Fire Fighter Dies When Struck By Water Tanker After Exiting

Kentucky Case Report: 05KY099

Date of Incident: November 23, 2005
Report Release Date: October 20, 2006

Summary

On November 23, 2005, a 75-year-old volunteer fire fighter (the decedent) died when the fire truck he had been driving ran over him. Volunteer fire fighters had been battling a structural fire for approximately an hour and a half when the decedent arrived to help. When he arrived at the scene, he was assigned by the fire chief to drive a water tanker and perform water shuttle service from a hydrant one mile away to the burning house. On his fourth trip from the hydrant to the house, the fire fighter parked the water tanker at the end of the driveway on the side of the flat road. He waited in the cab of the water tanker, with the engine idling, for the other fire fighters to use the water in his truck. While he was waiting, the decedent engaged the parking brake, left the engine idling, exited the water tanker, and walked in front of it. The water tanker began to roll forward, running over the fire fighter then continuing into the ditch along the roadside. Another fire fighter, walking in the grass on the roadside in front of the tanker, heard a commotion behind him. He turned around, saw the tanker rolling towards him, and jumped out of the way. Once the tanker came to rest in the ditch, he walked to the drivers’ side of the cab and found it empty. He then walked around to the back of the tanker and discovered the decedent underneath. He summoned the fire chief to come to the back of the tanker. The fire chief checked the decedent for vital signs and did not find any. Emergency medical services (EMS), state police and the local coroner were immediately called. Upon their arrival, they checked the fire fighter for vital signs and did not find any. The coroner pronounced the fire fighter dead at the scene.

To prevent future occurrences of similar incidents:

Fire fighters should set the parking brake on the vehicle, put the transmission in “park” or in gear and turn the ignition to the “off” position before exiting the vehicle.
Fire departments, should ensure that parking brakes on vehicles are capable of preventing movement when applied.
When exiting apparatus at the scene of an incident, operators should apply the parking brake and ensure that appropriate wheel chocks are in place to prevent inadvertent movement.
Fire departments should ensure all drivers of fire department vehicles receive driver training at least twice a year.

Background

In the early 1960’s, the 75-year-old decedent helped found the local volunteer fire department where he served for 15 years, then moved away from the area and drove a tractor-trailer. A year before his death, he retired from semi-truck driving, returned to the area and resumed volunteer duties at the department. His duties included driving an engine, when needed providing backup services for the other volunteers, and helping maintain operational equipment and the fire house station and grounds.

The fire station served a four square mile area and approximately 1200 homes, and included 18 volunteer fire fighters. Fire fighters were trained to fight structure and wild land fires, and in emergency response and rescue. Training logs were kept on each volunteer fire fighter. Every Monday evening, volunteers met to practice and review training techniques, standard operating procedures and guidelines, and perform maintenance on equipment.

Maintenance was scheduled and performed on all equipment (apparatus, hoses, etc.) on a monthly basis. If used between monthly maintenance checks, equipment was checked and made ready for the next emergency use. Hoses were inspected then properly stored on each truck after each use. Equipment was stored in the same physical location on each fire truck. Wheel chocks were stored in the back left storage compartment on each truck.

Engine #4 involved in this incident was manufactured in 1981 and had been purchased used from another county in 1993. Maintenance records on the truck were kept and maintenance performed by volunteers or by certified mechanics. It was unknown if there were any manufacturer recalls on the truck. There were no known brake failures on this engine. The truck had the capacity to carry two fire fighters, and haul 750 gallons of water. With a full tank of water, the truck weighed 33,775 pounds.

Weather temperature that day ranged from 24 degrees Fahrenheit – 45 degrees Fahrenheit with a trace of precipitation.

Investigation

On November 23, 2005, at approximately 8:00 PM, the volunteer fire department received a call that a residence in the fire district approximately six miles away from the department was on fire. Upon notification, eleven volunteer fire fighters from the local community, including the fire chief, were immediately dispatched to the residence. Eleven to twelve minutes after receiving notification of the fire, crews arrived on scene with all four of the department’s water tankers and reported that 80% of the structure was involved. The Chief assumed incident command (IC) and performed a size-up of the incident when fire fighters discovered a 500 gallon propane storage tank located between the house and the driveway. The IC called for a defensive attack, and due to the close proximity of the propane tank to the fire, the IC was forced to position the four water tankers down the driveway and as far away from the propane tank as feasible. Three water tankers were parked in the driveway with a fourth parked along the road at the end of the driveway. Because there was a limited water supply to extinguish the fire, the fire fighters were ordered first to save the part of the house that had not burned, then turn their attention to extinguishing the fire. There were two water sources the fire department used to extinguish the flames: a water hydrant one mile away and the creek across the road from the burning house. The fire chief and crew decided to initially draft water from the creek until that water source was depleted, then use tank water which would be refilled from the hydrant as needed. They drafted water from the creek for two hours then used the water from the trucks. After each water tank was depleted, it was driven one mile up the road and refilled from the hydrant. The water shuttle operation took approximately 10 minutes to complete the circuit from the house to the hydrant and return to the house with a full water tank.

At approximately 9:00 PM, the decedent was returning home from church when he noticed the fire trucks were gone from the fire station. He arrived home and his wife told him there was a fire so he immediately went to the fire station. When he arrived, the fire chief’s wife who also volunteered at the fire house, informed him of the house fire and its location. He decided to take drinking water to the fire fighters and help if he could. He loaded his vehicle with drinking water and drove to the incident via his personally owned vehicle (POV).

He arrived at the scene at approximately 9:30 PM and was assigned, along with another fire fighter, to drive a water tanker in the water shuttle operation. They drove the water tanker from the house to the hydrant and back four times. The decedent’s partner (partner) connected and disconnected the hoses from the water tanker and hydrant. At about 10:30 PM, less water was needed to put out the fire and the wait between water runs was about 15 minutes. On the fourth trip from the hydrant to the house, the partner asked the driver to stop so he could remove a tree limb from the road. The partner exited the cab, moved the tree limb, then proceeded to walk the remainder of the way to the driveway of the house. The driver drove past the partner, arrived at the driveway of the house, parked the truck on the roadside below the burning house next to a ditch, and waited. The headlights were on, the truck was idling in neutral and the parking brake was applied.

The partner walked in the grass between the road and ditch past the parked water tanker, then stood in the grass by the ditch with his back to the water tanker facing the activity at the burning house. At the same time, the driver exited the water tanker, but did not chock the back tire of the tanker. As the partner stood in the grass, he heard a strange sound behind him. He turned around and saw the water tanker rolling towards him so he jumped out of the way. The water tanker rolled into the ditch and stopped. The partner ran to the driver’s side door and opened it. Not seeing the driver in the cab, he ran around the water tanker to try to find the driver. He found the driver underneath the back of the tanker. He immediately shouted to the other fire fighters, telling them to summon the IC to the back of the tanker. The IC immediately walked to the back of the tanker, checked the 75-year-old fire fighter for vital signs (did not find any), and called for emergency personnel from a nearby neighboring area to come to the scene. Emergency personnel arrived, verified the 75-year-old to be without vital signs and contacted the state police. After the fatal incident, the fire chief asked emergency personnel to check the parking brake on the water tanker to see if it was engaged. Emergency personnel verified that the parking brake was engaged. The state police arrived and contacted the coroner. When the coroner arrived, he declared the 75-year-old dead at the scene.

Cause of Death

The death certificate stated the cause of death to be “blunt impact of head, torso, and extremities with multiple fractures and visceral lacerations”.

Recommendations and Discussion

Recommendation No. 1: Fire fighters should set the parking brake on the vehicle, put the transmission in “park” or in gear and turn the ignition to the “off” position before exiting the vehicle.

Vehicle operators should not exit the vehicle without turning the engine off either in the “park” position or in gear, and engaging the parking brake. This eliminates the possibility of the vehicle accidentally slipping into gear and the movement of the vehicle overriding the parking brake.

Recommendation No. 2: Fire departments, should ensure that parking brakes on vehicles are capable of preventing movement when applied.

National Fire Protection Association (NFPA) 1901 Standard for Automotive Fire Apparatus 2003 Edition, Section 12.3.1.6.2 states: “When the fire apparatus is loaded to its maximum in service weight, the parking brake system shall hold the apparatus on at least a 20 percent grade.” The roadway was relatively level and the parking brakes were applied but allowed the truck to roll.

Recommendation No. 3: When exiting apparatus at the scene of an incident, operators should apply the parking brake and ensure that appropriate wheel chocks are in place to prevent inadvertent movement.

Fire fighters should be trained to chock tires when parking the truck at all times when exiting the vehicle. According to the fire chief, the fire truck had chocks available on the apparatus to accommodate the size of the fire truck.

Recommendation No. 4: Fire departments should ensure all drivers of fire department vehicles receive driver training at least twice a year.

Driver training should be provided to all driver/operators as often as necessary to meet the requirements of NFPA 1451, but not less than twice a year. This training should be documented and cover driving and parking techniques during emergency and non-emergency conditions. Every driver/operator should be familiar with these basic concepts of driving and parking. Fire department driver training should be in accordance with NFPA 1451, “Standard for a Fire Service Vehicle Operations Training Program”, and NFPA 1002, Fire Apparatus Driver/Operator Professional Qualifications. These standards state that departments should establish and maintain a driver training education program and each member should be provided driver training not less than twice a year. During this training, each driver should operate the vehicle and perform tasks that the driver/operator is expected to encounter during normal operations to ensure the vehicle is safely operated in compliance with all applicable state and federal laws.

References

National Fire Protection Association Standards & Codes
NFPA 1915 – Standard for Fire Apparatus Preventive Maintenance Program 2000 Edition
803 KAR 2:015 (6)
NFPA [2003]. NFPA 1901: Standard for automotive fire apparatus. Quincy, MA: National Fire Protection Association
National Fire Protection Association [2002]: NFPA 1002, Standard for a fire department vehicle driver operator professional qualifications. Quincy, MA: National Fire Protection Association.
NFPA [2002]. NFPA1451: Standard for a fire service vehicle operations training program. Quincy, MA: National Fire Protection Association
USFA/FEMA [2003]. Safe operation of fire tankers. Emmitsburg, MD: U.S. Fire Administration

Acknowledgements

Local Coroner

Fire Chief

Fire Crew

National Institute of Occupational Safety & Health with special thanks to the Fire Fighter Fatality Investigation and Prevention Program

Photographs and Diagram

Photographs and Diagram

Photo 1: Picture of house involved in incident. The fire started on the back porch.

Diagram 1: Diagram of scene.

Photo 2: Picture with indication of where water tanker came to rest.

Photo 3: Picture of water tanker involved in incident.

Kentucky FACE Program

The Kentucky Fatality Assessment & Control Evaluation Program (FACE) is funded by a grant from the Centers for Disease Control and the National Institute of Safety and Health. The purpose of FACE is to aid in the research and prevention of occupational fatalities by evaluating events leading to, during, and after a work related fatality. Recommendations are made to help employers and employees to have a safer work environment.

To contact Kentucky State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

Kentucky Case Reports