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 F2009-05, 2010 Feb; :1-35
On January 9, 2009, a 52-year-old male career Lieutenant (the victim) died and three male career fire fighters were injured, when the ladder truck they were riding in failed to stop while traveling down a hill. The ladder crew had just cleared from a medical assist call prior to the incident. The chauffeur turned left out of a parking lot and immediately had to stop and back up to allow the aerial ladder overhanging the cab enough clearance to pass a utility pole on the street. After clearing the pole, the chauffeur immediately negotiated a right downward curve. He then applied the brake pedal and had no response. The chauffeur told the victim he had "no brakes" as the ladder truck gained speed descending the hill. The chauffeur tried placing the ladder truck in neutral and applying the parking (maxi) brake to slow the apparatus down, but there was no response. The chauffeur was able to navigate the ladder truck through a busy intersection, crashing through two parked cars and a brick wall, before coming to rest within a multi-story residential complex. The victim was pronounced dead at the scene; the chauffeur was extricated and transported to a local hospital where he was treated for serious traumatic injuries. The two fire fighters riding in the crew compartment were also transported to the hospital with minor injuries. Key contributing factors identified in this investigation include apparatus braking system deficiencies, deficiencies in the apparatus maintenance program, insufficient training for fire apparatus operators and fleet maintenance personnel, and failure to wear seat belts. NIOSH investigators concluded that, in order to minimize the risk of similar occurrences, fire departments should: 1.) Ensure that preventive maintenance programs are developed and implemented for fire apparatus according to manufacturer guidelines/specifications and national consensus standards. 2.) Ensure that preventive maintenance on fire apparatus is performed and/or overseen by qualified personnel who meet the certification requirements outlined in NFPA 1071 Standard for Emergency Vehicle Technician Professional Qualifications. 3.) Develop and utilize policies and procedures that monitor preventive maintenance and other automotive services performed by vendors. 4.) Work with local, state, and federal authorities having jurisdiction (AHJ) in adopting an air brake endorsement for noncommercial driver's licenses that would require individuals operating air brake equipped fire apparatus to verify their knowledge and skill proficiency (e.g. air brake system, air pressure gauges and alarms, and pre-trip inspection) prior to operating the fire apparatus. 5.) Ensure that current driver training programs provide ample classroom instruction, behind the wheel driving, procedures for driver clearance, and annual refresher training. 6.) Develop and implement fire apparatus inspection procedures and check sheets for their fleet, provide a systematic approach for communicating and receiving inspection sheets from the field, and institute a system to file and track fleet records (e.g., inspection sheets, work orders, repairs, apparatus specifications, and maintenance). 7.) Ensure that policies and procedures are developed and enforced on the use of seat belts. 8.) Develop policies and procedures that assist with determining specifications for new apparatus and replacement cycles of existing fire apparatus. Additionally, fire departments and fleet maintenance divisions should: 9.) Understand that the manual adjustment of automatic slack adjusters, a mechanical component of the air brake system that adjusts brakes as necessary when the vehicle is in operation, may contribute to unexpected brake failure. Additionally, governing municipalities (federal, state, regional, and local) should: 10.) Consider enacting legislation to include operators and occupants of fire department vehicles in existing seat belt legislation and/or repeal existing laws that exempt drivers and occupants of fire service vehicles from mandatory seat belt use.
Region-2; Accident-analysis; Accident-prevention; Accidents; Drivers; Emergency-responders; Fire-fighters; Injuries; Injury-prevention; Safety-belts; Safety-education; Safety-measures; Safety-monitoring; Safety-practices; Safety-programs; Training; Traumatic-injuries; Truck-drivers; Fire-fighting-equipment; Motor-vehicles; Surveillance