FIRE FIGHTER FATALITY INVESTIGATION AND PREVENTION

Who notifies us about line-of-duty deaths?

• The United States Fire Administration (USFA)
• Fire department representatives
• The International Association of Fire Fighters (IAFF)
• State fire marshal’s offices
• Media coverage

We investigate career and volunteer fire fighter deaths. Once informed of a fatality, we review each event and determine whether or not to investigate using a decision flow chartCdc-pdf to prioritize investigations. However, we are not able to investigate every fatality, depending on the case load of our investigative staff. We are continually balancing the need to initiate new investigations while at the same time completing open cases so that the fire departments are able to apply lessons learned as soon as possible.

If we decide to investigate, a NIOSH representative contacts the fire department to enlist their cooperation and schedule a site visit. For traumatic injury deaths, we work to conduct a site visit within three weeks of the incident. A fire department’s decision to participate is voluntary. However, past participants recognize the value of an objective, independent investigation that focuses on developing recommendations to prevent injuries and deaths.

We visit the incident site to gather information, take pictures, and get measurements. We review documents and records which can include:

• Department standard operating procedures
• Dispatch records
• Training records for the fallen fire fighter, incident commander, and officers
• The fire fighter’s medical records
• Coroner/medical examiner’s reports
• Death certificates
• Blueprints of the structure
• Police reports
• Photos
• Video

We interview fire department personnel and fire fighters who were on the scene at the time of the incident. Interviews are voluntary and witness statements are not made under oath or reviewed by the witness. Because the interviews are not recorded, we rely on our interview notes and the applicable documents to describe the conditions and circumstances leading to the fatalities. We describe the event circumstances in our reports to provide context for our prevention recommendations. We may work closely with other investigating agencies. When we do not have the necessary subject matter expertise, we enlist the help of others, such as experts in motor vehicle incident reconstruction, building construction, or fire growth modeling.

For cases that could be due to respirator or personal protective clothing performance, we request the equipment or clothing be sent to the NIOSH National Personal Protective Technology Laboratory for evaluation.

Once the investigation is complete, we describe the sequence of incident events and provide recommendations in a draft report. We ask each department, union (if present), or family (where applicable because some draft reports includes personal or medical history) to review the draft report. This helps ensure it is factually accurate. The final report is sent to the department, union, and family. For traumatic injury incidents, fire service subject-matter experts also review the draft report.

Once the fire department, union (if present), and family (where applicable) have received the final NIOSH report, we post it on the NIOSH website and notify FF Safety Announcements subscribers of each posting. All NIOSH reports and publications are public domain information and may be freely copied and reproduced for training and educational purposes. Reports are anonymous and do not name the fire department, fallen fire fighter, or other fire fighters involved in the incident.