On January 21, 1998, two male volunteer fire fighters, a 25-year-old fire fighter
(victim), and a 37-year-old Captain, entered a local supermarket that had heavy smoke
emitting through the rear ventilation system. The two fire fighters entered the store
through the front door and proceeded to the rear, where they became disoriented. The
victim died of smoke and soot inhalation and the Captain barely escaped. During the week
of February 2, 1998, the Chief of the Trauma Investigations Section and a Safety
Specialist conducted an investigation of this incident. Meetings were conducted with
officers and fire fighters from the volunteer fire department, including the Captain who
was able to escape from the store. Photographs and measurements were taken of the incident
site, dispatch times were obtained, and telephone interviews were also conducted with
officials from the State Fire Marshal's office.
The 30-member volunteer fire department involved in the incident serves a population of
1,200 in a geographic area of 5 square miles. The fire department requires all new fire
fighters to complete Fire Fighter Level I training, which consists of 36 hours of training
mandated by the State of West Virginia. The required training is designed to cover
personal safety, forcible entry, ventilation, fire apparatus, ladders, self-contained
breathing apparatus, search and rescue, hose loads, and nozzles. The victim had completed
Fire Fighter Level I training and had approximately 11 years of fire fighting experience.
Although nine volunteer fire departments were involved in this incident, only those
directly involved up to the time of the fatal incident are mentioned in this report.
On January 21, 1998, at approximately 1030 hours, an employee at a local business was
informed that smoke was detected at a supermarket adjacent to the employee's place of
employment. The employee was a Lieutenant in the local volunteer fire department. The
Lieutenant proceeded to the supermarket and made sure the supermarket and surrounding
evacuated and all delivery trucks were moved from the rear of the store. The Lieutenant
then received a ride from a passing motorist to the fire station. There, he was met by the
Captain and a fire fighter who had been notified by the dispatch paging system. At 1040
hours dispatch was notified to place a second volunteer department on standby status. The
Lieutenant, the Captain, and a fire fighter responded to the scene with Pumper 420, and
arrived at approximately 1046 hours. At approximately 1049 hours, backup was requested and
Engine 421 arrived on scene at 1052 hours. By 1107 hours, a total of 9 departments,
approximately 20 pieces of rolling equipment, and 75 to 90 fire fighters had arrived at
the fire scene.
The site of the incident was a one-story supermarket measuring 120 feet wide by 180
feet long, located in a shopping plaza. The exterior of the supermarket was of masonry and
brick construction, with a steel truss roof system. The roof was covered with metal sheet
roofing, except for a section which was covered with synthetic rubber. The structure was
built on a concrete slab foundation and was accessible from two front doors, a side door,
and the rear delivery doors. Two additional businesses were contained within the structure
of the supermarket.
When the first fire department arrived on the scene at 1046 hours, the Lieutenant
reported that heavy black smoke was emitting from the ventilation system at the rear of
the structure. Upon arrival Pumper 420 laid a 5-inch line to a hydrant located towards the
rear of the incident site. The Lieutenant was the driver of Pumper 420 and the pump
operator according to department procedures. As the Lieutenant made the hose connections
to the hydrant, additional manpower arrived on the scene, including the victim, who worked
at a local business next to the shopping plaza. The Captain from Pumper 420 went into to
the front entrance and found good visibility in the store, with the interior lights on,
and light smoke about 1 foot thick across the ceiling. The Captain exited the store and
returned to the pumper, where he called for additional backup. The fire fighter victim
approached the Lieutenant on Pumper 420
|and requested turnout gear and an SCBA. The victim, a former
employee of the supermarket, knew the layout of the structure and requested that he be
allowed to assist the Captain in completing an internal evaluation to locate the origin of
the fire. The Lieutenant (Pump Operator) would remain on the outside of the structure. The
Lieutenant gave the victim his turnout gear and an SCBA. Between 1055 and 1100 hours, the
Captain and the fire fighter (victim)equipped with full turnout gear, SCBA, ax, hand
light, and lights attached to their helmetswent to the front of the store and
entered through the front door. When they entered the store, conditions had deteriorated.
Heavy smoke obscured visibility, so they crouched/crawled approximately 15 feet into the
store (see Figure). Crouching/crawling to the right they encountered a wall. They decided
to stand and walk along the wall, which was approximately 5 feet long. Coming to the end
of the wall, they crouched back down and began to crawl down an aisle toward the rear of
the store. They felt it was safe to proceed, since they did not feel any increase in
temperature. As they crawled toward the rear of the store, with extremely poor visibility,
the two became separated approximately 2 to 3 feet. The victim reached an oversized steel
hinged door that led to the meat room and storage area. As the victim started to enter, he
stood up and was repelled by intense heat. The heat apparently panicked or startled the
victim, who immediately turned and bumped into the Captain, stating, " it's too hot,
we have to get out of here." The victim grabbed the air hose on the Captain's SCBA
and pulled him in a direction which the victim apparently thought was the exit. Both fire
fighters, moving at a fast pace through heavy black smoke, ran into a wall. At this point
the victim realized they were lost and requested that the Captain radio for help. Feeling
around in an attempt to find their location, they were able to determine that they were in
the general area of the meat section. At approximately 1107 hours, the Captain used the
portable radio to call for help, stating that they were in trouble and could not get out.
At this time the low-air alarm on the victim's SCBA was sounding. Both fire fighters were
now in a crouched position to await help when the victim told the Captain that he was out
of air. The Captain told the victim to pull
his SCBA air line from his regulator, and
put it inside his jacket. The Captain began asking the victim questions about their
location when he realized the victim was now unresponsive. The Captain stated he began to
crawl to his left, bumping into shopping carts and a product display. His attention was
drawn to a distant light. The Captain crawled toward the light, discovered an opening, and
exited between 1108 and 1112 hours. He was able to escape without injury, exiting through
the opposing front entrance from where he had entered (see Figure). The Captain stated
that heat was not a problem as they attempted to exit, and that it was unclear if the
victim was equipped with a personal alert safety system (PASS) device, but was sure he
(Captain) did not have a PASS device on.
Incident command had directed search and rescue efforts for the two fire fighters who
were in the structure at approximately 1107 hours. The Chief from the local department and
a Lieutenant from a different volunteer department went in through the same door as the
victim, with a 1½-inch uncharged line. They advanced approximately 15 feet before being
distracted by one of their low-air alarms, which forced the two to retreat and exit the
structure. Additional attempts to enter through the rear of the structure were
coordinated, but were unsuccessful due to the heat and heavy smoke. The search and rescue
was terminated approximately 1 hour later. Positive pressure ventilation fans were placed
in the doors to force fresh air into the structure after the Chief and Lieutenant exited.
At 1300 hours, the State Fire Marshall ordered the victim's department off the fire
ground. The victim was eventually found and was removed from the interior of the
supermarket, at approximately 1500 hours.
CAUSE OF DEATH
The medical examiner's report listed the cause of death as smoke and soot inhalation.
Recommendation #1: Fire departments should ensure that fire fighters who enter
hazardous areas, e.g., burning or suspected unsafe structures, be equipped
|with safety lines or a hose line.1
Fire fighters who enter smoke-filled enclosures should be equipped with a safety line or
hose line in the event that a fire fighter becomes disoriented or trapped. By using a hose
line the fire fighter is able to determine the direction of exit by the couplings that
connect two hose lines together. The male coupling signifies the exit direction.
Recommendation #2: Fire departments should strictly enforce the wearing and use
of PASS devices when fire fighters are involved in fire fighting, rescue, and other
Discussion: The PASS device is a small electronic device worn by the fire fighter which
will emit a loud and distinctive audible alarm if the fire fighter becomes motionless for
more than 30 seconds. The fire fighter can also activate the alarm manually if needed. A
fire fighter who becomes trapped or disoriented should manually activate the PASS device.
The captain was not equipped with a PASS device and it was unclear whether the victim was
equipped with one. If the victim was equipped with a PASS device, the fire fighters never
heard it sounding.
Recommendation #3: Fire departments should implement an incident
management system with written procedures for all fire fighters.3
The system should provide the following:
A well-coordinated approach to the emergency
Overall safety of all fire fighters at the scene of the emergency
Personal Protective Equipment
Fire fighters should be trained in this system and should be provided with periodic
refresher courses to review policies and procedures. Fire fighters must always be fully
aware of standard operating procedures, and their individual roles and responsibilities.
recommendation outlines the areas covered by most departmental policies and procedures;
however, individual department systems will vary due to specific needs and services.
Recommendation #4: Fire departments should ensure that backup personnel are
standing by with equipment, ready to provide assistance or rescue.4
Discussion: During interior structural fire fighting (in Immediately Dangerous to Life
or Health (IDLH) atmospheres) self-contained breathing apparatus is required and at least
two fire fighters must enter and remain in visual and voice contact with each other at all
times. In addition, two fire fighters must be on standby if two fire fighters are engaged
in interior structural fire fighting in the burning building ("two-in /
two-out") to provide safety. The two exterior fire fighters should form a rescue team
that is stationed outside the hazardous area.
The rescue team should be trained and equipped to begin a rescue immediately if any
other fire fighters in the hazardous area require assistance. A dedicated rapid-response
team may be required if more than a few fire fighters are in the hazardous area.
1. Essentials of Fire Fighting, 3rd edition, The International Fire Service
Training Association. Fire Protection Publications, Oklahoma State University. Edited by;
Wieder M, Smith C, Brackage C, 1995.
2. Morris GP, Brunacini N, Whaley L . Fire ground accountability: the Phoenix
system. Fire Engineering 147(4):45-61.
3. National Fire Protection Association. NFPA 1500, 1992 Edition, Standard on Fire
Department Occupational Safety and Health Program, National Fire Protection Association,
4. 29 Code of Federal Regulations 1910.120(q)(3)(vi), Hazardous waste operations and