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Career Firefighter Dies After Becoming Disoriented in a Three-Story Apartment Building—Massachusetts


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

F2018-18 Date Released: March 15, 2021

Executive Summary

On December 9, 2018, a 36-year- old male firefighter died in a three-story duplex apartment building after becoming disoriented on the 2nd floor at Box 5-49. At 0358 hours, Fire Alarm dispatched Engine 5, Engine 4, Engine 2, Engine 13, Ladder 4, Ladder 7, Rescue 1, Ladder 1 (Rapid Intervention Crew) and Car 4 to Box 5-49 for a report of a basement fire. The fire was reported in a three-story occupied duplex apartment building. At 0402 hours, Engine 5 arrived on scene with smoke showing from underneath the front porch. Engine 5 reported a working fire. Ladder 4 reported on scene at 0403 hours. Ladder 4 advised smoke was showing, and they were investigating. Engine 5 initially stretched a 1¾-inch hoseline to Side Alpha. It was determined that the fire was located in the basement with the only access from Side Charlie. Upon, arrival, Engine 2 stretched a 1¾-inch hoseline to Side Charlie with Engine 5. Crews assigned to the basement had difficulty accessing the basement due to the bulkhead entrance blocked by debris. The fire extended to the 1st floor and 2nd floor of the fire building. A 2nd Alarm for Box 5-49 was transmitted at 0419 hours at the request of Command (Car 4). Crews still were operating in the basement, but due to fire extension, Command sent Engine 4 to the 1st floor on Side Alpha. At 0428 hours, Ladder 7 was positioned in front of the building and the tower ladder was put in service for roof ventilation. At 0432 hours, the fire in the basement was knocked down. At 0437 hours, Engine 12 reported fire on the 2nd floor and found that the fire was also in the walls. At 0442 hours, Engine 12 exited the building. Ladder 4, Ladder 5, and a firefighter from Engine 4 were operating on the 2nd floor trying to knock down the fire on this floor. At 0444 hours, a 3rd Alarm was transmitted for Box 5-49. At 0446 hours, the officer of Ladder 5 transmitted a Mayday for crews trapped on the 2nd floor. A firefighter from Engine 4 (E402) was separated from the other firefighters on the 2nd floor. E402 was able to get to a bedroom window on the Side Alpha/Delta corner and was removed via a ground ladder. Four other firefighters came out another bedroom window and onto the platform of Ladder 7. A firefighter from Ladder 5 (L502) and a firefighter from Ladder 4 (L403) were separated from the other crews and from each other. Both firefighters moved toward Side Charlie of the fire building. As L502 moved toward Side Charlie, L502 heard an end-of-service time indicator (EOSTI) sounding and found L403. L502 moved toward the other firefighter and asked for L403’s name but heard no answer. L502 started looking for a window to escape because the 2nd floor was getting hot. L502 entered a bedroom and found a window on Side Charlie, broke the window, called a Mayday on the radio, and started yelling for help. L502 retrieved L403, led him to the window and put the firefighter’s hands on the windowsill. L502 then exited the window and descended a ground ladder. L403 did not follow L502 down the ladder. The time was approximately 0455 hours. Rescue efforts were started to remove L403 from the bedroom. Using a rope-haul rescue system, L403 was removed from the building at 0551 hours. L403 was transported to the local trauma center and pronounced deceased. The fire was declared under control at approximately 0651 hours.

Contributing Factors

  • Lack of continuous scene size-up and risk assessment
  • Lack of incident management and command safety
  • Lack of forecasting
  • Lack of tactical objectives
  • Loss of crew integrity
  • Lack of rapid intervention crew(s)
  • Below-grade fire
  • Company staffing
  • Personnel accountability system
  • Arson

Key Recommendations

  • Fire departments should ensure a detailed scene size-up and risk assessment is conducted during initial fireground operations and throughout the incident. Incident commanders should continually reevaluate the strategy and adjust the incident action plan (IAP) based upon the continuous size-up and risk assessment.


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