Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 98-F07, 1998 Jul; :1-11
On March 8, 1998, one male fire fighter, the Captain on Engine 57 (the victim), died while trying to exit a commercial structure after his egress was cut off by the wooden trussed roof that collapsed. Task Force 66 was the first on scene and reported light smoke showing from a one-story commercial building. A ventilation team from Truck 66 proceeded to the roof of the building and commenced roof ventilation. Forcible entry into the building required about seven and a half to nine and a half minutes from arrival on scene to force open the two metal security doors in the front. While fire companies waited for the security doors to be opened, fire conditions changed dramatically on the roof. Fire was coming from the ventilation holes opened by the ventilation crew. As soon as the security doors were opened, three engine crews (Engine 66, Engine 57, and Engine 46) advanced hand lines through the front door in an attempt to determine the origin of the fire. Approximately 15 feet inside the front door, the fire fighters encountered heavy smoke with near zero visibility conditions. The engine crews advanced their hose lines approximately 30 to 40 feet inside the building. As conditions continued to deteriorate inside the building, the members from the four engine companies involved in the fire attack began to withdraw. During this time the victim became separated from his crew and remained in the building. The victim was subsequently located by the Rapid Intervention Team and cardiopulmonary resuscitation was performed immediately and en-route to the hospital, where the victim was pronounced dead. NIOSH investigators conclude that, to prevent similar occurrences, fire departments should: ensure that incident command conducts an initial size up of the incident before initiating fire fighting efforts, and continually evaluate the risk versus gain during operation at an incident ensure that incident command always maintains close accountability for all personnel at the fire scene ensure communications are established between the interior and exterior attack crews, e.g., the ventilation crew and the interior fire attack crew should communicate conditions among themselves and back to incident command ensure that Rapid Intervention Teams are in place before conditions become unsafe ensure that some type of tone or alert that is recognized by all fire fighters be transmitted immediately when conditions become unsafe for fire fighters ensure sufficient personnel are available and properly functioning communications equipment are available to adequately support the volume of radio traffic at multiple-responder fire scenes consider placing a bright, narrow-beamed light at the entry portal to a structure to assist lost or disoriented fire fighters in emergency egress.