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 F2010-10, 2010 Sep; :1-39
On March 30, 2010, a 28-year-old male career fire fighter/paramedic (victim) died and a 21-year-old female part-time fire fighter/paramedic was injured when caught in an apparent flashover while operating a hoseline within a residence. Units arrived on scene to find heavy fire conditions at the rear of a house and moderate smoke conditions within the uninvolved areas of the house. A search and rescue crew had made entry into the house to search for a civilian who was entrapped at the rear of the house. The victim, the injured fire fighter/paramedic, and a third fire fighter made entry into the home with a charged 2 ½ inch hoseline. Thick, black rolling smoke banked down to knee level after the hoseline was advanced 12 feet into the kitchen area. While ventilation activities were occurring, the search and rescue crew observed fire rolling across the ceiling within the smoke. They immediately yelled to the hoseline crew to "get out." The search and rescue crew were able to exit the structure safely, then returned to rescue the injured fire fighter/paramedic first and then the victim. The victim was found wrapped in the 2 ½ inch hoseline that had ruptured and without his facepiece on. He was quickly brought out of the structure, received medical care on scene, and was transported to a local hospital where he was pronounced dead. Contributing Factors: 1. Well involved fire with entrapped civilian upon arrival; 2. Incomplete 360 degree situational size-up; 3. Inadequate risk-versus-gain analysis; 4. Ineffective fire control tactics; 5. Failure to recognize, understand, and react to deteriorating conditions; 6. Uncoordinated ventilation and its effect on fire behavior; 7. Removal of self-contained breathing apparatus (SCBA) facepiece; 8. Inadequate command, control, and accountability; and, 9. Insufficient staffing. Key Recommendations: 1. Ensure that a complete 360 degree situational size-up is conducted on dwelling fires and others where it is physically possible and ensure that a risk-versus-gain analysis and a survivability profile for trapped occupants is conducted prior to committing to interior fire fighting operations. 2. Ensure that interior fire suppression crews attack the fire effectively to include appropriate fire flow for the given fire load and structure, use of fire streams, appropriate hose and nozzle selection, and adequate personnel to operate the hoseline . 3. Ensure that fire fighters maintain crew integrity when operating on the fireground, especially when performing interior fire suppression activities. 4. Ensure that fire fighters and officers have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior. 5. Ensure that incident commanders and fire fighters understand the influence of ventilation on fire behavior and effectively coordinate ventilation with suppression techniques to release smoke and heat. 6. Ensure that fire fighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures.