lieutenant entered the building and brought Captain Stott and his firefighter to the exterior. The IC ordered Captain Stott and his firefighter to the rear of the building with their handline for exposure protection. As the IC and Captain Stott walked in front of the building, a structural collapse occurred. Captain Stott was buried in the debris. Firefighters immediately began to dig through the rubble looking for Captain Stott. He was located and removed from the pile. CPR was initiated immediately and Captain Stott was transported to the hospital. Due to the massive injuries inflicted on Captain Stott when he was crushed by the structural collapse, he was pronounced dead at the hospital. The cause of death was listed as blunt force trauma to the head and chest. An employee of the body shop was arrested and charged with murder and 2 counts of arson resulting in serious bodily injury.

NIOSH recommendations: Fire departments should establish and implement written standard operating procedures (SOPs) regarding emergency operations on the fireground. Fire departments should ensure that officers and fire fighters at a structure fire continuously analyze the building to identify collapse potential. Fire departments should ensure that a collapse zone is established and clearly identified at structure fires involving buildings susceptible to collapse. Fire departments should ensure that pre-emergency planning is completed for mercantile and business occupancies. Fire departments should ensure that a separate Incident Safety Officer (ISO), independent from the Incident Commander, is appointed.

Click here for the NIOSH investigative report


DiOrio, Timothy


Age: 36
Sex: Male
Rank: Lieutenant
Department: Coal Township Fire Department, Coal Township, Pa.
Status: Volunteer
Incident date: 11/01/02
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 4
Firefighters arriving within 10 minutes (suggested 15): 8?
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Struck by or contact with object
Nature of death: Internal trauma
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/01/02
Property type: Residential

Summary by USFA: Lieutenant DiOrio and the members of his department were dispatched to a mutual aid structure fire involving a large old house that was being used for storage. During the fire fight, a portion of the wraparound porch collapsed and pinned Lieutenant DiOrio's leg in the rubble. Two firefighters came to his aid immediately, 1 tried to pull Lieutenant DiOrio free by his arms and the other attempted to lift the debris off Lieutenant DiOrio's leg. Moments later, the entire house collapsed, propelling the rescuers away from Lieutenant DiOrio. The secondary collapse covered Lieutenant DiOrio. It took firefighters hours to control the fire and remove the wreckage that covered Lieutenant DiOrio. He was crushed by a large wooden beam and died of traumatic asphyxiation. Lieutenant DiOrio was also a Pennsylvania State Trooper based in Selinsgrove.

NIOSH recommendations: Fire departments should ensure that Incident Command (IC) continually evaluates the risk versus gain when deciding an offensive or defensive fire attack. Fire departments should ensure that a collapse zone is established, clearly marked, and monitored at structure fires where buildings have been identified at risk of collapsing. Fire departments should establish and implement written standard operating procedures (SOPs) regarding emergency operations on the fireground. Fire departments should develop and coordinate pre-incident planning protocols throughout mutual aid departments. Fire departments should implement joint training on response protocols throughout mutual aid departments. Fire departments should ensure that an Incident Safety Officer, independent from the Incident Commander, is appointed and on-scene early in the fireground operation.

Click here for the NIOSH investigative report


Carpenter, Randall E


Age: 46
Sex: Male
Rank: Lieutenant
Department: Coos Bay Fire Department, Coos Bay, Ore.
Status: Career
Incident date: 11/25/02
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 11
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Auto parts store
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/25/02
Property type: Store/Office

Summary by USFA: Coos Bay Fire & Rescue was dispatched to the report of a fire in a building that contained a truck and auto supply store and a machine shop. The fire was first discovered by building occupants who smelled smoke and discovered warm walls and fire behind the wall in an upstairs bathroom. The occupants attempted to fight the fire prior to calling the fire department. When firefighters arrived on the scene, they reported a light smoke condition. Firefighters advanced 2 attack lines into the building. Lieutenant Carpenter, Firefighter Common, and Firefighter Hanners were working on the second floor of the building. Finding no visible fire, the firefighters opened up the walls and ceiling to expose and extinguish the fire. When the fire hidden in these concealed spaces was exposed to fresh air, it progressed rapidly. Firefighters on the roof reported that the roof was feeling spongy, and the IC ordered an evacuation of the building. At approximately the same time, the roof and other structural supports over the second floor collapsed. Fire spread rapidly throughout the building. Lieutenant Carpenter and Firefighter Common were trapped under the debris on the second floor. Firefighter Hanners, who may have been descending the stairs at the time of the collapse, was propelled down the stairs by the force of the collapse and ended up behind a customer service counter. A personnel accountability report found that 3 firefighters were missing. Other firefighters advanced attack lines into the building to search for the trapped firefighters. Firefighter Hanners was discovered and removed from the building. Due to fire conditions and structural instability, firefighters were unable to reach Lieutenant Carpenter and Firefighter Common until the fire was controlled. All 3 firefighters died of asphyxiation and exposure to heat and smoke. Lieutenant Carpenter had a carboxyhemoglobin level of 53 percent and Firefighter Common's level was 49 percent. Firefighter Hanners' carboxyhemoglobin level at autopsy was 3 percent. The medical examiner noted that Firefighter Hanners had undergone extensive life-saving measures including the administration of oxygen, and that the level of carbon monoxide in his blood was likely much higher prior to his removal from the building. The fire was caused when heat from the flue of a propane-fueled incinerator/parts cleaner ignited structural components in the wall and ceiling of the building's second floor. The fire may have burned in these concealed spaces for as long as 4 hours prior to discovery. The cleaner had been installed without a permit, and it was improperly installed. The owner of the business and the installer were later charged with criminally negligent homicide.

NIOSH recommendations: Fire departments should ensure that fire fighters provide the Incident Commander with interior size-up reports. Fire departments should ensure that fire fighters open concealed spaces to determine whether the fire is in these areas. Fire departments should ensure that pre-emergency planning is completed for mercantile and business occupancies. Fire departments should ensure that a Rapid Intervention Team (RIT) is established and in position. Fire departments should consider using a thermal imaging camera as a part of the interior size-up operation to aid in locating fires in concealed areas. Fire Departments should ensure that local citizens are provided with information on fire prevention and the need to report emergency situations as soon as possible to the proper authorities. Fire departments should ensure that self-contained breathing apparatus (SCBAs) and equipment are properly inspected, used, and maintained to ensure they function properly when needed. Fire departments should ensure that fire command always maintains close accountability for all personnel operating on the fireground. Building owners should ensure that building permits are obtained and local building codes are followed when additions or modifications are made.

Click here for the NIOSH investigative report


Common, Jeffery E


Age: 30
Sex: Male

Firefighter/Engineer
Department: Coos Bay Fire Department, Coos Bay, Ore.
Rank: Volunteer
Department: 11/25/02
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 11
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Auto parts store
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/25/02
Property type: Store/Office

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Hanners, Robert Charles


Age: 33
Sex: Male
Rank: Firefighter/Engineer
Department: Coos Bay Fire Department, Coos Bay, Ore.
Status: Volunteer
Incident date: 11/25/02
Minutes to first responder arriving: 4
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 5
Firefighters arriving within 10 minutes (suggested 15): 11
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Auto parts store
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/25/02
Property type: Store/Office

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


Staley, Gary L


Age: 32
Sex: Male
Rank: Firefighter
Department: Porter Volunteer Fire Department, Porter, Texas
Status: Volunteer
Incident date: 01/19/03
Minutes to first responder arriving: 8
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 7
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Vehicle sales
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/19/03
Property type: Store/Office

Summary by USFA: Firefighter Staley and members of his department and mutual aid departments were dispatched to a fire in a commercial occupancy. The fire involved a specialized vehicle restoration shop. The first-arriving command officer reported a working fire and requested additional resources. Firefighter Staley arrived on the first engine company. Firefighter Staley and other firefighters stretched a 1-3/4 inch handline with Compressed Air Foam (CAF). Upon entry to the shop, they found light smoke from the ceiling to the floor. A portable positive pressure fan was placed in a doorway. The fire began to intensify and began to roll over the top of the attack crew. One attack crewmember was forced to leave because his hands were burning. As this firefighter reached to exterior, air horns began to sound indicating that firefighters should evacuate the building. Two of the attack line crewmembers exited the building; both suffered burns. Firefighter Staley did not exit. Approximately 30 seconds after the third firefighter left the building, an explosion occurred inside of the building. Firefighters quickly determined that Firefighter Staley was missing. A Rapid Intervention Crew (RIC) was deployed to the interior but they were forced to exit the building when evacuation horns were sounded again. Ladder pipes were used to knock down the fire and the RIC was allowed to reenter the structure. The RIC was forced to leave again due to fire progress and an unreliable water supply. After master streams were used to knock down the fire again, firefighters located Firefighter Staley inside of the structure. Firefighter Staley likely became disoriented inside of the structure and ran out of air. He received injuries from the explosion, both of his eardrums were ruptured and there was damage to his lungs consistent with the explosion. He was found in the prone position with the regulator removed from his SCBA facepiece. His PASS device was sounding but was muffled by the position of his body. The cause of death was listed as thermal injuries with smoke inhalation and blast injuries. The fire began when a flooring contractor used a flammable liquid to prepare a floor. Vapors were ignited when a portable heater was used to speed the drying process.

NIOSH recommendations: Fire departments should develop and enforce standard operating procedures (SOPs) for structural fire fighting that include, but are not limited to, Accountability, Rapid Intervention Crews (RIC), and Incident Command System. Fire departments should ensure that a complete size-up is conducted before initiating fire fighting efforts, and that risk versus gain is evaluated continually during emergency operations. Fire departments should ensure that team continuity is maintained. Fire departments should ensure that the Incident Commander maintains the role of director of fireground operations and does not become involved in fire-fighting efforts. Fire departments should ensure that an adequate fire stream is maintained based on characteristics of the structure and fuel load present. Fire departments should ensure that pre-incident planning is performed on commercial structures. Fire departments should establish and maintain training programs for emergency scene operations. Fire departments should review dispatch/alarm response procedures with appropriate personnel to ensure that the processing of alarms is completed in a timely manner. Manufacturers and researchers should continue to refine existing and develop new technology to track and locate lost fire fighters on the fireground.

Click here for the NIOSH investigative report


Hess, Keith Robert


Age: 22
Sex: Male
Rank: Firefighter/EMT
Department: Fannett-Metal Fire & Ambulance, Dry Run, Pa.
Status: Career
Incident date: 01/20/03
Minutes to first responder arriving: 13
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 0
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Salvage and overhaul
Death date: 01/20/03
Property type: Residential

Summary by USFA: Firefighter Hess responded with the members of his department to a fire in a large residence. After the main body of the fire was controlled, a process that took about 2 hours, firefighters moved into the structure to locate and extinguish hot spots. A number of firefighters were in the structure, including Firefighter Hess. A centrally located chimney collapsed and brought down the second floor of the structure onto firefighters. Three firefighters were trapped by the collapse; 1 was able to extricate himself and get out of the structure. Firefighters entered the building and located the 2 trapped firefighters. One firefighter was removed and suffered minor injuries. Firefighter Hess was severely injured and he was found to be without a pulse and not breathing. Firefighter Hess was transported by helicopter to a local hospital where he was pronounced dead. The cause of death was listed as compressional asphyxia. Firefighter Hess was also a Lieutenant with the West End Fire and Rescue Company.

NIOSH recommendations: The Incident Commander should ensure that an assessment of the stability and safety of the structure (e.g., roofs, ceilings, partitions, load-bearing walls, floors, and chimney) is conducted before entering fire and water-damaged structures for overhaul operations. The Incident Commander should establish and monitor a collapse zone to ensure that no activities take place within this area as part of overhaul operations. Fire departments should ensure that an Incident Safety Officer, independent from the Incident Commander, is appointed and on scene early in the fire operation. Fire departments should ensure consistent use of personal alert safety system (PASS) devices even during overhaul operations. Fire departments should ensure that fire fighters who enter hazardous areas, e.g., suspected unsafe structures during overhaul, be equipped with two-way communications with Incident Command.

Click here for the NIOSH investigative report


Armstrong, Oscar III


Age: 25
Sex: Male
Rank: Firefighter
Department: Cincinnati Fire Department, Cincinnati, Ohio
Status: Career
Incident date: 03/21/03
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 17
Firefighters arriving within 10 minutes (suggested 15): 17
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Single-family home
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 03/21/03
Property type: Residential

Summary by USFA: Firefighter Armstrong and the members of his fire company responded to the report of a fire in a 2-story residence. The first fire department unit on the scene, a command officer, reported a working fire. Firefighter Armstrong assisted with the deployment of a 350-foot 1-3/4 inch handline to the front door of the residence. Once the door was forced open, firefighters advanced to the interior. The handline was dry as firefighters advanced; the hose had become tangled in a bush. As the line was straightened and water began to flow to the nozzle, a flashover occurred. The firefighters on the handline left the building and were assisted by other firefighters on the front porch of the residence. All firefighters were ordered from the building, air horns were sounded to signal a move from offensive to defensive operations. Several firefighters saw Firefighter Armstrong trapped in the interior by rapid fire progress. These firefighters advanced handlines to the interior and removed Firefighter Armstrong. A rapid intervention team assisted with the rescue. Firefighter Armstrong was severely burned. He was transported by fire department ambulance to the hospital where he later died. The Cincinnati Fire Department prepared a death investigation preliminary report related to this incident. The report is available at the fire department web site for download. The origin of the fire was determined to be a pan of oil on the stove.

NIOSH recommendations: Fire departments should review and revise existing standard operating procedures (SOPs) for structural fire fighting to ensure fire fighters enter burning structures with charged hose lines. Fire departments should ensure that a Rapid Intervention Team (RIT) is established and in position prior to initiating an interior attack. Fire departments should ensure that ventilation is closely coordinated with interior operations. Fire departments should ensure that crew continuity is maintained on the fireground. Fire departments should ensure that fire command always maintains close accountability for all personnel operating on the fireground. Emergency dispatchers should obtain as much information as possible from the caller and report it to the responding fire fighters.

Click here for the NIOSH investigative report


Kirk, Trent Anthony


Age: 39
Sex: Male
Rank: Lieutenant
Department: Memphis Fire Department, Memphis, Tenn.
Status: Career
Incident date: 06/15/03
Minutes to first responder arriving: 7
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 16
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: Commercial building
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 06/15/03
Property type: Store/Office

Summary by USFA: Lieutenant Kirk and Private Zachary were assigned to Engine Company 31. Lieutenant Kirk was working an overtime shift. At 1946hrs, E31 and other Memphis Fire Department companies were dispatched to the scene of a structure fire involving a Family Dollar Store. As they arrived on-scene, they found smoke showing from the store at the end of a strip mall. Lieutenant Kirk and a Lieutenant from another fire company proceeded through the retail area of the store and encountered only light smoke. When they attempted to enter a small office in the stock area at the rear of the store, they encountered a working fire. They were unable to close the office door and the fire advanced rapidly. Private Zachary and other firefighters advanced handlines into the interior of the store and began fire suppression operations. As they worked in the rear of the structure, conditions worsened rapidly as dense smoke and high heat levels filled the building. Private Zachary requested relief and left the nozzle to return to the exterior. He likely became disoriented in the smoke although his actions after leaving the nozzle are unknown. Lieutenant Kirk and another firefighter began to direct their hose stream into the stockroom area. They heard a firefighter call for help. A structural collapse occurred and knocked Lieutenant Kirk and the other firefighter to their knees. Lieutenant Kirk transmitted a Mayday call and said that he was trapped in the building. The collapse occurred approximately 17 minutes after the initial dispatch. The firefighter with Lieutenant Kirk was able to free him from the debris and both firefighters headed for the front of the store following their hoseline. As the firefighter crawled over a large pile of debris, he and Lieutenant Kirk lost contact. Previous to the collapse, a rescue company had been assigned Rapid Intervention Crew (RIC) duties. Upon hearing Lieutenant Kirk's Mayday, the RIC advanced into the interior of the store and began their search. The RIC located and removed a firefighter; he was out of air and disoriented. The RIC then located the firefighter that had been with Lieutenant Kirk; he too was out of air and disoriented. A ladder company was the only fire company at the rear of the building. They had forced entry to a rear door but did not have a handline and could not advance into the building. These firefighters heard an activated PASS device in the interior after hearing reports of missing firefighters. The rear sector commander allowed firefighters to enter the interior without a handline to search for the downed firefighters. Upon entering the structure, firefighters heard 2 PASS devices. They were able to follow the sound to Private Zachary and remove him from the building. Upon his removal, ALS-level EMS procedures were initiated and he was transported to the hospital. Firefighters made repeated rescue efforts but were driven from the store by rapid fire progress and their efforts were slowed by the structural collapse. Due to fire conditions, the IC ordered an end to all interior operations. After the major body of fire was controlled with exterior streams, a rescue company breached a wall at the rear of the structure. The location of the hole was based on reports of the whereabouts of Lieutenant Kirk. He was removed from the building and transported to the hospital, where he was pronounced dead. Lieutenant Kirk received burns over 97-percent of his body, his carboxyhemoglobin level was 29-percent. The cause of death was listed as burns. Private Zachary suffered severe surface and inhalation burns. Private Zachary died as the result of his thermal inhalation injuries on June 16, 2003. The cause of the fire was determined to be arson. The store manager ignited the fire in an office to the rear of the structure. The fire was set to cover the theft of several thousand dollars from the store safe.

NIOSH recommendations: Fire departments should ensure that the first arriving company officer does not become involved in fire fighting efforts when assuming the role of Incident Command. Fire departments should ensure that the Incident Commander (IC) conducts an initial size-up and risk assessment of the incident scene before beginning interior fire fighting operations conduct pre-incident planning and inspections for mercantile and business occupancies. Fire departments should ensure that ventilation is closely coordinated with the fire attack. Fire departments should ensure that fire fighters immediately open ceilings and other concealed spaces whenever a fire is suspected of being in a truss system. Fire departments should 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 consider using a thermal imaging camera as a part of the size-up operation to aid in locating fires in concealed areas. Additionally, municipalities should consider requiring specific building construction information on an exterior placard

Click here for the NIOSH investigative report


Zachary, Charles A


Age: 39
Sex: Male
Rank: Private
Department: Memphis Fire Department, Memphis, Tenn.
Status: Career
Incident date: 06/15/03
Minutes to first responder arriving: 7
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 16
Any possible indication of anyone inside to save: Yes
Anyone in fact inside to save: No
Type of building: Commercial building
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 06/16/03
Property type: Store/Office

Summary by USFA: (See above)

NIOSH recommendations: (See above)

Click here for the NIOSH investigative report


McNamara, Martin H, V


Age: 31
Sex: Male
Rank: Firefighter
Department: Lancaster Fire Department, Lancaster, Mass.
Status: Volunteer
Incident date: 11/29/03
Minutes to first responder arriving: 6
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 2
Firefighters arriving within 10 minutes (suggested 15): 6
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Residence
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 11/29/03
Property type: Residential

Summary by USFA: Firefighter McNamara and members of his fire department responded to the scene of a structure fire involving a 2-1/2-story wood balloon frame residential building that contained multiple apartments. Two additional 1-1/2-story buildings were attached to the rear of the main building. Firefighters found a working fire. Firefighter McNamara was assigned as a part of a crew that advanced an attack line into the basement of the structure. After a series of explosions, the firefighters were forced to leave the building. Once outside, a headcount was completed and Firefighter McNamara was discovered missing. Firefighters immediately reentered the basement; they could hear the chirp of Firefighter McNamara's PASS device but could not reach him due to fire conditions. After the fire was controlled, a rescue team entered the structure and located the body of Firefighter McNamara. The cause of death was listed as smoke and soot inhalation. Firefighter McNamara also suffered facial burns prior to his death. Three other firefighters were injured in the fire; including a deputy chief who suffered severe smoke inhalation during an attempt to rescue Firefighter McNamara. The cause of the fire was identified as the overheating of a power strip and extension cord in the basement.

NIOSH recommendations: Fire departments should develop and implement standard operating procedures (SOPs) addressing emergency scene operations, including specific procedures for basement fires. Fire departments should ensure that ventilation is closely coordinated with the fire attack. Fire departments should ensure that a Rapid Intervention Team is in place before conditions become unsafe. Fire departments should develop and coordinate pre-incident planning protocols with mutual aid departments. Fire departments should implement joint training on response protocols with mutual aid departments. Municipalities should establish one central dispatch center to coordinate and communicate activities involving units from multiple jurisdictions. Municipalities should ensure that companies responding to mutual aid incidents are equipped with mobile and portable communications equipment that are capable of handling the volume of radio traffic and allow communications between all responding companies within their jurisdiction.

Click here for the NIOSH investigative report


Harvey, Derrick T


Age: 45
Sex: Male
Rank: Lieutenant
Department: Philadelphia Fire Department, Philadelphia, Pa.
Status: Career
Incident date: 01/09/04
Minutes to first responder arriving: 3
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 20
Firefighters arriving within 10 minutes (suggested 15): 20
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Residence
Cause of death: Caught or trapped
Nature of death: Burns
Activity: Advancing Hose Lines / Fire Attack
Death date: 01/15/04
Property type: Residential

Summary by USFA: Lieutenant Harvey was seriously injured and burned when he fell through the first floor of a residential structure and was left hanging from the joists over the basement where the fire originated. Other companies initiated rescue efforts and extricated Lt. Derrick from the row house. He was transported to Albert Einstein Medical Center via PFD Medic Unit then transferred to Temple University Hospital Burn Unit where he died from injuries received. The Philadelphia Fire Department Fire Marshall has determined the cause of the fire to be combustibles too close to a fixed heater.

NIOSH recommendations: Fire departments should require, and all officers should enforce the requirement, that all fire fighters wear their SCBAs whenever there is a chance they might be exposed to a toxic or oxygen-deficient atmosphere, including during the initial assessment. Fire departments should ensure fire fighters are trained to recognize the danger of operating above a fire. Fire departments should ensure that team continuity is maintained with two or more fire fighters per team.


Click here for the NIOSH investigative report

Fierro, Steve


Age: 40
Sex: Male
Rank: Firefighter
Department: Carthage Fire Department, Carthage, Mo.
Status: Career
Incident date: 02/18/04
Minutes to first responder arriving: 9
Firefighters arriving within 6 minutes (suggested 4 on an engine or ladder): 0
Firefighters arriving within 10 minutes (suggested 15): 0
Any possible indication of anyone inside to save: No
Anyone in fact inside to save: No
Type of building: Bronc Busters Bar
Cause of death: Caught or trapped
Nature of death: Asphyxiation
Activity: Advancing Hose Lines / Fire Attack
Death date: 02/18/04
Property type: Store/Office

Summary by NIOSH: On February 18, 2004, a 40-year-old male career fire fighter (the victim) was fatally injured in a commercial restaurant/lounge structure fire. The victim, providing mutual aid, had been searching for the seat of the fire with two volunteer fire fighters from another department, when one of these fire fighters lost the seal on his self contained breathing apparatus (SCBA) face piece. The fire fighter immediately abandoned the nozzle position and retreated out of the closest door. The backup fire fighter also retreated out of the building when his partner left. In the black smoke and zero visibility, the fire fighters were unaware that the victim was still inside the structure. Soon after, the Incident Commander (IC) ordered an emergency evacuation because of an imminent roof collapse, and an air horn signal was sounded. Personnel accounting indicated that a missing fire fighter (the victim) was still inside the building when the roof partially collapsed. After several search attempts, the victim was found in a face-down position with his mask and a thermal imaging camera cable entangled in a chair. His facemask was dislodged and not over his mouth. He was pronounced dead on scene.

NIOSH recommendations: Conduct pre-incident planning and inspections to facilitate development of a safe fire ground strategy. Review, revise where appropriate, implement, and enforce written standard operating guidelines (SOGs) that specifically address: incident command (IC) duties, emergency evacuation procedures, personnel accountability, rapid intervention teams (RIT) and mutual aid operations on the fireground. rain on the SOGs, the incident command system, and lost fire fighter procedures with mutual aid departments to establish interagency knowledge of equipment, procedures and capabilities. Ensure that the incident commander (IC) maintains the role of directing operations for the duration of the incident or until the command role is formally passed to another individual. Ensure that the IC conducts a risk-versus-gain analysis prior to committing fire fighters to the interior and continually assesses risk versus gain throughout the operations. Consider appointing a separate, but systematically integrated incident safety officer. Ensure that all fire fighters are equipped with radios capable of communicating with the incident commander. Ensure that Personnel Accountability Reports (PAR) are conducted in an efficient, organized manner and results are reported directly to the incident commander. Revise and enforce policies and guidelines regarding activation of personal alert safety systems (PASS) devices. Ensure that fire fighters train with thermal imaging cameras (TIC) and they are aware of their proper use and limitations. Ensure that fire fighters are aware of the hazards of exposure to carbon monoxide and other fire gases.

Click here for the NIOSH investigative report

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