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 99-F08, 1999 May; :1-9
On May 7, 1998, a 43-year-old male Fire Suppression Technician (the victim), who had 20 years of experience with the fire department, was involved in a maze training exercise, and experienced difficulty; however, he completed the required evolution. The victim had gone on duty for a 24-hour shift at 1145 hours on May 6, 1998, and the maze training was scheduled for 0800 hours on May 7, 1998. During the exercise, the victim hit his head twice, once at the bottom of a segment that has descending steps, and once on a wooden panel slide-door. The victim was questioned by the instructor on both occasions if he was alright and if he wanted to finish the evolution. The victim stated he was alright and wanted to complete the evolution. The victim completed the maze evolution and later that day he became ill and was taken to the emergency room by his wife. The victim was hospitalized later that month for seizures, subsequently released from the hospital, remained under a doctor's care, (but was not released for duty) and died in January 1999. NIOSH investigators conclude that, to minimize the chances of similar occurrences, fire departments should: consider scheduling maze training for fire fighters at times other than at the completion of a 24-hour shift use a pre-screening questionnaire to determine a fire fighter's physical and mental status prior to undertaking maze training de-emphasize time as a factor for completion of the maze evolution and retraining for unsuccessful attempts evaluate the rungs of the ladder in the maze - recommend the distance from the wall to the rungs be increased to allow for safe footing when climbing.