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-F21, 1999 Nov; :1-19
On May 30, 1999, fire fighters responded to a box alarm involving a townhouse fire. The initial report came in as a house fire, and it was later reported that the fire was in the basement (all fire fighters did not receive the follow-up report of fire in the basement). Engine 26 (Lieutenant and 3 fire fighters) was the first to arrive on the scene and reported smoke showing on the front (side 1) of a row of townhouses (see Diagram 1). A fire fighter (Victim #1) from Engine 26 advanced a 1 and a half inch attack line through the front door (1st floor). Soon after, the layout man from Engine 26 entered to back up Victim #1. Engine 17 (Lieutenant and 3 fire fighters) arrived shortly after and stretched a 350-foot 1 and a half inch hose line to the rear (side 3) (see Diagram 1). Truck 15 (Captain and 3 fire fighters) arrived on the scene and began ventilation on the front. Truck 4 (Lieutenant and 3 fire fighters), responding for Truck 13 (out of service), arrived later and began ventilation in the rear. Engine 10 (Lieutenant, Victim #2, and 2 fire fighters) arrived on the scene as the third-due engine and backed up Engine 26 on side 1. Engine 12 arrived as the fourth-due engine and proceeded to side 1 of the building. Battalion Chief 1 (the Incident Commander [IC]) and Rescue 1 (Lieutenant and 4 fire fighters) also responded as a part of the box alarm. Engine 26 and Engine 10 advanced their lines through the front door in a search for the fire and the basement door (at the top of the basement steps). As the two crews searched, Truck 4 made forcible entry through a sliding-glass door in the rear (basement entrance door at ground level). Engine 17 (at the basement door with a charged line) reported to the IC that they were on the first floor, in the rear, with a small fire showing (Engine 17 was actually at the basement level). Engine 17 radioed the IC for permission to open their line and knock down the fire. Knowing that he had two engine crews on the first floor in the front, the IC denied Engine 17's request until he could locate the interior crews' positions. He radioed the officer from Engine 26 several times for their position, but received no response. Engine 17 asked a second time for permission to hit the fire, as it began to grow. The IC denied the request a second time and again tried unsuccessfully to radio the officer from Engine 26. Conditions in the interior rapidly deteriorated, forcing the fire fighters on the first floor to search for an exit. A fire fighter in the interior recalled seeing fire appear from a doorway on the first floor. After seeing the fire, the fire fighter stated that everything went black and he felt an intense blast of heat. Victim #1 and Victim #2 were unable to escape, while the Lieutenant and a fire fighter from Engine 26 escaped with severe burns. All injured fire fighters were transported to a local hospital. The Lieutenant and fire fighter were admitted with burn injuries. Victim #1 was treated for severe burns and was pronounced dead the following day. Victim #2 was pronounced dead on arrival at the hospital. NIOSH investigators concluded that, to minimize the risk of similar incidents, fire departments should: Ensure that the department's Standard Operating Procedures (SOPs) are followed and refresher training is provided. Provide the Incident Commander with a Command Aide. Ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts. Ensure that when a piece of equipment is taken out of service, appropriate back up equipment is identified and readily available. Ensure that personnel equipped with a radio position the radio to receive and respond to radio transmissions. Consider using a radio communication system that is equipped with an emergency signal button, is reliable, and does not produce interference.