Career Captain and Career Firefighter Die After Running Out of Air During a Search in a Public Library, California
Death in the Line of Duty…A summary of a NIOSH fire fighter fatality investigation
F2020-10 Date Released: March 28, 2022
Executive Summary
On February 18, 2020, a 35-year-old career captain and a 25-year-old career firefighter died searching for a reported civilian using a walker in a public library. At 1616 hours, the communication center dispatched Engine 71, Engine 72, Truck 73, and Battalion 77 to a commercial structure fire at the library caused by arson. A minute later, a city police officer arrived, made entry, and reported the first floor was clear. At approximately 1618 hours, Engine 71 arrived with a captain, firefighter, and engineer from the fire station. The rear of the fire station shares a common wall with the rear of the library. The captain reported heavy smoke from Side Alpha. Battalion Chief 70 also responded from the adjacent fire station. A bystander informed a second police officer that a woman with a walker was on the second floor. The Engine 71 crew made entry without a hoseline and without informing Battalion Chief 70. At approximately 1621 hours, Battalion 77 arrived on scene, assumed command, and advised everyone go to Channel 2. Battalion 77 saw Engine 71 in front of the building and tried to contact the Engine 71 captain on Channel 2 to confirm they were in the building. A minute later, the Engine 71 captain contacted Battalion Chief 77 on Channel 1 and reported they cleared Division 2 and were headed to the stairwell for Division 1. At 1626 hours, fire conditions had worsened, and Battalion Chief 77 declared a defensive attack and attempted multiple times to radio the Engine 71 captain on Channels 1 and 2 with no response. At 1631 hours, a rapid intervention team (RIT) was assembled and made entry to locate the Engine 71 crew. A minute later, the fire chief arrived, and the Engine 71 captain called a Mayday from Division 2. The Engine 71 captain stated that he and his firefighter were running low on air in the banquet room and were trying to locate the stairs. At 1638 hours, the RIT reported no fire and zero visibility in the stairwell to the second floor. The RIT could hear activated PASS alarms. The Engine 71 captain was located in a bathroom and handed off to a second RIT because the first RIT was low on air.
The captain was removed from the building and later died at the hospital. Several more RIT attempts were made to locate the Engine 71 firefighter. Efforts were suspended due to progressing fire conditions and collapse of the building. The Engine 71 firefighter was located by an urban search and rescue team (USRT) late the next day and was extricated from the building the following morning by the USRT and his fire department members.
Contributing Factors
- Air management factors at the task and tactical level
- Risk assessment/size up difficulties
- Primary search without a tagline or hoseline in a large commercial occupancy
- Large area search in an occupied structure (public library)
- Ineffective Mayday procedures and survival techniques
- Residential tactics in a commercial structure
- Crew integrity lost during search
- Radio/communication difficulties
- Lack of sprinkler system
- Rapid fire growth.
Key Recommendations
- Fire departments should ensure all firefighters are trained on and actively practice air management principles.
- Fire departments should use risk management principles at all structure fires.
- Fire departments should ensure that primary search crews and RIT advance with a hoseline or tagline in commercial or complex structures.
- Fire departments should ensure all firefighters are trained in large area search procedures.
- Fire departments should ensure firefighters are trained in situational awareness, personal safety, and accountability.
- Fire departments should ensure firefighters are trained in Mayday procedures and survival techniques.
- Fire departments should develop and implement standard operating procedures/guidelines to define fireground strategies and tactics for commercial structures.
- Fire departments should ensure all members engaged in emergency operations receive annual proficiency training and evaluation on fireground operations, including operations within commercial structures.
- Fire departments should ensure crew integrity is properly maintained by voice or radio contact when operating in an atmosphere that is immediately dangerous to life and health (IDLH).
- Fire departments should ensure all firefighters are trained on radio discipline and proper use, including using the emergency alert button (EAB) on their portable radio.
- Fire departments should ensure firefighters and officers are trained in understanding fire development and growth during size-up, and that incendiary fires can rapidly develop and grow beyond predictions.
- Fire departments should incorporate the principles of command safety into the incident management system during the initial assumption of command to ensure strategic-level safety responsibilities are incorporated into the command functions throughout the incident.