Revised January 15, 2008.
Career Officer Injured During a Live Fire Evolution at a Training Academy Dies Two Days Later - Pennsylvania
Death in the Line of Duty...A summary of a NIOSH fire fighter fatality investigation
F2005-31 Date Released: August 27, 2007
On October 23, 2005, a 47-year-old male career Captain (the victim) was severely burned during a live fire training evolution in the burn building at the State Fire Academy. The victim was an adjunct instructor at the Academy in addition to being a career fire officer. The Academy was teaching an Suppression Instructor Development (train the trainer) course when the incident occurred. The victim was in the basement of the burn building adding pallets to the fire prior to the last evolution of a 5-day training course. Three students in the course found the victim on the floor in the burn room as they were advancing a hose line during their evolution. The students immediately carried the victim outside where emergency medical care was administered. The victim was transported via ambulance to a community hospital were he was stabilized prior to transport via helicopter to a regional trauma/burn center. The victim died from his injuries on October 25, 2005.The NIOSH investigator concluded that, to minimize the risk of similar occurrences, fire departments and training academies should:
- ensure that two training officers are present with a charged hoseline during the ignition or refueling of a training fire in accordance with NFPA 1403.
- determine the minimum amount of flame, heat and/or smoke required during live fire evolutions to perform the training while ensuring fire fighter safety.
- use the minimum fuel load necessary to conduct live fire training.
- have a written respiratory protection program and ensure that self-contained breathing apparatus (SCBAs) facepieces are properly inspected, used, and maintained.
- have burn rooms with at least two exits.
- avoid having basement burn rooms
- installing instrumentation within live fire training structures to record information such as heat, the effects of suppression and the byproducts of combustion.
- installing a ventilation system within the burn structure.
- having a qualified engineer evaluate fuel loads, heat retention, and the instrumentation and ventilation systems of live fire training facilities.
On October 23, 2005, a 47-year-old male career Captain (the victim) was severely burned during a live fire evolution at the State Fire Academy. On October 23, 2005, the State Fire Commissioner notified the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program of the injured instructor and requested an investigation. The victim later died from his injuries on October 25, 2005. On October 25-27, 2005, an occupational safety and health specialist from NIOSH began an investigation into the incident. The NIOSH investigator met with the State Fire Commissioner, the Administrator of the Training Academy, and Resident and Adjunct Academy instructors. The NIOSH investigator examined photographs and video of the burn building, and reviewed witness statements, training records and course documents. The incident site was evaluated and photographed by the NIOSH investigator. The victim's SCBA and bunker gear were examined and shipped to the NIOSH National Personnel Protective Technology Laboratory in Pittsburgh, PA for further analysis (see full report). On November 18, 2005, the NIOSH investigator met with officials of the Academy and conducted interviews with the adjunct instructors present during the incident.
The State Fire Academy was established in 1955 and is the primary resource for fire fighting and emergency response training within the State. There are seven buildings situated on an 11 acre campus. The Academy has 13 full time employees including a facility administrator, 2 resident instructors, 3 field education supervisors, a curriculum specialist, a certification program manager, and 5 support personnel. The Academy has over 80 adjunct instructors that also teach at the facility. The Academy teaches about 40 classes each year with outside 'hands-on' training from April to November. In addition to training programs conducted on site, the State Fire Academy is also responsible for delivering special curriculum locally to emergency service organizations. The three field education supervisors manage a statewide local level training program. Each year, this program delivers over 3,000 programs across the State; and, the majority of the programs are conducted at local fire departments. The Academy also administers the State Fire Service Certification program which has certified over 6,000 emergency responders.
The Academy was teaching an Suppression Instructor Development course when the incident occurred. This 40-hour class is designed to develop and evaluate the instruction skills of the students called "Instructor Candidates". The course graduates will become State-certified as fire suppression instructors. The course has 16 evolutions and the fatal event occurred during the last evolution of the 5-day course. The course had 1 resident instructor, 9 adjunct instructors, 1 field supervisor, 1 curriculum specialist and 16 students. The student makeup included a mix of career and volunteer fire fighters from throughout the State.
The 2½ story residential non-gas-fired burn building used in structural fire fighting training at the Academy was built in 1993 (see Photo 1) and completely renovated in 2000-2001. The building foundation is approximately 36 x 26 feet and approximately 30 feet to the roof line. The burn building has 4 training levels: the basement, the first floor, the second floor, and the attic. The building has one internal stairwell with an additional stairwell from the basement to the exterior. The D-side of the structure includes a simulated attached garage that is also used as a storage area. The building has a slightly pitched flat concrete roof. The building is constructed of concrete cinder block with high temperature lining (HTL) fire brick in the basement burn room. The doors are steel and the window openings include steel shutters that can be opened or closed to vary interior conditions during live burns. Burn rooms are located in the basement and on the second floor. The incident occurred in the basement burn room (see Diagram). The basement can be accessed from an interior stairway and another stairway that leads to the exterior. The basement burn room has only one means of entry or exit. Fires are only set with wooden pallets and excelsior (a wooden packing material similar to straw).
Training and Experience
The victim had over 30 years of fire fighting experience beginning in 1974 as a junior fire fighter with a volunteer department. The victim had been a career fire fighter for nine years and held the rank of Captain. He had extensive training and was State certified as Fire Fighter I and II, Fire Officer I and II, Fire Service Instructor I and II, HAZMAT Technician, and Rescue Technician - vehicle and machinery. The victim was also an Emergency Medical Technician (EMT). The victim had been an adjunct instructor at the Fire Academy since 1998.
At the time of the incident, the victim was wearing the full array of personal protective clothing and equipment, consisting of bunker gear (coat and pants), helmet, Nomex® hood, gloves, boots, and a self-contained breathing apparatus (SCBA) with an integrated personal alert safety system (PASS). The victim was also equipped with a portable radio. The SCBA and radio were provided by the training academy.
Diagram of Basement in Burn Building
At approximately 0805 hours on October 23, 2005, the instructors (including the victim) had a staff meeting to discuss the 6 evolutions that would take place in the residential burn building (see Photo 1). The evolutions involved not only extinguishing the fire but also a series of pre-scripted simulated emergencies. The students were unaware of which simulated event would occur during which evolution. The purpose of these simulated events was to evaluate the students' ability to respond and effectively manage emergency situations. The fatal event occurred during the last evolution and the scenario was to simulate that the fire in the basement burn room had not been knocked down enough from the previous evolution. (Note: The students' ability to evaluate the fire conditions within the building was an important part of the course since they would be training live fire suppression techniques to new fire fighters). The lead instructor had two teams of 4 adjunct instructors in addition to 2 academy staff. The adjunct instructor teams worked every other evolution; they participated in an evolution then wrote student evaluations during the next.
Prior to the instructor staff meeting, the students were given assignments to prepare for the upcoming evolutions. The evolutions began at approximately 0845 hours. The first 5 class evolutions of the day (11-15) were completed from about 0900 hours until 1200 hours without incident. The incident command structure during the training consisted of the students serving as the Incident Commander (IC), Incident Safety Officer and Rapid Intervention Team (RIT) members, all monitored by the course instructors. The victim completed evolution 12 evaluating students in the basement, on evolution 14 he was outside evaluating the student IC, and on evolution 16 (when the fatal event occurred) he served as the basement instructor and as "the arsonist" or ignition officer for the basement burn room.
The final evolution of the course began at approximately 1238-1240 hours. The victim went to the basement and another instructor went to the 2nd floor. They were "arsonists" who would tend the burn rooms by placing more pallets on the fire and then evaluate the students as they began suppression. (Note: The students are prohibited from entering the basement burn room and the instructor "arsonists" only remain in the burn room long enough to add additional fuel to the fires).
A third instructor (the curriculum specialist) went into the burn building in preparation to monitor the basement attack crew. Instructor #3 went in the front entrance and awaited the crew's entry. There was still good visibility with some smoke. The instructor had waited about 2 minutes, then heard the basement door open. The instructor saw another fire instructor come over and lay flat on the floor, while pulling and lifting on his bunker gear. (Note: The fire instructor was the victim, but instructor #3 could not immediately identify him). The instructor asked the victim twice, "Are you OK?" The victim responded that "It's hot as hell down there!" The instructor asked if the victim wanted to go outside and again asked if he was OK. The victim responded "No, I'm OK." As the victim was beginning to sit up, the instructor said "I really think you need to go outside." The victim responded "No, I'm all right", got up and said "Yeah, I'm fine I will see you down there." The victim went back down the basement steps. (Note: It is estimated that 1½ minutes elapsed from the time the victim came up the stairwell until he went back down to the basement).
At approximately 1245 hours, the victim was in the basement of the structure putting additional pallets on the fire. A few minutes later, three students in the course were advancing a hose line to the basement during their evolution. They encountered low visibility and moderate heat at the base of the basement stairwell. As they approached the burn room they heard a person moaning. They found the victim struggling on the floor in the right corner of the burn room. (Note: According to interviews and witness statements, fire fighters did not report hearing the victim's PASS device. The PASS device may not have activated because the victim was still moving. Immediately after the incident, the PASS device began sounding but could not be deactivated due to heat damage. The PASS device was still sounding weakly two days later during the NIOSH investigation ).
They were surprised to find the victim in this location. (Note: Initially there was confusion about whether this was a training scenario or a real event. Some students thought that the final scenario would be a grand finale.) One of the students radioed "Mayday! Mayday! Mayday! Firefighter Down!" The IC immediately deployed the RIT team and the students in the basement immediately carried the victim up the D-side stairwell (see Photo 2) and outside where emergency medical care was administered. (Note: An ambulance staffed by two EMTs was already on scene for the training. Additionally, an adjunct instructor and a student in the class were paramedics.)
After the last evolution started, the lead instructor and 4 of the adjunct instructors went to the instructor's room in an adjacent building to discuss the final student evaluations. They heard the radio transmissions that were not part of the training scenario and immediately went to investigate. They saw the victim being carried up the basement stairs at 1253 hours.
The victim was transported via the ambulance to a community hospital were he was stabilized prior to transport via helicopter to a regional trauma/burn center. The victim died from his injuries on October 25, 2005.NPPTL and NIST Investigations
Based on the National Personal Protective Technology Laboratory (NPPTL) respirator investigation report and fire experiments conducted by the National Institute of Standards and Technology (NIST) Fire Research Division, it is hypothesized that excessive heat in the burn room caused a catastrophic failure of the victim’s SCBA facepiece lens. This failure was a result of the heat conditions within the burn room and not a problem with the facepiece’s manufacture. (Note: Any SCBA facepiece exposed to these conditions probably would have failed). The failure occurred as the victim was carrying pallets in the burn room to add to the existing fire. The victim dropped the pallets and fell forward (see Diagram and Photo 3). The victim then struggled on the ground and crawled towards the exit.
The NPPTL report indicated that many components of the victim’s SCBA had suffered severe damage from heat exposure.1 The lens is molded from polycarbonate plastic, which has a transition temperature in the range of 145-150°C (293-302°F).2 (Note: The transition temperature is the point the material changes from a rigid state to a soft, rubbery state.) At even higher temperatures, the plastic begins to melt. The lens material of the victim’s facepiece appears to have reached temperatures possibly higher than 300°F. This is supported by the charring of the voicemitter tubes which are made of Neoprene rubber, which begin to decompose around 342°C (647°F).2 The polycarbonate buttons on the two upper head-harness attachment points were covered by the protective hood, as were portions of the lens. These components appear to have been heated well in excess of the glass transition temperature but did not reach melting temperature.
Photo 3. Basement Burn Room after Incident.
Cause of Death
The county coroner's office reported the cause of death as thermal trauma listed as accidental. The coroner's office found no medical reason for the victim to have collapsed within the burn building.
Recommendation #1: Fire departments and training academies should ensure that two training officers are present with a charged hoseline during the ignition or refueling of a training fire in accordance with NFPA 1403.
Discussion: Discussion: Live fire training evolutions should be conducted in accordance with NFPA 1403, Standard on Live Fire Training Evolutions.3 NFPA 1403, Chapter 6 Non-Gas-Fired Live Fire Training Center Structures, Section 4 Safety, states that an instructor shall be designated as the "ignition officer" to control the materials being burned and a charged hose line shall accompany the ignition officer when he or she is igniting any fire. The decision to ignite the training fire shall be made by the instructor-in-charge in coordination with the safety officer and the fire shall be ignited by the ignition officer in the presence of and under the direct supervision of the safety office
Recommendation #2 : Fire departments and training academies should determine the minimum amount of flame, heat and/or smoke required during live fire evolutions to perform the training while ensuring fire fighter safety.
Discussion: The fire fighters in this course were already highly trained, skilled fire fighters and their training was focused on the ability to instruct new fire fighters, not fire fighting skills. In this incident, high heat conditions were probably not necessary for this training.
Recommendation #3 : Fire departments and training academies should use the minimum fuel load necessary to conduct live fire training.
Discussion: The basement burn room was lined with material that retained heat within the room. There was only one doorway to enter the room and there was no way to release heat that built up during the live fire evolutions. The basement burn room was also not given sufficient cool down time between evolutions. The minimum fuel load necessary to conduct the training should be used to minimize heat retention within the burn room. During fires in training facilities, consideration should be given to monitoring and controlling both the air temperature (convective heat) and the radiant heat experienced by firefighters to limit the risk to their safety. Fire academies should ensure that temperature sensing instruments are available and working throughout the structure, and monitored during training evolutions.
Recommendation #4 : Fire departments and training academies should have a written respiratory protection program and ensure that self-contained breathing apparatus (SCBAs) facepieces are properly inspected, used, and maintained.
Discussion: Based on a witness statement, the SCBA facepiece the victim had worn during this training had a heat damaged lens similar to the one shown in Photo 4. Facepieces on two additional SCBAs submitted by the Training Academy to NPPTL for testing also showed heat damage. Facepieces in this condition should be removed from service. The Fire Academy did not have a written respiratory protection program at the time of the incident. Anecdotal evidence based on inquiries directed to NIOSH over time tends to support the notion that heat damage to SCBAs occurs more frequently during training and flashover simulation situations than during fires in ordinary structures.1 NFPA 1404, NFPA 1852 and OSHA 29 CFR 1910.134 all outline the requirements for a respiratory protection program.4-6 NFPA 1404 contains the minimum requirements for the training component of a respiratory protection program covered in NFPA 1500. NFPA 1852 contains general guidelines that all fire departments and training academies should follow to ensure that all in-service SCBAs are in good working order and will function properly when needed. OSHA 29 CFR 1910.134 contains requirements for respiratory protection programs including the selection, fit testing, use, maintenance, and medical screening.
Recommendation #5 : Fire departments and training academies should have burn rooms with at least two exits.
Discussion: The purpose of the live fire training structure is to provide a location for safely training fire fighters in the methods of interior fire suppression. NFPA Standard 1402, Guide to Building Fire Service Training Centers states in Chapter 10.1.4 on Live Fire Training Structures that every burn room or compartment should have a minimum of two means of escape.7
Recommendation #6 : Fire departments and training academies should avoid having basement burn rooms.
Discussion: NFPA Standard 1402, Guide to Building Fire Service Training Centers states in Chapter 10.1.5 that burn areas that are fully below grade are hazardous and should be avoided.7 For live fire training structures where a walk-out basement configuration is impractical, basement or cellar fires could be simulated at the ground floor. An exterior stair to a second-floor landing at an exterior second-floor door could be constructed; fire fighters could then enter at the second floor and simulate attacking below-grade fires by working down the interior stairs to the ground floor.
Recommendation #7 : Training academies should consider installing instrumentation within live fire training structures to record information such as heat, the effects of suppression and the byproducts of combustion.
Discussion: NFPA Standard 1402, Guide to Building Fire Service Training Centers, Chapter 10.3 suggests that instrumentation be installed within the burn structure to monitor temperatures in order to provide information to help keep the fire within safe parameters, to observe the effect of suppression and to record the byproducts of combustion.7 Thermocouples or other analyzing equipment could be used to measure heat within the training compartments. The thermocouples could be installed between protective linings and structural elements of the live fire training structure to monitor temperatures radiating through the lining system that could affect the structure. The system should be designed and installed by qualified personnel.
Recommendation #8 : Training academies should consider installing a ventilation system within the burn structure.
Discussion: NFPA 1402 Guide to Building Fire Service Training Centers, Chapter 10.4.1 recommends a ventilation system capable of removing heat and smoke as a safeguard.7 If a ventilation system is installed, it should be sized to provide a minimum of one air change per minute in the training space and designed to withstand the high temperatures related to repetitive live fire training.
Recommendation #9 : Training academies should consider having a qualified engineer evaluate fuel loads, heat retention, and the instrumentation and ventilation systems of live fire training facilities.
Discussion: NFPA 1403, Standard on Live Fire Training Evolutions, Chapter 6 Non-Gas-Fired Live Fire Training Center Structures, Section 6 Structures and Facilities states that training structures shall be inspected visually for damage prior to live fire training evolutions and that the structural integrity of the burn structure be evaluated and documented periodically by a licensed professional engineer with live fire training structure experience and expertise.3 During the structural integrity inspection the engineer should also evaluate fuel loads, heat retention, and the instrumentation and ventilation systems within burn structures.
Photo 4. Another SCBA Facepiece Exhibiting Conditions Similar to the One Worn by the Victim
- NIOSH . Status Investigation Report of Three Self-Contained Breathing Apparatus Submitted by the Pennsylvania State Fire Academy. Kochenderfer V. Pittsburgh, PA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Task No. 14292
- Beyler CL and Hirschler MM . Thermal Decomposition of Polymers. In: DiNenno PJ et al., eds. SFPE Handbook of Fire Protection Engineering, 2nd Edition. Quincy, MA: National Fire Protection Association, pp. 1-99 to 1-119.
- NFPA . NFPA 1403, Standard on live fire training evolutions. Chapter 6 non-gas-fired live fire training center structures. Quincy, MA: National Fire Protection Association.
- NFPA . NFPA 1404, Standard for fire service respiratory protection training. Quincy, MA: National Fire Protection Association
- NFPA . NFPA 1582, Standard on Selection, Care, and Maintenance of Open-Circuit Self-Contained Breathing Apparatus (SCBA). Quincy, MA: National Fire Protection Association.
- OSHA . 29 CFR Part 1910.134, respiratory protection; Final Rule. US Department of Labor. Federal Register, Vol. 63, No. 5.
- NFPA . NFPA 1402, Guide to building fire service training centers. Quincy, MA: National Fire Protection Association.
This incident was investigated by Steve Berardinelli, Occupational Safety and Health Specialist with the Fire Fighter Fatality Investigation and Prevention Team, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located in Morgantown, WV. Technical reviews were provided by Dan Madrzykowski, National Institute of Standards and Technology and Deputy Chief William Goldfeder, Loveland-Symmes Fire Department and editor of http://www.FireFighterCloseCalls.com.
The results of the NIST fire experiments conducted within the Fire Academy basement burn room will be available in the future at www.fire.nist.gov.
This page was last updated on 09/19/07.
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