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 F2008-07, 2009 Aug; :1-52
On March 7, 2008, two male career fire fighters, aged 40 and 19 (Victims #1 and #2 respectively) were killed when they were trapped by rapidly deteriorating fire conditions inside a millwork facility in North Carolina. The captain of the hoseline crew was also injured, receiving serious burn injuries. The victims were members of a crew of four fire fighters operating a hoseline protecting a firewall in an attempt to contain the fire to the burning office area and keep it from spreading into the production and warehouse areas. The captain attempted to radio for assistance as the conditions deteriorated but fire fighters on the outside did not initially hear his Mayday. Once it was realized that the crew was in trouble, multiple rescue attempts were made into the burning warehouse in an effort to reach the trapped crew as conditions deteriorated further. Three members of a rapid intervention team (RIT) were hurt rescuing the injured captain. Victim #1 was located and removed during the fifth rescue attempt. Victim #2 could not be reached until the fire was brought under control. The fourth crew member had safely exited the burning warehouse prior to the deteriorating conditions that trapped his fellow crew members. Key contributing factors identified in this investigation include radio communication problems (unintelligible transmissions in and out of the fire structure that may have led to misunderstanding of operational fireground communications), inadequate size up and incomplete pre-plan information, a deep-seated fire burning within the floor of the office area that was able to spread into the production and warehouse facility, the procedures used in which operational modes were repeatedly changed from offensive to defensive, lack of crew integrity at a critical moment in the event, and weather which restricted fireground visibility. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. ensure that detailed pre-incident plan information is collected and available when needed, especially in high risk structures; 2. limit interior offensive operations in well-involved structures that are not equipped with sprinkler systems and where there are no known civilians in need of rescue; 3. develop, implement, and enforce clear procedures for operational modes. Changes in modes must be coordinated between the Incident Command, the command staff and fire fighters; 4. ensure that Rapid Intervention Crews (RIC) / Rapid Intervention Teams (RIT) have at least one charged hose line in place before entering hazardous environments for rescue operations; 5. ensure that the incident commander establishes the incident command post in an area that provides a good visual view of the fire building and enhances overall fireground communication; 6. ensure that crew integrity is maintained during fire suppression operations; 7. encourage local building code authorities to adopt code requirements for automatic protection (sprinkler) systems in buildings with heavy fire loads. Additionally, manufacturers, equipment designers, and researchers should: 1. continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communication in conjunction with properly worn self-contained breathing apparatus (SCBA); 2. conduct research into refining existing and developing new technologies to track the movement of fire fighters inside structures.