On December 16, 2003, a 30-year-old male fire fighter (the victim) died after he became separated from his crew members while searching for the seat of a fire at a furniture warehouse. His crew exited due to worsening conditions and a missing member announcement was made. At one point while inside the warehouse, members of an engine crew thought they heard a scream but could not identify the source. After an evacuation order was given and as engine crew members were exiting, the victim's officer mistakenly identified one of them as the missing member and cancelled the emergency message. Once fire fighters had exited, a personnel accountability report (PAR) was taken on the street which revealed that the victim was still missing. The victim's officer initiated a second emergency message for a missing member and a search was begun. The victim, who had a working radio, was found lying face down with his face piece removed and 900 psi left in his self-contained breathing apparatus (SCBA). His Personal Alert Safety System (PASS) alarm was reported by fire fighters to be inaudible. His carboxyhemoglobin (COHb) level was 74.8% in the emergency room. NIOSH investigators concluded that to minimize the risk of similar occurrences, fire departments should: 1. ensure that pre-incident planning is performed on commercial structures; 2. ensure that Incident Commanders (ICs) conduct a risk-versus-gain analysis prior to committing fire fighters to an interior operation, and continue to assess risk-versus-gain throughout the operation; 3. use guidelines/ropes securely attached to permanent objects and/or a bright, narrow-beamed light at all entry portals to a structure to guide fire fighters during emergency egress; 4. instruct fire fighters on the hazards of exposure to products of combustion such as carbon monoxide (CO) and warn them never to remove their face piece in areas in which such products are likely to exist; 5. ensure that team continuity is maintained during fire suppression operations; 6. train fire fighters on proper radio discipline and operation, and on when and how to initiate emergency traffic when in distress; 7. train fire fighters on actions to take while waiting to be rescued if they become lost or trapped inside a structure; 8. ensure that accountability is maintained on the fire ground; and, 9. establish a system to facilitate the reporting of unsafe conditions or code violations observed by fire fighters during fire suppression activities. In addition, manufacturers, researchers, and standard setting bodies should investigate the performance of PASS devices/alarms under extreme conditions such as those encountered in structural fires. Manufacturers and researchers should: 1. continue to refine existing and develop new technology to track and locate lost fire fighters on the fireground; and, 2. continue to develop and refine durable, easy-to-use systems to enhance verbal and radio communication in conjunction with properly worn SCBA. Additionally, fire prevention personnel should enforce current building codes to improve the safety of occupants and fire.
Region-2; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Self-contained-breathing-apparatus; Personal-protective-equipment; Personal-protection; Protective-equipment; Fire-fighters; Fire-fighting-equipment; Fire-hazards; Fire-protection-equipment; Fire-safety