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Career Lieutenant Dies and Four Firefighters Injured at a 3-Story Multi-Family Residential Occupancy–Massachusetts

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

F2019-18 Date Released: March 25, 2022

Executive Summary

On November 13, 2019, a 39-year-old career lieutenant died, and four other firefighters were injured while fighting a multi-family residential structure fire. At 01:00:06, Fire Alarm dispatched Car 4, Engine 15, Engine 2, Engine 13, Engine 12, Ladder 5 Ladder 3, Rescue 1, and Ladder 4 (rapid intervention team (RIT)) to Box 15-14 for a fire with occupants on the 2nd floor and a baby on the 3rd floor. At 01:02:27, Engine 15 arrived on scene and reported a Type V structure with heavy fire showing on the 2nd floor of Side Bravo. At 01:03:37, Car 4 arrived and had assumed Command. Engine 2 also arrived at this time and was assigned to stretching a supply line from a hydrant to Engine 15. Command reported smoke showing from the roof and 3rd floor Side Bravo and requested a 2nd alarm. Engine 5, Engine 6, Ladder 1, and Car 3 were dispatched at 01:04:25. Engine 15 did a quick transitional attack to fire venting on Side Delta from the 2nd floor. Within minutes, Engine 15 and Ladder 5 were going to the 2nd floor on Side Delta. Engine 13 was going to the 2nd floor on Side Alpha and Ladder 3 was going to the roof. Engine 13 was knocking down the exterior fire on Side Bravo. Engine 12 was assigned to supply Ladder 3 with water. At 01:09:59, Rescue 1 split into two teams. Team 1 went to Division 2 and Team 2 went to Division 3. At 01:14:41 Rescue 1-Team 2 encountered heavy fire on the 3rd floor hallway Side Alpha and Engine 2 knocked down fire in the front stairwell on their way to assist Rescue 1. At approximately 01:19:16, Engine 13 made it to the doorway of the room of the fire origin which was the bedroom midway on the 2nd floor in the Side Bravo. Engine 13 knocked down the fire, but it wasn’t completely extinguished. At 01:21:40, Engine 6 used a yard lay off of Engine 12, which was pumped by Engine 15 and went to the 3rd floor. Engine 5 also was assigned to the 3rd floor. At 01:23:56, Ladder 5 re-entered the structure and went to the 3rd floor. At 01:27:36, the lieutenant from Ladder 5 called a Mayday. The lieutenant stated they were on Division 3 with fire all around them, exit blocked, and they did not have a personnel accountability report (PAR). Command acknowledged the Mayday and sent in a rapid intervention team (Ladder 4) to the 3rd floor. Command advised the lieutenant there was a ladder (Ladder 3 platform) on 2nd floor Side Bravo. At 01:28:37, the lieutenant stated they were trapped, it was very hot, and they needed a hose line. The lieutenant and chauffeur of Ladder 5 had temporarily taken shelter in a shed on the porch at the Bravo/Charlie corner. At approximately 01:32, the lieutenant of Ladder 5 grabbed the chauffeur of Ladder 5 and pushed him out of a window on the 3rd floor of Side Charlie to get him out of the hazardous area. He fell approximately 15 feet, hitting an awning over the basement man-door, then rolled off and fell about another 10 feet to the ground. At 01:34:03, Car 400 notified Command that a civilian stated a firefighter was lying in the backyard (Side Charlie). At 01:34:21, Engine 5 located the Ladder 5 chauffeur on the ground and requested EMS. Over next 23 minutes, Ladder 4 (RIT), Ladder 1, Rescue 1-Team 2, Engine 12, Engine 4 and Car 2 encountered heavy fire while trying to get to the 3rd floor and locate the lieutenant. Crews struggled to access the 3rd floor due to limited space in the enclosed stairwell that had high heat, zero visibility due to smoke, and the added obstruction of a hose line that had burned through and was gushing water between the 2nd and 3rd floors in the Side Delta/Charlie stairwell. At 02:07:20, Rescue 2 (Rescue 1-Team 2 and Ladder 4) (Note: This designation was assigned by the officer of Ladder 4) reached the 3rd floor of the Side Delta/Charlie stairs, but debris blocked the entrance to the porch. A member of Rescue 2 breached the wall to the porch. Several minutes later, after crawling across the porch and avoiding holes, Rescue 2 made it to the porch shed door where the lieutenant had returned to take shelter. Rescue 2 could hear the lieutenant’s personal alert safety system (PASS) sounding. Rescue 2 breached the shed door and found the lieutenant. Rescue 2 accompanied by Ladder 1 located grabbed the lieutenant. Crews from Ladder 4, Ladder 1, and Engine 4 moved the lieutenant from the 3rd floor to the 1st floor down the Side Delta/Charlie stairs. The lieutenant was brought out the Side Delta/Charlie rear door where an EMS crew was waiting at approximately 02:13. The lieutenant was transported by EMS to the local trauma center where he was pronounced deceased. Command advised Fire Alarm that the fire at Box 15-14 was declared under control at 04:05 and was marked out at 06:31.

Contributing Factors

  • Building construction and contents enhanced fire spread
  • Wind driven fire
  • Lack of scene size-up and risk assessment
  • Lack of incident management and command safety
  • Lack of a defined incident action plan
  • Lack of crew integrity
  • Poor survivability profile
  • Inadequate company level staffing
  • Lack of professional development opportunities
  • Lack of required sprinkler system

Key Recommendations

  • Incident commanders should ensure a detailed size-up and define a strategy and incident action plan (IAP) based on the scene size-up and risk assessment. Incident commanders should continually reevaluate the strategy and adjust the IAP based on continuous size-up, risk assessment, risk management, and the completion of tactical objectives
  • Fire departments should use risk management principles, including occupant survivability profiling, at all structure fires
  • Fire departments should develop and implement standard operating procedures/standard operating guidelines (SOP/SOG), training programs, and tactics for wind-driven fires
  • Fire departments should ensure that all companies are operating based upon the assignment given by the incident commander, eliminating freelancing and ensuring tactical priorities are met
  • The early establishment of divisions/groups provides an effective incident management organizational framework that the IAP can build on and expand. This enhances the accountability of resources operating in the hazard zone.
  • Fire departments need to ensure that critical incident benchmarks are communicated to the incident commander throughout the incident
  • Fire departments should ensure that once Command is established at an incident, the incident commander maintains control of situation status, resource status, fireground communications, and ensures the completion of the tactical objectives
  • Fire departments should incorporate the principles of command safety into the incident management system during the initial assumption of command. This ensures that strategic-level safety responsibilities are incorporated into the command functions throughout the incident
  • Fire departments should ensure adequate staffing for deployment to urban incidents involving high hazard occupancies and a concentrated population.


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