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Volunteer Fire Fighter Dies After Running Out of Air and Becoming Disoriented in Retail Store in Strip Mall Fire – North Carolina

FF ShieldDeath in the Line of Duty…A summary of a NIOSH fire fighter fatality investigation

F2016-07 Date Released: December 19, 2017

Executive Summary

On April 30, 2016, a 20-year-old male volunteer fire fighter died after he ran out of air and became disoriented while fighting a fire in a commercial strip mall. The fire fighter was a member of the first-due engine company, Engine 3 from Department 7. Once Engine 3 arrived on-scene, a preconnected 1¾-inch crosslay was stretched into the 7,000-square-foot retail store to attack the fire. The Engine 3 hoseline crew consisted of a senior captain, a lieutenant, and two fire fighters. After the fire was located and water was flowed on the fire, a fire fighter working the nozzle ran low on air, gave the nozzle to the second fire fighter (victim), and proceeded to follow the hoseline to exit the structure. While operating the nozzle near the Charlie/Delta corner of the retail store, the remaining fire fighter also ran low on air and told the lieutenant and captain that he had to go outside. He immediately tried to exit but quickly became disoriented in the near-zero visibility conditions within the retail store. The fire fighter returned to the hoseline near the nozzle and the lieutenant and captain tried to calm him down. The lieutenant was low on air and told the captain that he would take the fire fighter outside but the fire fighter broke away and disappeared into the thick smoke toward Side C, the rear of the store. The lieutenant began to follow the hoseline out. He heard the missing fire fighter yelling for help off to his right and tried to make his way toward the missing fire fighter but became entangled in the display racks. After freeing himself, the lieutenant briefly located the missing fire fighter who stated he was completely out of air and had to get out. The fire fighter again disappeared, moving toward the rear of the store. The lieutenant also ran out of air and had to remove his helmet and facepiece because his facepiece was fogging up. The lieutenant activated his PASS device and was soon located by the Engine 16 crew and helped outside. The lieutenant told rescuers that the fire fighter was missing inside the store. A Mayday was transmitted by the Engine 20 captain at the front door for a missing fire fighter. The Engine 3 fire fighter was located about 2 minutes later and transported to the hospital where he was pronounced dead. The lieutenant was transported to the hospital for treatment of smoke inhalation and was released later that day.

Contributing Factors

  • Lack of crew integrity
  • Inadequate air management training
  • Inexperienced fire fighter
  • Ineffective fireground communications (incident action plan)
  • Failure to call a Mayday in a timely manner
  • No sprinkler system in commercial structure
  • Zero-visibility conditions in smoke-filled retail store
  • Restricted mobility due to arrangement of floor displays. (incident action plan)

Key Recommendations

  • Fire departments should ensure that crew integrity is properly maintained by sight, voice, or radio contact when operating in an immediately-dangerous-to-life-or-health (IDLH) atmosphere.
  • Fire departments should ensure all fire fighters are trained on and actively practice air management principles.
  • State, local and municipal governments, building owners, and authorities having jurisdiction should consider requiring the use of sprinkler systems in commercial structures.
  • Fire departments should train company officers and fire fighters to report interior conditions to the incident commander as soon as possible and on a regular basis.
  • Dispatch centers should provide timeframe bench marks to Incident Command on a regular basis.
  • Fire departments should ensure that fire fighters are trained and proficient on following hoselines outside as a means for egress and self-rescue.


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