Residential Structure Flashover and FF LODD- NIOSH Report

Photo Warren Skalski

On March 30, 2010, a 28-year-old male career fire fighter/paramedic (victim) died and a 21-year-old female part-time fire fighter/paramedic was injured when caught in an apparent flashover while operating a hoseline within a residence. Units arrived on scene to find heavy fire conditions at the rear of a house and moderate smoke conditions within the uninvolved areas of the house. A search and rescue crew had made entry into the house to search for a civilian who was entrapped at the rear of the house. The victim, the injured fire fighter/paramedic, and a third fire fighter made entry into the home with a charged 2 ½ inch hoseline. Thick, black rolling smoke banked down to knee level after the hoseline was advanced 12 feet into the kitchen area. While ventilation activities were occurring, the search and rescue crew observed fire rolling across the ceiling within the smoke. They immediately yelled to the hoseline crew to “get out.” The search and rescue crew were able to exit the structure safely, then returned to rescue the injured fire fighter/paramedic first and then the victim. The victim was found wrapped in the 2 ½ inch hoseline that had ruptured and without his facepiece on. He was quickly brought out of the structure, received medical care on scene, and was transported to a local hospital where he was pronounced dead.

Contributing Factors

  • Well involved fire with entrapped civilian upon arrival
  • Incomplete 360 degree situational size-up
  • Inadequate risk-versus-gain analysis
  • Ineffective fire control tactics
  • Failure to recognize, understand, and react to deteriorating conditions
  • Uncoordinated ventilation and its effect on fire behavior
  • Removal of self-contained breathing apparatus (SCBA) facepiece
  • Inadequate command, control, and accountability
  • Insufficient staffing.

Key Recommendations

  • Ensure that a complete 360 degree situational size-up is conducted on dwelling fires and others where it is physically possible and ensure that a risk-versus-gain analysis and a survivability profile for trapped occupants is conducted prior to committing to interior fire fighting operations
  • Ensure that interior fire suppression crews attack the fire effectively to include appropriate fire flow for the given fire load and structure, use of fire streams, appropriate hose and nozzle selection, and adequate personnel to operate the hoseline
  • Ensure that fire fighters maintain crew integrity when operating on the fireground, especially when performing interior fire suppression activities
  • Ensure that fire fighters and officers have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior
  • Ensure that incident commanders and fire fighters understand the influence of ventilation on fire behavior and effectively coordinate ventilation with suppression techniques to release smoke and heat
  • Ensure that fire fighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures.


Recommendation #1: Fire departments should ensure that a complete 360 degree situational size-up is conducted on dwelling fires and others where it is physically possible and ensure that a risk-versus-gain analysis and a survivability profile for trapped occupants is conducted prior to committing to interior fire fighting operations.

Discussion: Among the most important duties of the first officer on the scene is conducting an initial 360 degree situational size-up of the incident. A proper size-up begins from the moment the alarm is received, and it continues until the fire is under control. The size-up should include an evaluation of factors such as the fire size and location, length of time the fire has been burning, conditions on arrival, occupancy, fuel load and presence of combustible or hazardous materials, exposures, time of day, available staffing on scene or en route, and weather conditions. Information on the structure itself should include size, construction type, age, condition (e.g., evidence of deterioration, weathering), renovations, lightweight construction, loads on roof and walls (e.g., air conditioning units, ventilation ductwork, utility entrances), and available preplan information-all key information that can affect whether an offensive or defensive strategy is employed. The size-up should also include a risk-versus-gain assessment during incident operations, especially after primary searches have been conducted, situational awareness, and a survivability profile.

Even before the IC takes command of an incident he will be faced with having to determine what critical tasks are going to have to be performed to bring the incident under control. He will use current knowledge and previous experience to formulate a plan for his arriving apparatus and personnel. When the IC arrives he needs to ascertain as much information as possible to make a determination whether his plan will still work. The IC may be faced with several priorities such as an entrapped civilian, a larger scale incident then previously determined, and the fire environment itself. This is additionally part of the initial situational size-up and the risk assessment, which will constantly change as the incident progresses until it is brought under control. The IC should be willing to prioritize and change his strategy and plan based on these assessments. Situational awareness is a highly critical aspect of human decision making: the understanding of what is happening around you, projecting future situation events, comprehending information and its relevance, being realistic, and an individual’s perception. Conducting accurate risk assessments and receiving interior/exterior status updates is critical to the safety of fire fighters in the incident, rescue/recovery efforts, and overall control of the incident. “The decision to commit interior fire fighting personnel should be made on a case-by-case basis with proper risk-benefit decisions being made by the incident commander. The commitment of firefighters’ lives for saving property and an unknown or marginal risk of civilian life must be balanced appropriately.”

Another tool that the IC should consider using is survivability profiling. Survivability profiling uses the knowledge learned of fire behavior and spread, smoke (i.e., color, condition, movement), and building construction to examine a situation and make an intelligent decision of whether to commit fire fighters to life saving and/or interior operations. In other words, survivability profiling involves assessing the probability that a trapped occupant is still alive and can safely be rescued with the current or impending conditions. The NIOSH publication Preventing Deaths and Injuries of Fire Fighters Using Risk Management Principles at Structure Fires states that the IC must make a determination that offensive (interior) operations may be conducted without exceeding a reasonable degree of risk to fire fighters before ordering an offensive attack and must be prepared to discontinue the offensive attack if the risk evaluation changes during the fire fighting operation. The fireground is very dynamic, and conditions can either improve or deteriorate based on fire suppression activities, and available resources. Most importantly, assessments/size-ups of the incident are necessary to detect a change on the fireground.

During this incident, the responding departments were made aware while en route that there was a paralyzed civilian entrapped in the structure. His wife advised 911 and arriving units that the chair he was sitting in caught fire with him still in it. Units arrived on scene 6 minutes after the 911 call to find heavy fire conditions to the addition on the C-side of the house where the entrapped civilian was last seen by his wife sitting in the chair. Prior to a complete 360 degree situational size-up, decisions were made to send a hoseline crew through the A-side front door to assist with search and rescue, and to locate and attack the fire (located on the C-side in the addition and garage). Fire fighters entering the house from the A-side were initially met with moderate smoke conditions banked down to waist level, which quickly changed to thick, black smoke conditions that went to the floor due to the fire being uncontrolled and spreading into the house from the C-side. The victim and injured fire fighter/paramedic were eventually exposed to a flashover. The civilian was not rescued. A full range of factors must be considered in making the risk evaluation including a realistic evaluation of the ability to execute a successful offensive fire attack with the resources that are available and a realistic evaluation of occupant survivability and rescue potential.

Fire departments should be aware of the recently released 2010 International Association of Fire Chiefs’ (IAFC) Rules of Engagement (ROE) of Structural Firefighting. These guidelines recommend that ICs conduct or obtain a 360 degree situational incident size-up, determine the occupant survival profile, and conduct an initial risk assessment.

Recommendation #2: Fire departments should ensure that interior fire suppression crews attack the fire effectively to include appropriate fire flow for the given fire load and structure, use of fire streams, appropriate hose and nozzle selection, and adequate personnel to operate the hoseline.

Discussion: An assessment and decision of suppression methods must be made before attacking a fire in hopes of extinguishing it and keeping fire fighters safe while doing so. To accomplish such tasks, ICs, officers, and fire fighters need to consider such factors as fire load and flow, hose and nozzle selection, placement and use of fire streams, and required staffing. Fire load, or heat released from combustible materials, will directly affect how the fire develops throughout the incident and how long and severely it may burn. The more combustible materials involved, the greater the heat that will be produced requiring additional fire flow. Fire flow is the calculated amount of water in gallons per minute needed to extinguish a fire in a specific structure. To assist fire fighters in calculating the fire flow, one of three formulas could be used: the Iowa Rate-of-Flow Formula, the National Fire Academy (NFA) Formula, and the Insurance Services Office Formula. The Iowa Rate-of-Flow and NFA Formulas were designed to be used on the fireground because they allow fire fighters to mentally compute the fire flow with relative ease by estimating such things as the square footage (area) of a structure or the cubic footage (volume) of a room, and percentage involved, then inputting that data into a predetermined formula.

Iowa Rate-of-Flow Formula: rate of fire flow=volume of room in cubic feet÷100

NFA Formula: fire flow in gallons per minute for one floor at 100% involvement=(length ×width)÷3. If less than 100% involvement,then multiply answer by estimated percentage of involvement.

The fire stream, or water stream, is an important aspect both for fire fighter safety and tactical considerations. The wrong choice of fire stream can place a fire fighter and crew in a bad situation. Also, the wrong type of fire stream will affect the tactical outcome of the incident in regards to how quickly the fire is controlled. To produce an effective fire flow, there must be a viable water supply; sufficient water pressure; a means to transport the stream to the desired point (fire); and trained, competent personnel to deploy these three elements. These elements are applied through the use of a fire hose and nozzle. The diameter of the fire hose can affect how much water is flowed on a fire, but the larger the diameter, the more potential to max out the delivering pump’s capacity, and additional personnel will be needed to handle the hoseline. The nozzle will allow the water to leave its mechanical hold within the hoseline to produce the desired fire stream. Typical fire streams include solid, fog, and broken, and each have their own characteristics, advantages/disadvantages, and application. Proper training on all these aspects will greatly influence fire fighter’s knowledge on the fireground, provide for quicker control and extinguishment of the fire, and increase overall fire fighter safety.

During this incident, arriving fire departments were faced with a large volume of fire and an entrapped civilian. Prior to the flashover, the fire was burning uncontrolled at the rear of the house (house addition and garage) and spreading into the house. FF1, the victim, and injured fire fighter/paramedic were tasked with advancing a charged 2½-inch hoseline into the house to assist with the search and for fire suppression. They were able to advance this hoseline approximately 12 feet into the house, but advancing and operating a large-diameter hoseline within tight quarters may be extremely cumbersome even if adequate staffing is available to accomplish this task. Note: When FF1 had a problem with his PPE, he handed the nozzle over to the victim, and eventually backed out of the structure, that left only two personnel available to operate the hoseline. Fire fighters and officers need to understand that while a 2½-inch hoseline provides a greater flow, fire fighters need to be able to move the line quickly and efficiently interiorly, especially when performing a search and experiencing deteriorating fire conditions. An alternate decision to advancing the 2½-inch hoseline into the small house could have been to deploy and advance a 1¾-inch hoseline(s), which would have been easier to maneuver within the house.

Due to the large volume of fire at the C-side that was extending into the house, the 2½-inch hoseline(s) could have been deployed exteriorly to the B- and/or D-sides to combat the fire, paying close attention to directly attack the fire, an elevated master stream (carefully directed on fire burning uncontrolled within the addition and garage) could have been deployed early into the fire had the assessment been made that the entrapped civilian (last reported to be in the addition) could not be saved, thus possibly stopping further progression of fire and volatile smoke into the house. Additionally, a lightweight portable master stream, placed exteriorly at the B- and/or D-sides, which is fairly easy to deploy by using a 2½- to 3-inch supply line, may only require one fire fighter to operate once in position. These types of water delivery appliances are capable of delivering a large volume of water that will assist in extinguishing the fire from an exterior position, especially when conditions are deteriorating interiorly, which could place fire fighter’s safety at risk.

An incident commander needs to constantly assess whether his strategies and tactics to control and extinguish the fire are working, paying close attention to fire and smoke conditions/changes, the affects from ventilation performed by fire fighters and occurring naturally as the fire progresses, and to fire fighter safety.

Recommendation #3: Fire departments should ensure that fire fighters maintain crew integrity when operating on the fireground, especially when performing interior fire suppression activities.

Discussion: Fire fighters should always work and remain in teams whenever they are operating in a hazardous environment. Team integrity depends on team members knowing who is on their team and who is the team leader; staying within visual contact at all times (if visibility is low, teams must stay within touch or voice distance of each other); communicating needs and observations to the team leader; and rotating together for team rehab, team staging, and watching out for each other (e.g., practicing a strong buddy system). Following these basic rules helps prevent serious injury or even death by providing personnel with the added safety net of fellow team members. Teams that enter a hazardous environment together should leave together to ensure that team continuity is maintained.The 2010 IAFC ROE of Structural Firefighting states, “Go in together, stay together, come out together.”

Recommendation #4: Fire departments should ensure that fire fighters and officers have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior.

Discussion: Reading fire behavior indicators and recognizing fire conditions serve as the basis for predicting likely and potential fire behavior. Reading the fire requires recognition of patterns of key fire behavior indicators. It is essential to consider these indicators together and not to focus on the most obvious indicators or one specific indicator (e.g., smoke). Identifying building factors, smoke, wind direction, air movement, heat and flame indicators are all critical to reading the fire. Focusing on reading “smoke” may result in fire fighters missing other critical indicators of potential fire behavior. One important concept that must be emphasized is that smoke is fuel and must be viewed as potential energy. Smoke that is thick, black and pressurized can emit from a structure at a high rate. This is indicative of a potentially under-ventilated structure or a ventilation controlled fire. This smoke is fuel-rich and is termed “black fire.” It can potentially do as much damage as fire itself, but it is an indicator that some type of extreme fire behavior may occur.

Since the IC should be staged at a designated command post (outside), the interior conditions should be communicated by interior company officers (or the member supervising the crew) as soon as possible to their supervisor (e.g., IC, division supervisor). Knowledge of interior conditions could change the IC’s strategy or tactics. Interior crews can aid the IC in this process by providing reports of the interior conditions as soon as they enter the fire building and by providing regular updates. In addition to the importance of communicating reports on fire conditions, it is essential that fire fighters recognize what type of information is important. Command effectiveness can be impaired by excessive and extraneous information as well as from a lack of information. In the case of communicating observations related to fire behavior, this requires development of fire fighters’ skill in recognition of key fire behavior indicators and reading the fire.

During this incident, FF1 made a decision to quickly open and close the smooth bore nozzle (water applied as a solid stream) while aiming at the ceiling. It is believed this was done in an attempt to cool the thermal (hot gas) layer, a common practice, in hopes of preventing a potential flashover. Ceiling temperatures can be reduced through carefully considered fire control actions, such as applying short bursts of water spray into the hot gas layer, or directly applying water onto the fire itself which will limit the release of unburned products of combustion as well as reduce ceiling temperature.

Also, the search and rescue crew (operating without the protection of a hoseline) were able to make a quick determination that the conditions within the house were imminent to flashover. They made an attempt to alert the victim and injured fire fighter/paramedic, but were too late. If conditions are right for a flashover, there are only seconds to make a decision. Fire fighters will be met with a sudden increase in heat and rollover within the ceiling level. The injured fire fighter/paramedic was unaware that the conditions she was operating in deteriorated quickly. She remembers thick, black smoke pushing down to the floor while in the structure and then “the room and everything in it caught fire.” Prior to the flashover, windows on the B-side were vented and thick, black and heavily pressurized smoke billowed from these windows. The IC, and individuals working on the exterior, need to recognize this as a potential for extreme fire behavior and evacuate interior crews. Obtaining proper training and hands-on experience through the use of a flashover simulator may assist interior fire fighters in making sound decisions on when to evacuate a structure fire.

Recommendation #5: Fire departments should ensure that incident commanders and fire fighters understand the influence of ventilation on fire behavior and effectively coordinate ventilation with suppression techniques to release smoke and heat.

Discussion: Ventilation is the systematic removal of heated air, smoke, and fire gases from a burning building and replacing them with cooler air.1 The two types of ventilation are vertical and horizontal. During vertical ventilation the natural convection of the heated gases creates upward currents that draw the fire and heat in the direction of the vertical opening. Horizontal ventilation allows for heat, smoke, and gases to escape by means of a doorway or window but is highly influenced by the location and extent of the fire, and special caution should be taken if the fire is in the attic.

Properly coordinated ventilation can decrease the rate the fire spreads, increase visibility, and lower the potential for flashover or backdraft. Proper ventilation reduces the threat of flashover by removing heat before combustibles in a room or enclosed area reach their ignition temperatures. Proper ventilation can reduce the risk of a backdraft by reducing the potential for superheated fire gases and smoke to accumulate in an enclosed area. Properly ventilating a structure fire will reduce the tendency for rising heat, smoke, and fire gases, trapped by the roof or ceiling, to accumulate, bank down, and spread laterally to other areas within the structure. The ventilation opening may produce a chimney effect, causing air movement from within a structure toward the opening. These air movements help facilitate the venting of smoke, hot gases, and products of combustion but may also cause the fire to grow in intensity and may endanger fire fighters who are between the fire and the ventilation opening. For this reason, ventilation should be closely coordinated with hoseline placement and offensive fire suppression tactics. Close coordination means the hoseline is in place and ready to operate, so that when ventilation occurs, the hoseline can overcome the increase in combustion, which is likely to occur. If a ventilation opening is made directly above a fire, fire spread may be reduced, allowing fire fighters the opportunity to extinguish the fire. If the opening is made elsewhere, the chimney effect may actually contribute to the spread of the fire.1

ICs and fire fighters need to consider the following and how it will affect ventilation and overall control of the fire:

  • Who will ventilate (knowledge and skills)?
  • What type of ventilation?
  • When to ventilate?
  • Where to ventilate?
  • Why ventilate?
  • How to properly and safely ventilate?
  • What are the expected results from ventilation?

Fire development in a compartment may be described in several stages, although the boundaries between these stages may not be clearly defined.1 The incipient stage starts with ignition, followed by growth, fully developed, and decay stages. The available fuel largely controls the growth of the fire during the early stages. This is known as a fuel-controlled fire, and ventilation during this time may initially slow the spread of the fire as smoke, hot gases, and products of incomplete combustion are removed. As noted above, increased ventilation can also cause the fire to grow in intensity as additional oxygen is introduced. Effective application of water during this time can suppress the fire but if the fire is not quickly knocked down, it may continue to grow.

If the fire grows until the compartment approaches a fully developed state, the fire is likely to become ventilation controlled. Further fire growth is limited by the available air supply as the fire consumes the oxygen in the compartment. Ventilating the compartment at this point will allow a fresh air supply (with oxygen to support combustion), which may accelerate the fire growth, resulting in an increased heat release rate. If coordinated fire suppression activities do not quickly decrease the heat release rate, a ventilation induced flashover can occur.1 Considering that most fires beyond the incipient stage are or will quickly become ventilation controlled, changes in ventilation are likely to be some of the most significant factors in changing fire behavior.

During this incident, uncoordinated ventilation occurred while the hoseline and search and rescue crews were inside the house. The victim and other fire fighters, within the small house, were between the fire and the ventilation source. One fire fighter accounts heavy, turbulent, black smoke pushing from a window on the B-side after it was broken. Shortly after, the house sustained an apparent ventilation-induced flashover.

Recommendation #6: Fire departments should ensure that fire fighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures.

Discussion: Fire fighters are tasked at times to operate within environments which pose inhalation hazards (e.g., toxic smoke and oxygen deficiency),defined by the Occupational Safety and Health Administration (OSHA) as immediately dangerous to life and health (IDLH). Proper training along with an implemented and enforced policy or procedure will assist fire fighters with proper maintenance, use, and removal of a SCBA. OSHA 29 CFR 1910.134 (g)(4)(iii) states, “The employer shall ensure that all employees engaged in interior structural firefighting use SCBAs.”

According to the autopsy report, the victim died from carbon monoxide intoxication due to inhalation of smoke and soot. The medical examiner also indicated that the victim’s COHb level (a measure of carbon monoxide in the bloodstream) was 30%. Even if nothing but carbon dioxide, water vapor, and nitrogen were present in the fire products and these were to mix with the air being breathed by a fire fighter, then the oxygen percentage would be reduced below the normal 21%. At 15% oxygen, fire fighters can experience lethargy, poor coordination, and confused thinking. The two principal toxins in smoke—carbon monoxide and hydrogen cyanide—act to deprive the brain of oxygen, and their effects would be enhanced due to the lower levels of oxygen in the air. The victim was discovered with his facepiece off, but still connected to his regulator. Due to the smoke conditions, the victim would have had to have been on air when entering the structure. It has not been determined why the victim was found without his facepiece on.

Emergencies created by, or associated with, SCBA can be overcome in several ways. Fire departments can develop and implement a comprehensive respiratory protection program that includes fire fighter fitness, training, and competency and skill assessments in SCBA and emergency procedures. Firefighters should remember the first rule in any emergency situation-to not panic. Panic causes an increased breathing rate and consequently, an increase in air consumption; and an inability to focus on emergency procedures. If fire fighters become lost, trapped, or disoriented, they need to focus on managing remaining air in their SCBA cylinder until other fire fighters can make a rescue attempt. Removing one’s facepiece in an IDLH atmosphere can immediately expose the respiratory system to a potentially fatal environment, thus incapacitating an individual. Choosing to leave one’s SCBA facepiece on may be the best chance in providing additional time for a fire fighter to be rescued. Fire fighters should follow their department’s SOPs regarding emergency SCBA procedures and emergency communications.

Recommendation #7: Fire departments should ensure that adequate staffing is available to respond to emergency incidents.

Discussion: NFPA 1710 Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments contains recommended guidelines for minimum staffing of career fire departments. NFPA 1710 states the following: “On-duty fire suppression personnel shall be comprised of the numbers necessary for fire-fighting performance relative to the expected fire-fighting conditions. These numbers shall be determined through task analyses that take the following factors into consideration:

  1. Life hazard to the populace protected.
  2. Provisions of safe and effective fire-fighting performance conditions for the fire fighters.
  3. Potential property loss.
  4. Nature, configuration, hazards, and internal protection of the properties involved.
  5. Types of fireground tactics and evolutions employed as standard procedure, type of apparatus used, and results expected to be obtained at the fire scene.

The NFPA standard states that both engine and truck companies shall be staffed with a minimum of four on-duty personnel. The standard also states that companies shall be staffed with a minimum of five or six on-duty members in jurisdictions with tactical hazards, high-hazard occupancies, high-incident frequencies, geographical restrictions, or other pertinent factors identified by the authority having jurisdiction.

During this incident, the victim’s department responded with three personnel on the engine and two personnel on the ambulance, but the Still assignment also consisted of an engine, two ladder trucks, and a squad, with four fire personnel on each. It was routine to have an ambulance respond with an engine on a first due fire assignment. Due to short staffing, the ambulance personnel were tasked with fire suppression activities, thus taking them out-of-service as a medical unit. Also, due to short staffing, the lieutenant/acting officer (IC) was required to ride and operate as the officer of E534. This removed him from his command response vehicle which would have allowed him to command at a tactical level versus having to potentially perform tasks.

Recommendation #8: Fire departments should ensure that staff for emergency medical services is available at all times during fireground operations.

Discussion: Although there is no evidence that this recommendation would have prevented this fatality, it is being provided as a reminder of a good safety practice. Emergency medical care and transportation for injured or ill fire fighters should be immediately available on the scene of working structure fires. Many fire departments incorporate an automatic dispatch of an EMS unit to working structure fires. Automatic dispatch can help to ensure that qualified emergency medical care and transportation for injured or ill fire fighters is available without having to call and wait for a unit after a medical emergency or injury has occurred.

During this incident, the victim and the injured fire fighter/paramedic responded in an ambulance. Upon their arrival to the scene, the IC immediately tasked them with interior operations due to staffing issues. The IC did not request an additional ambulance to respond to the scene for medical care until after the victim was down within the house. Additional resources (e.g., apparatus and personnel) arrived minutes after the ambulance’s arrival.

Recommendation #9: Fire departments and dispatch centers should ensure they are capable of communicating with each other without having to monitor multiple channels/frequencies on more than one radio.

Discussion: Although there is no evidence that this recommendation would have prevented this fatality, it is being provided as a reminder of a good safety practice. It is important that fire service personnel have an efficient means of communicating during an emergency incident. The use of radio communications provides fire fighters on scene with the ability to communicate to individuals they cannot see or to receive vital information about the incident. To assist with this, localities should ensure that communications can occur without having to utilize different radios and/or monitor multiple channels/frequencies.

During this incident, the IC had to monitor more than one radio and even had to go to the cab of his engine to accomplish this task. Having to monitor multiple radios and potentially take your eyes off the scene for a moment could be extremely detrimental to the management of the incident.

Recommendation #10: Fire departments should ensure that the incident commander, or designee, maintains close accountability for all personnel operating on the fireground.

Discussion: Although there is no evidence that this recommendation would have prevented this fatality, it is being provided as a reminder of a good safety practice. The use of an accountability system is recommended by NFPA 1500 Standard on Fire Department Occupational Safety and Health Program and NFPA 1561 Standard on Emergency Services Incident Management System.21 A functional personnel accountability system requires the following:

  • Development of a departmental SOP
  • Training all personnel
  • Strict enforcement during emergency incidents

As the incident escalates, additional staffing and resources may be needed, adding to the burden of tracking personnel. At this point, an accountability system should be in place which includes an incident command board that is established and maintained by an assigned accountability officer or aide. A properly maintained incident command board allows the IC to readily identify the location and time of all fire fighters on the fireground. As a fire escalates and additional fire companies respond, a chief’s aide or accountability officer assists the IC with accounting for all fire fighting companies at the fire, at the staging area, and at the rehabilitation area. The personnel accountability report (PAR) is an organized on-scene roll call in which each supervisor reports the status of his crew when requested by the IC or emergency dispatcher.1 A properly initiated and enforced accountability system on every response, which is consistently integrated into fireground command and control, enhances fire fighter safety and survival by helping to ensure a more timely and successful identification and rescue of a disoriented or downed fire fighter.

During this incident, the accountability system was never set in place and a PAR was not conducted following the Mayday.

Recommendation #11: Fire departments should ensure that fire fighters wear a full array of turnout clothing and personal protective equipment appropriate for the assigned task while participating in fire suppression.

Discussion: Although there is no evidence that this recommendation would have prevented this fatality, it is being provided as a reminder of a good safety practice. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program states, “The fire department shall provide each member with protective clothing and protective equipment that is designed to provide protection from the hazards to which the member is likely to be exposed and is suitable for the tasks that the member is expected to perform…protective clothing and protective equipment shall be used whenever a member is exposed or potentially exposed to the hazards for which the protective clothing (and equipment) is provided.” NFPA 1971 Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting has established minimum requirements for structural fire fighting protective ensembles and ensemble elements designed to provide fire fighting personnel limited protection from thermal, physical, environmental, and bloodborne pathogen hazards encountered during structural fire fighting operations. These requirements will assist in protecting firefighters, but only if they wear the PPE as recommended by the manufacturer.

During this incident, the victim was discovered without a hood over his head or rolled down on his neck. NIOSH investigators could not determine whether this equipment was properly donned prior to the incident.

Recommendation #12: Fire departments should ensure that a separate incident safety officer, independent from the incident commander, is appointed at each structure fire.

Discussion: Although there is no evidence that this recommendation would have prevented this fatality, it is being provided as a reminder of a good safety practice. According to NFPA 1561 Standard on Emergency Services Incident Management System,“The incident commander shall have overall authority for management of the incident and the incident commander shall ensure that adequate safety measures are in place.” This shall include overall responsibility for the safety and health of all personnel and for other persons operating within the incident management system. While the incident commander is in overall command at the scene, certain functions must be delegated to ensure adequate scene management is accomplished.According to NFPA 1500 Standard on Fire Department Occupational Safety and Health Program,“as incidents escalate in size and complexity, the incident commander shall divide the incident into tactical-level management units and assign an incident safety officer (ISO) to assess the incident scene for hazards or potential hazards.” These standards indicate that the incident commander is in overall command at the scene but acknowledge that oversight of all operations is difficult. On-scene fire fighter health and safety is best preserved by delegating the function of safety and health oversight to the ISO. Additionally, the incident commander relies upon fire fighters and the ISO to relay feedback on fireground conditions in order to make timely, informed decisions regarding risk versus gain and offensive-versus-defensive operations. The safety of all personnel on the fireground is directly impacted by clear, concise, and timely communications among mutual aid fire departments, sector command, the ISO, and the incident commander. NFPA 1521 Standard for Fire Department Safety Officer defines the role of the ISO at an incident scene and identifies duties such as recon of the fireground and reporting pertinent information back to the incident commander; ensuring the department’s accountability system is in place and operational; monitoring radio transmissions and identifying barriers to effective communications; and ensuring established safety zones, collapse zones, hot zones, and other designated hazard areas are communicated to all members on scene. Larger fire departments may assign one or more full-time staff officers as safety officers who respond to working fires. In smaller departments, every officer should be prepared to function as the ISO when assigned by the incident commander. The presence of a safety officer does not diminish the responsibility of individual fire fighters and fire officers for their own safety and the safety of others. The ISO adds a higher level of attention and expertise to help the fire fighters and fire officers. The ISO must have particular expertise in analyzing safety hazards and must know the particular uses and limitations of protective equipment.3

Recommendation #13: Fire departments should ensure that all fire fighters are equipped with a means to communicate with fireground personnel before entering a structure fire.

Discussion: Although there is no evidence that this recommendation would have prevented this fatality, it is being provided as a reminder of a good safety practice. NFPA 1561 Standard on Emergency Services Incident Management System states, “To enable responders to be notified of an emergency condition or situation when they are assigned to an area designated as immediately dangerous to life or health (IDLH), at least one responder on each crew or company shall be equipped with a portable radio and each responder on the crew or company shall be equipped with either a portable radio or another means of electronic communication. Radio communications on the fireground are imperative for the IC to command and control the incident and for fire fighters to work effectively and safely within a structure fire. Fire fighters within a structure are unable to see all areas affected by fire and whether the structure is maintaining its stability. Having radio communications can enhance fire fighter safety and health by providing fire fighters a means to communicate with other crew members or with the IC when they find themselves in need of assistance.

During this incident, the victim did have a radio, but it was positioned in the back pocket of his station pants. Thus, when he donned his bunker pants, his radio became inaccessible during the incident.

Recommendation #14: The National Fire Protection Association (NFPA) should consider developing more comprehensive training requirements for fire behavior to be required in NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA 1021 Standard for Fire Officer Professional Qualifications.

Discussion: Structural fires frequently display indicators and warning signs of rapid fire development such as flashover, backdraft, and fire gas ignition for which many fire fighters and officers may not have been sufficiently trained to recognize or understand. It is imperative that fire fighters and officers develop the understanding and skills necessary to identify and interpret the indicators so that they can anticipate the potential for extreme fire behavior and immediately communicate their findings to the IC.  This requires comprehensive training in fire behavior (theory) and practical application inclusive of realistic live fire training.

NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA 1021 Standard for Fire Officer Professional Qualifications were developed to ensure that fire fighters and officers have the skills necessary to perform their job, also known as job performance requirements (JPRs). Currently, these JPRs include language that individuals have requisite knowledge on such topics as heat transfer, principles of thermal layering, advantages and disadvantages of different types of ventilation, and fire behavior in a structure. These standards do not include guidance on how many hours or what available scientific information will be used to verify that an individual has a sound understanding of the physical, chemical, and thermal behavior of fire and how to make a connection between fire dynamics/behavior and the influence of tactical operations (e.g., fire flow, types of ventilation) and external factors (e.g., wind). These JPRs are taken by curriculum developers and formatted into educational content. Standard setting agencies, states, curriculum developers, and other authorities having jurisdiction should consider developing a nationwide curriculum so that fire fighters and officers receive fundamental and refresher training on how to: recognize and interpret fire behavior and indications of impending extreme fire behavior (e.g., flashover, back draft, smoke explosion); and, anticipate what could or should happen when a tactical operation is performed (e.g., ventilation, fire flow). Standard setting agencies and curriculum developers should also consider providing guidelines (e.g., required topics and hours) for instructors to deliver such information and recommendations for verifying an individual’s learning and retention.

According to documented training reviewed by NIOSH investigators, the victim, injured fire fighter/paramedic, and IC had a combined 24 hours of fire behavior training out of 5,654 total combined training hours. Additional fire behavior training to include such areas as theory, chemistry, physics, smoke reading, current research, and the cause and effects of tactics during fire suppression operations may improve fire fighter safety.


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