NIOSH Fire Fighter Fatality Investigation and 
Prevention Program - Death in the line of duty... A summary of a NIOSH fire fighter fatality investigation

Revised on January 30, 2008.

Career Fire Fighter Dies When Trapped by Collapsed Canopy during a Two Alarm Attached Garage Fire – Pennsylvania


On February 4, 2007, a 27-year-old male career fire fighter (the victim) and a 38-year-old male career fire fighter were trapped under a canopy which collapsed off of a burning residential garage. The victim was pinned under the canopy debris, and was found not breathing while still wearing his SCBA and SCBA mask. The second fire fighter received injuries requiring time off from work.

Incident Scene
Incident scene. Photo courtesy of fire marshal’s office

As the fire fighters pulled the hoseline from the garage, the canopy, which was connected to the garage roof rafters by long metal bars, fell on both fire fighters, trapping them underneath. The designated rapid intervention team (who had just arrived on-scene) worked for approximately 10 minutes to extricate both fire fighters. The victim and injured fire fighter were sent to the local hospital by ground ambulance. The victim was pronounced dead at the hospital, and the injured fire fighter was treated for injuries requiring time off from work.

NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should:


On February 4, 2007, a 27-year-old male career fire fighter (the victim) died when he was trapped underneath a canopy which collapsed / separated from the front of a burning residential garage. A 38-year-old male career fire fighter (injured fire fighter) was also trapped under the canopy. The victim was found lying on his right side, not breathing while still wearing his SCBA. It was the victim’s first working fire with this career department. The injured fire fighter received injuries that required time off from work.

On February 5, 2007, the U. S. Fire Administration notified the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR) of this incident. On February 12 and 28, 2007 the DSR Chief of the Fatality Investigations Team, a DSR Safety Engineer, and a medical resident (guest researcher) from the NIOSH Fire Fighter Fatality Investigation and Prevention Program traveled to Pennsylvania to investigate this incident. The NIOSH investigation team met with officials of the fire department, the mutual aid fire department that extricated the trapped fire fighters, representatives of the International Association of Fire Fighters (IAFF) union, and local police and state police fire marshals. The investigation team conducted interviews with officers and fire fighters present at the scene, examined photographs of the incident scene, visited the fireground site, and reviewed other pertinent documents including the fire department’s standard operating procedures and the victim’s and incident commanders’ (IC) training records. The victim’s personal protective clothing worn at the time of the incident was examined. The victim’s SCBA was transferred to the NIOSH National Personal Protective Technology Laboratory (NPPTL) for evaluation and testing. The NIOSH test results (see full report) show the SCBA failed the positive pressure test and failed to meet the required 30.0 minute duration. These test failures are not believed to have significantly contributed to the fatality as the victim was trapped and could not move his arms to remove his facepiece when he ran out of air.

Fire Department
The career fire department involved in this incident serves a population of approximately 20,000 residents in a geographic area of about 3.2 square miles. It has a contract with a neighboring borough to cover an additional 3,850 residents.

In February 2007, the fire department consisted of 18 uniformed fire fighters and fire officers. The department has two fire stations and extensive written standard operating procedures. In 2006, the fire department responded to 37 structural fires.

Typical staffing is four fire fighters plus one officer per shift. Two fire fighters and an officer are located at Fire Station 1, and two fire fighters staff Fire Station 2. A standard work shift is 24 hours on-duty and 48 hours off-duty. Additionally, all off-duty fire fighters are called to report to Fire Station 1 when there is a confirmed structural fire. The fire fighters who arrive at the station are briefed and respond on an assigned apparatus.

Vehicles which the department operates include two engines (Engine 8 at Station 2 and Engine 9 at Station 1), a 75-foot tele-squirt, a 100 foot aerial ladder truck, 1 pickup truck, and the Chief’s command vehicle. Both engines have 500 gallon tanks with 2000 gallons-per-minute (gpm) pumps. The ladder truck has a 300 gallon tank and a 1,500 gpm pump. The department has 1 thermal imaging camera (TIC).

Just weeks prior to the incident, the department entered into a cooperative agreement with a neighboring combination fire department to provide mutual aid in the form of a designated rapid intervention team (RIT) at all working fires in this department’s jurisdiction. A 4-person RIT goes on stand-by when the principle fire department is dispatched, and responds when the fire is confirmed (second alarm). Their response time is 7 – 10 minutes.

Training and Experience
The fire department follows the city’s requirements in hiring and training a probationary fire fighter. The minimum level of training required is NFPA Fire Fighter Level I.

Both the victim and the injured fire fighter had extensive training and fire fighting experience during their careers. The victim had worked for the fire department for approximately one-half year, but had been a volunteer fire fighter in a neighboring borough for approximately 12.5 years. His training included NFPA Fire Fighter Level I, emergency medical technician (EMT), and hazardous materials training.

The injured fire fighter had 18 years of total fire fighting experience (11 years career at this department, in addition to 7 years as a volunteer). His training included Fire Fighter Level I, paramedic training, 7 weeks of annual training at the fire academy, driver operator training, and confined space rescue.

The Chief of the department had over 27 years of total fire fighting experience at this department and served as Chief since 2004. His training included various fireground tactic and incident management classes. The Chief assumed incident command (IC) when he arrived at the fire scene and remained as the IC throughout the incident.

Administratively, the fire department enforces fire alarm and sprinkler system requirements. The city’s Building Inspector’s Office enforces building codes. The city follows the International Building Code.

Equipment and Personnel
The career fire department responded with 3 apparatus and 14 fire fighters on scene prior to the fatal event. Only the units directly involved in operations preceding the fatal event are discussed in this report. Additional volunteer departments were dispatched after the collapse. The timeline for this incident included initial dispatch at 0934 hours. The response, listed in order of arrival and key events, includes:

0934 hours
Initial alarm; via homeowner call to 911
0938 hours
Engine 8 (victim and injured fire fighter from Station 2) left Station 2
Engine 8 arrived on scene and reported heavy black smoke
Engine 9 (Captain, 2 fire fighters from Station 1) left Station 1
0939 hours
Command Vehicle (Chief) arrived on scene; Chief assumes Incident Command (IC)
0941 hours
Engine 9 (1 Captain, 2 fire fighters from Station 1) arrived on scene
0942 hours (approximate)
Engine 8 crew enters garage with charged hoseline
0951 hours
Dispatch notified power company and state fire marshal
1000 hours
Telesquirt -2 (TS-2) (4 off duty fire fighters called back to Station 1) arrived on scene
1007 hours
Victim and the injured fire fighter exited garage to change SCBA bottles
Victim and the injured fire fighter re-entered garage
Small burning debris hit the injured fire fighter
Victim and the injured fire fighter started to back out of the garage
1010 hours
Ladder (4 fire fighters, mutual aid Rapid Intervention Team) arrived on scene
Canopy collapsed
Rapid Intervention Team began extrication of the injured fire fighter
1018 hours
RIT extricated the injured fire fighter
1027 hours
Air ambulance helicopter on scene
1028 hours
Victim extricated from collapse
1030 hours
Two ground ambulances arrive on scene (1 advanced life support (ALS) and 1 basic life support (BLS)
1041 hours
ALS ambulance to air landing zone with victim
Victim’s heart is in pulseless electrical activity
1047 hours
BLS ambulance arrived at the hospital’s emergency room with the injured fire fighter
1048 hours
ALS ambulance redirected to the emergency room

Personal Protective Equipment
At the time of the incident, the victim and injured fire fighter were wearing their full array of personal protective clothing and equipment, consisting of turnout gear (coat and pants), helmet, Nomex® hoods, gloves, boots, and a self-contained breathing apparatus (SCBA) with an integrated personal alert safety system (PASS). The victims were also equipped with portable radios.

The structure involved in this incident included a residential two story house with an attached garage built in 1910, and renovated in 1950 (Photos 1-3 ). The house dimensions were approximately 48 feet long by 20 feet wide and the garage was approximately 24 feet long and 24 feet wide. The garage was of traditional wooden construction. The garage had a peaked gable roof with attic storage, and the floor was concrete. Several layers of siding were present on the garage including wooden clapboard, covered with weather brick, covered by aluminum siding. The garage was connected to the property’s 2-story house by a small vestibule room. The home was of balloon construction, was 1,316 square feet, and was listed as having 5 rooms (2 bedrooms, 1 bathroom). The garage was also attached to an irregular-shaped concrete block structure that had been a commercial motorcycle shop at one time (Figure 1).

A large canopy covered the main garage door (Photo 3). This canopy did not have support columns underneath. Three metal bars connected the canopy to the garage’s roof rafters by turn buckles (Photos 4-7). The canopy had a slight pitch for water runoff and it was two layers thick (studs, plywood, and shingles covered by another layer of studs, plywood, and shingles.)

location of crew

According to state fire marshal investigators, the cause and origin of the fire was faulty electrical wiring in the vestibule. The fire started low on an interior wall and traveled up the wall to both the house and garage. The fire spread rapidly through the garage attic area. The owner of the building tried to put the fire out with a ½-inch garden hose before calling the fire department. Both the house and the garage were extremely cluttered with an accumulation of various household articles which restricted access and made entry difficult.


The weather at the time of the incident included a temperature high of 14°F, and a low of 3°F. Winds were variable between 10-20 mph, with gusts up to 30 mph from the West and Northwest. No precipitation was reported on the day of the incident. It was determined that the cold weather conditions may have played a significant factor in this incident. Fire fighters were limited in their mobility and slipped on the frozen overspray, and equipment failed (low-pressure air bags failed to deploy to raise debris, regulator couplings froze and could not connect after becoming frozen). The streets around the structure were plowed prior to the incident.


On February 4, 2007, at approximately 0934 hours, the homeowner called 911 (emergency dispatch) and reported a fire in his house. The homeowner had attempted to extinguish the fire with a garden hose for some time before reporting the fire. The municipal (career) fire department was immediately dispatched for “an unknown type fire.”

At the time of the dispatch five fire fighters were on duty. A captain and two fire fighters were working at Station 1, and two fire fighters were on duty at Station 2. Engine 8 (E8) was the first engine dispatched. It left Station 2 at 0938 hours with the victim (E8 fire fighter) and injured fire fighter (E8 engineer/operator or EO) on-board. The incident site was approximately 6 city blocks from Station 2.

The Chief of the department was off-duty but driving through town near Station 1 when he heard the dispatch. He immediately proceeded to the scene. Engine 9 (E9) left Station 1 with a captain and two fire fighters on-board at 0938 hours. Just days prior to the incident, the same crews had responded to the same address for a downed power line and wondered whether this call was related.

Engine 8 arrived on the scene and the fire fighters saw heavy black smoke. The EO called dispatch to report what they saw, and the victim pulled a 150-foot length of 1 ¾-inch preconnected hose line from the truck. The E8 EO confirmed the hose the E8 FF (victim) was using, and then engaged the pump and charged the line. As this was occurring, the Chief arrived on scene and assumed Incident Command (IC) while the two fire fighters were preparing to make entry. Note: Due to limited staffing, the fire department does not have a fire fighter stationed at the pump panel during fire suppression operations. The EO engages the pump than assists with handling the hoseline.

The homeowner met the E8 fire fighters at the garage door and told them the fire was in the back right corner of the garage. The E8 FF advanced through the open garage door (side A) holding the nozzle, and the E8 EO backed him up. The E8 EO also carried an ax.

While enroute, the E9 captain heard Engine 8 arrive on-scene and report heavy smoke showing so he radioed dispatch to request the mutual aid RIT team be dispatched. When Engine 9 arrived on-scene at 0941, the captain radioed dispatch and requested a 2nd alarm for additional mutual aid.

Engine 9 was positioned about 70 yards behind Engine 8. The crew on Engine 9 laid a 4-inch hose from the hydrant to Engine 8. The steamer valve blew off when the Engine 9 crew first tried to connect to the hydrant, so the hydrant was shut off, the steamer valve was reconnected, and the water flow was resumed. A volunteer fire fighter from a neighboring department arrived on-scene and assisted with connecting the line to the hydrant. Engine 8 did not run out of water during this process.

The Chief (IC) and the captain did a 360 degree walk-around, and found a door on side D that accessed the vestibule. Entry was attempted but could not be made due to the accumulation of cluttered objects inside.

After establishing the water supply to Engine 8, the Engine 9 fire fighters went to the structure to assist with the fire ground operations. The volunteer fire fighter was asked to monitor the pumps on Engine 8. One Engine 9 fire fighter got a 24’ ladder intending to vent the garage roof. The second Engine 9 fire fighter was directed by the Chief to go to side D to vent the windows in the house. The second Engine 9 fire fighter met the captain on the D side. Dispatch notified the power company and the state fire marshal of the fire at 0951 hours.

TS-2 arrived on scene with 4 fire fighters at 1000 hours and prepared to start a master stream directed at the roof. TS-2 members laid a 4-inch line from another hydrant to supply the master stream. The captain directed the crew to make entry into side D. Three fire fighters took a 1 ¾-inch preconnected handline to side D along with irons (an ax and a Halligan bar). Entry was difficult due to clutter blocking the door. The Engine 9 fire fighter on side D retrieved a 24’ ladder from TS-2 and put it up to the second floor window. The captain left side D and walked completely around the house to check the conditions on the other sides. The Chief assisted the fire fighters on side D in knocking out windows in the house for horizontal ventilation.

The first Engine 9 fire fighter had just completed throwing a ladder up to the garage canopy (side A) intending to vent the garage roof when the captain returned and stated he needed manpower on side B. A second 1 ¾-inch preconnected handline was pulled from Engine 8 and pulled to side B, and the Engine 9 fire fighter took this nozzle and entered the house with the captain following him. Fire was observed near the front of the house. The Engine 9 fire fighter began flowing water to knock the fire down. The captain’s SCBA ran low on air and his alarm began to sound, so both fire fighters backed out of the house. The captain went to Engine 8 to change his air cylinder while the other fire fighter remained at the side B door and continued to flow water through the door.


The Chief (IC) called to the E8 EO as he and the victim were fighting the fire inside the garage. The E8 EO backed up a few steps to hear the Chief say that the TS-2 master stream was going to go into operation to stop the fire spread on the back side of the house. The E8 FF (victim) remained in the garage, bouncing water off of the ceiling onto the fire. At this point, both E8 fire fighters backed out of the garage to change SCBA cylinders since they were running low on air.

Meanwhile, one of the fire fighters who arrived on TS-2 went to side B to assist the Engine 9 fire fighter with the hand line while the Captain was changing his air cylinder. These two fire fighters made entry through the side B door and into the house. They advanced about 10 feet and encountered heavy fire to the right. Water was directed in this area and appeared to be effective in knocking down the fire there. The Captain returned to side B and called the two fire fighters outside to tell them that the master stream on TS-2 was going into operation. As the two fire fighters were talking with the captain, they heard an air horn and then heard the Chief call a mayday over the radio.

After changing cylinders, the E8 crew (victim and E8 EO) had re-entered the garage to resume putting water on the fire. Some debris from the ceiling fell on the E8 EO’s head, knocking him to his knees. He told the E8 FF (the victim) that they needed to back out due to the deteriorating conditions.

They backed out of the garage door, but remained near the doorway and still under the canopy with the hose line still in operation. The E8 FF was on his knees, directing the nozzle towards the fire. The E8 EO told the E8 FF they needed to back up more to get out from under the canopy. As they were stepping back, the canopy collapsed on them without warning. They were approximately 3 minutes into their second SCBA cylinders.

The canopy hit the E8 EO in the back and knocked his helmet off. One arm was pinned by the construction materials of the canopy (2x4 and 2x6 lumber). The other arm was free, so he activated his PASS and started pounding on debris. He saw daylight, and was able to move enough so that he could free his arm and wiggle out of his SCBA straps and scoot toward the light. When he reached the light, he was able to wave his hand through a small opening in the debris. He removed his face piece when the air in his SCBA cylinder ran out. The E8 EO heard the victim’s PASS and was able to speak to him.

The Chief (IC) had just returned to side D and began knocking out windows for ventilation, when a civilian told him that the canopy had just collapsed on two fire fighters. The Chief returned to side A to see the collapse as the mutual aid Rapid Intervention Team (RIT) arrived on scene. At 1010 hours, the Chief called a mayday, and all the career fire fighters were directed to the front of the building. A volunteer fire department kept water flowing at the back of the house and garage.


The mutual aid rapid intervention team (RIT) arrived just as the canopy collapsed. Two civilians ran up to the RIT team and told them that two fire fighters were trapped under the canopy. The RIT team took its tool bag (cordless saw and drill, rope, hand tools and irons), and the RIT team leader took a 6-foot steel roof hook.

The RIT team leader approached the front of the garage and directed his team to use cribbing to support the canopy. He then crawled into the void space between the collapsed canopy and the garage wall and was able to speak to the injured fire fighter.

Air bags were brought out to lift the collapsed canopy, but the intense cold and overspray froze the airbags and line couplings, rendering them useless. A mechanical spreader was used to lift the canopy, but it just broke through the wood without lifting the canopy and its use was discontinued. A ventilation fan was started to blow smoke away from the canopy.

The RIT team then used power saws to cut the injured fire fighter out of the debris. The E8 EO told the RIT team where he thought the victim was. (Note: it was stated by the RIT team leader that it was difficult to cut the victim out of the debris because his exact location was not known. Some rescuers reported hearing a muffled PASS device while others stated they did not hear a PASS device.) When found, the victim’s upper torso was uncovered first. His face piece and helmet were still on and in place. His arms were pinned, and he did not appear to be breathing. Additionally, the victim was laying on his right side because the SCBA tank was still on his back. Rescuers removed the victim’s face piece to administer oxygen while his legs were still pinned. The canopy was fully cut away, and the victim was removed from the debris.

A helicopter landed on scene, but it was not used because the victim did not have vital signs. Both the victim and the injured fire fighter were transported to the city hospital by ground ambulance. The E8 EO was treated for smoke inhalation and an ankle sprain.


According to the coroners’ findings, the cause of death for the victim was asphyxiation due to entrapment under a collapsed roof.


Recommendation #1: Fire departments should review and follow existing standard operating procedures (SOPs) for structural fire fighting to ensure that fire fighters follow a 2- in 2-out policy.

Discussion: The Occupational Safety and Health Administration (OSHA) Respirator Standard and Hazardous Waste Operations and Emergency Response Standard requires four persons (two in and two out); each with protective clothing and respiratory protection as the minimum number essential for the safety of those performing work inside a structure.1,2 The National Fire Protection Association (NFPA), and the fire department’s standard operating procedure, also recommend two in and two out and that the team members should be in communication with each other through visual, audible, or electronic means to coordinate all activities, and determine if emergency rescue is needed. 3,4 During this incident’s initial response, the limited manpower both on duty and available, was not adequate to ensure compliance with two in two out requirements at all times.

Recommendation #2: Fire departments should ensure that adequate numbers of staff are available to immediately 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 (2004 Edition) contains recommended guidelines for minimum staffing of career fire departments.5

NFPA 1710 § 5.2.2 (Staffing) 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 in jurisdictions with tactical hazards, high hazard occupancies, high incident frequencies, geographical restrictions, or other pertinent factors identified by the authority having jurisdiction, these companies shall be staffed with a minimum of five or six on-duty members. Jurisdictions where fire companies deploy quint apparatus designed to operate as either an engine company or a ladder company should also follow these same staffing guidelines.

NFPA 1710 also states that the fire department’s fire suppression resources shall be deployed to provide for the arrival of an engine company within a 4-minute response time and/or the initial full alarm assignment within an 8-minute response time to 90 percent of the incidents as established in Chapter 4. The fire department shall have the capability to deploy an initial full alarm assignment within an 8-minute response time to 90 percent of the incidents as established in Chapter 4. The initial full alarm assignment shall provide for the following:

  1. Establishment of incident command outside of the hazard area for the overall coordination and direction of the initial full alarm assignment. A minimum of one individual shall be dedicated to this task.
  2. Establishment of an uninterrupted water supply of a minimum 1520 L/min (400 gpm) for 30 minutes. Supply line(s) shall be maintained by an operator who shall ensure uninterrupted water flow application.
  3. Establishment of an effective water flow application rate of 1140 L/min (300 gpm) from two handlines, each of which shall have a minimum of 380 L/min (100 gpm). Each attack and backup line shall be operated by a minimum of two individuals to effectively and safely maintain the line.
  4. Provision of one support person for each attack and backup line deployed to provide hydrant hookup and to assist in line lays, utility control, and forcible entry.
  5. A minimum of one victim search and rescue team shall be part of the initial full alarm assignment. Each search and rescue team shall consist of a minimum of two individuals.
  6. A minimum of one ventilation team shall be part of the initial full alarm assignment. Each ventilation team shall consist of a minimum of two individuals.
  7. If an aerial device is used in operations, one person shall function as an aerial operator who shall maintain primary control of the aerial device at all times.
  8. Establishment of an Incident Rapid Intervention Crew (IRIC) that shall consist of a minimum of two properly equipped and trained individuals.

Due to staffing and manpower limitations within the department, the small size of the initial responding crews at this incident could not appropriately and safely respond to the necessary fireground operations–e.g. incident command, scene size-up, search-and-rescue, a staged Incident Rapid Intervention Crew (IRIC), hydrant connections, ventilation, and medical aid and transport. Additional manpower was requested and off-duty fire fighters were called to return to work.

The city funds the fire department involved in the incident. According to the Fire Chief, staffing has been a concern since 1997 when a consultant was hired to determine the number of fire fighters needed for the city. The consultant recommended a minimum of 21, with at least 27 fire fighters as optimal.

Recommendation #3: Fire departments should establish a collapse zone when structures become unstable.

Discussion: Buildings can collapse due to the structural damage directly caused by a fire, or the activities of fire fighting operations. A fire department’s familiarity with types of construction in their community is an important tool in safely fighting fires. Fire fighters should be able to immediately evacuate a building where collapse is possible. A collapse zone equal to one and a half times the height of the building should be established. This perimeter assists in keeping personnel out of imminent danger. 6-8 Once a collapse zone is established, fire departments should enforce a “no re-entry” policy unless the Incident Commander is aware and approves. In this incident, the first crew arrived on-scene at 0938 hours and the collapse occurred at approximately 1010 hours. Fire fighters had been on the scene for 32 minutes and the fire had been affecting the structural integrity of the building for at least that long.

Fire fighters need to recognize the dangers of operating underneath or near overhanging awnings, porches, and other areas susceptible to collapse. Immediate safety precautions must be taken if factors indicate the potential for a building collapse. An external load, such as a parapet wall, steeple, overhanging porch, awning, sign, or large electrical service connections reacting on a wall weakened by fire conditions may cause a wall to collapse. Other factors include fuel loads, damage, renovation work, deterioration caused by the fire as well as pre-existing deterioration, support systems and truss construction.6,7 A collapse is a possibility after fire involvement of more than 10 minutes.8 The canopy which collapsed in this incident was supported by metal rods connected to the garage’s roof rafters.

Recommendation #4: Fire departments should ensure that the Incident Commander continuously evaluates the risks versus gain when determining whether the fire suppression operation will be offensive or defensive.

Discussion: The initial size-up conducted by the first arriving officer allows the officer to make an assessment of the conditions and to assist in planning the suppression strategy. The following general factors are important considerations during a size-up: occupancy type involved, potential for civilians trapped in the structure, smoke and fire conditions, type of construction, age of structure, exposures, and time considerations such as the time of the incident, length of time fire was burning before arrival, and time fire was burning after arrival.9,10 The Incident Commander must perform a risk analysis to determine what hazards are present, what the risks to personnel are, how the risks can be eliminated or reduced, and the benefits to be gained for interior or offensive operations.11 The initial size-up should include a complete 360º walk-around of the structure if possible.

The size-up must include continued assessment of risk versus gain during incident operations. According to NFPA 1500 §A-6-2.1.1, “The acceptable level of risk is directly related to the potential to save lives or property. Where there is no potential to save lives, the risk to the fire department members must be evaluated in proportion to the ability to save property of value. When there is no ability to save lives or property, there is no justification to expose fire department members to any avoidable risk, and defensive fire suppression operations are the appropriate strategy.”3 Retired New York City Fire Chief Vincent Dunn states “When no other person’s life is in danger, the life of the firefighter has a higher priority than fire containment.”12

The first-responding officer, as well as the incident commander, needs to make a judgment as to what is at risk – people or property. This will help determine the risk profile for the incident. Many fire fighters stand by the notion that all incidents are “people” events until proven otherwise. Some fire fighters are willing to concede that a fire environment has become too hostile to sustain life and therefore, the only thing left to save is property.13

In this incident, the structure involved was not occupied, the only resident of the adjoining house was known to be outside and the garage and house were greatly cluttered making entry difficult. The first crew arrived on-scene at 0938 hours and the collapse occurred at approximately 1010 hours. Fire fighters had been on the scene for 32 minutes and the fire had been affecting the structural integrity of the building for at least that long. Fire officers and fire fighters need to understand that they have very little time to offensively fight a fire once the structural elements have become involved and also how different construction types, age of construction, and factors such as the steel support rods on the canopy can be affected by fire.

Recommendation #5: Fire departments should ensure that the first arriving company officer does not become involved in the fire fighting effort when assuming the role of the Incident Commander.

Discussion: Fire fighter safety starts with a strong command presence. According to NFPA 1561, §4.1.1, “the Incident Commander shall be responsible for the overall coordination and direction of all activities at an incident.” In addition to conducting an initial size-up, Incident Command (IC) should maintain a command post outside of the structure to assign companies and delegate functions, and continually evaluate the risk versus gain of continued fire fighting efforts.14 According to the International Fire Service Training Association (IFSTA) publication, Fire Department Company Officer, there are three modes of operation for the first-arriving officer assuming IC: nothing showing, fast attack, and command. 15

Nothing-showing mode. When the problem generating the response is not obvious to the first-in unit, the company officer should assume command of the incident and announce that nothing is showing. He should direct the other responding units to stage at Level I, accompany the crew on an investigation of the situation, and maintain command using a portable radio.”

Fast-attack mode. When the company officer’s direct involvement is necessary for the crew to take immediate action to save a life or stabilize the situation, the officer should take command and announce that the company is in the fast-attack mode.”

Command mode. Because of the nature of some incidents, immediate and strong overall command is needed. In these incidents, the first-in officer should assume command by naming the incident and designating the command post, give an initial report on conditions, and request the additional resources needed.”

In this incident, smoke coming from the roof and inside the building required the “Command mode” of operation. The first arriving officer initiated the “Command mode” by declaring command of the incident over the radio and reporting smoke coming from the roof and inside the building. However, due to insufficient staffing and manpower limitations, the Incident Commander became involved in fire ground duties such as pulling hose lines and assisting in ventilation.

To effectively coordinate and direct fire fighting operations on the scene, it is essential that the IC does not become involved in fire fighting efforts. A delay in establishing an effective command post may result in confusion of assignments, lack of personnel and apparatus coordination which may contribute to rapid fire progression. The involvement of the initial IC in fire fighting also hampers the communication of essential information as command is transferred to later arriving officers.

Recommendation #6: Fire departments should consider using a thermal imaging camera as a part of the initial size-up operation to aid in locating fires in concealed areas.

Discussion: Thermal imaging cameras are being used more frequently by the fire service. One function of the camera is to locate the fire or heat source. Infrared thermal cameras assist fire fighters in quickly getting crucial information about the location of the source (seat) of the fire from the exterior of the structure, so they can plan an effective and rapid response with the entire emergency team before initiating the interior attack. Knowing the location of the most dangerous and hottest part of the fire may help fire fighters determine a safe approach and avoid structural damage in a building that might have otherwise been undetectable. Ceilings and floors that have become dangerously weakened by fire damage and are threatening to collapse may be spotted with a thermal imaging camera. The use of a thermal imaging camera may provide additional information the Incident Commander can use during the initial size-up. 16 In this incident, the use of a thermal imaging camera may have aided the fire fighters in identifying that the fire was burning in the garage’s roof rafters sooner, allowing them to exit the garage sooner.

Recommendation #7: Fire departments should ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed at each structural fire.

Discussion: According to NFPA 1561 Standard on Emergency Services Incident Management System, 2005 Edition, paragraph 7.1.1, “The Incident Commander shall have overall authority for management of the incident (7.1.1) and the Incident Commander shall ensure that adequate safety measures are in place (7.1.2).” 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 (IC) is in overall command at the scene, certain functions must be delegated to ensure adequate scene management is accomplished.14 According to NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, 2007 Edition, “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 (8.1.6).”3 These standards indicate that the IC 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 IC 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 IC.

Chapter 6 of 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 fire ground 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 zone, and other designated hazard areas are communicated to all members on scene.17

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 IC. The presence of a safety officer does not diminish the responsibility of individual fire fighters and fire officers for safety. The ISO adds a higher level of attention and expertise to help the individuals. The ISO must have particular expertise in analyzing safety hazards and must know the particular uses and limitations of protective equipment.17

The department involved in this incident did not have a permanent safety officer position and limited manpower and staffing at the incident did not allow for the designation of a separate Incident Safety Officer. A designated safety officer could have assisted with continual size-up and timely communications regarding safety on the fireground, including the need to establish a collapse zone.


  1. OSHA [1998]. Final Rule – Respiratory Protection. 29 CFR Part 1910 and 1926. Federal Register Notice. Thursday, January 8, 1998. Vol. 63, No. 5.

  2. 29 Code of Federal Regulations 1910.120, Hazardous waste operations and emergency response.

  3. National Fire Protection Association. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, National Fire Protection Association, Quincy, MA.

  4. Fire Department [5/2006]. Standard operating procedures.

  5. NFPA [2004]. 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. 2004 Edition. Quincy, MA: National Fire Protection Association.

  6. Klaene BJ and Sanders RE [2000]. Structural fire fighting. Quincy, MA: National Fire Protection Association.

  7. NIOSH [2007]. Career fire fighter dies and chief is injured when struck by 130-foot awning that collapses during a commercial building fire – Texas. Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. FACE Report F2007-01.

  8. Brannigan FL [1999]. Building construction for the fire service, 3rd ed. Quincy, MA: National Fire Protection Association, pp 517-563.

  9. IFSTA [1998]. Essentials of Fire Fighting. 4th ed. Stillwater, OK: Fire Protection Publications. International Fire Service Training Association

  10. NIOSH [2005]. Career fire fighter dies and two career captains are injured while fighting night club arson fire – Texas. Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2004–14, p. 6.

  11. IFSTA [2002]. Fireground support operations. 4th ed. Stillwater, OK: Fire Protection Publications. International Fire Service Training Association

  12. Dunn V [1992]. Safety and survival on the fire ground. Saddlebrook, NJ: Fire Engineering Books & Videos, p. 291.

  13. Dodson, D [2005]. The art of first-due. Fire Engineering. Vol. XX. March, pp. 135-141

  14. NFPA [2005]. NFPA 1561: Standard on emergency services incident management system. 2005 Edition. Quincy, MA: National Fire Protection Association.

  15. IFSTA [1998]. Fire department company officer, 3rd ed. Stillwater, OK: Oklahoma State University, Fire Protection Publications. International Fire Service Training Association.

  16. Corbin DE [2000]. Seeing is believing. Dallas, TX: Occupational Safety and Health, (Aug).

  17. NFPA [2008]. NFPA 1521: Standard for fire department safety officer. 2008 Edition. Quincy, MA: National Fire Protection Association.


This investigation was conducted by Robert Koedam, Chief, Fatality Investigations Team, and Tim Merinar, Safety Engineer, with the Fire Fighter Fatality Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH. Vance Kochenderfer, NIOSH Quality Assurance Specialist, National Personal Protective Technology Laboratory, conducted an evaluation of the victim’s self-contained breathing apparatus. Luci Kovacevic, MD, Guest Researcher at the NIOSH, Division of Safety Research also assisted in the investigation. This report was authored by Luci Kovacevic. An expert technical review was conducted by Battalion Chief of Safety Stephen Miles, Virginia Beach (VA) Fire Department.

Aerial view of house and garage

Photo 1: Aerial view of house and garage.  Photo courtesy

Canopy pre-collapse
Photo 2: Canopy pre-collapse, side D.  Canopy is just visible above and to the right of the truck. 
Photo courtesy of fire marshal’s office

Canopy pre-collapse

Photo 3: Canopy pre-collapse, side B as viewed from A-B corner.  Photo courtesy of fire marshal’s office

Canopy post-collapse

Photo 4: Canopy post-collapse, side D.   
Photo courtesy of fire marshal’s office

Canopy post-collapse

Photo 5: Canopy post-collapse, side D.  Note failed metal support rods and turn-buckles. 
Photo courtesy of fire marshal’s office

Failed metal support rods and turn-buckle

Photo 6:  Failed metal support rods and turn-buckle. 
Photo courtesy of fire marshal’s office.

Failed metal support rods bolted to roof rafter

Photo 7:  Failed metal support rods bolted to roof rafter.   Photo courtesy of fire marshal’s office.

Return to Fire Fighter Homepage

Return to Fire Fighter Homepage

NIOSH Homepage

NIOSH Homepage

This page was last updated on 01/30/08.