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 F2008-11, 2009 Nov; :1-40
On August 29, 2007 a 55-year-old male career fire fighter (Victim #1) and a 52-year-old male career fire fighter (Victim #2) died while conducting an interior attack to locate, confine, and extinguish a fire located in the cockloft of a restaurant. Upon arrival, fire was showing through the roof with negligible smoke and heat conditions in the main dining area. Victim #1 was on the nozzle flowing water on the fire in the ceiling area above the exhaust hood and duct work for the stove/broiler in the kitchen. His officer and the officer from the first arriving ladder company provided back-up on the 1 ¾-inch handline. Victim #2 was in the main dining area searching for fire extension above the suspended ceiling. Approximately five minutes after the first crew arrived on the scene, a rapid fire event occurred. Victim #1 was separated from his crew and was later found on the handline under debris with trauma to his head. Victim #2 had a lapel microphone with an emergency distress button which sounded a minute after the rapid fire event, likely from fire impingement. He was found in the area of the dining room where he was operating just before the rapid fire event occurred. Key contributing factors identified in this investigation include an insufficient occupational safety and health program, ineffective incident management system at the incident, insufficient incident management training and requirements, insufficient tactics and training, ineffective communications, delay in establishing a rapid intervention team (RIT), inadequate building code enforcement and development, and inadequate turnout clothing and personal protective equipment. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. develop, implement, and enforce an occupational safety and health program in accordance with NFPA 1500 Standard for a Fire Department Occupational Safety and Health Program; 2. ensure that their members are thoroughly trained, understand, and utilize the incident management system at all emergency incidents; 3. develop, implement and enforce written standard operating procedures (SOPs) that identify incident management training standards and requirements for members expected to serve in command roles; 4. ensure that the incident commander conducts an initial size-up and risk assessment of the incident scene before beginning interior fire fighting operations and continually evaluates the conditions to determine if the operations should become defensive; 5. ensure that the incident commander establishes a stationary command post, maintains the role of director of fireground operations, does not become involved in firefighting efforts, and that transfer of command follows established procedures; 6. develop, implement and enforce written standard operating procedures (SOPs) that address the hazards and define the strategies and tactics to be used while operating at specific structures known as "taxpayers;" 7. ensure that all fire fighters and officers receive fundamental and annual refresher training according to NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA 1021 Standard for Fire Officer Professional Qualifications; 8. ensure that the initial attack line is charged and capable of controlling the fire conditions; 9. ensure that staffed back-up hoselines are utilized to protect the means of egress for the primary attack and search crews; 10. ensure that fire fighters immediately open ceilings and other concealed spaces whenever a fire is suspected of being above them; 11. use thermal imaging cameras (TICs) during the initial size-up and search phases of a fire; 12. ensure that fire fighters understand the influence of ventilation on fire behavior and coordinate with interior fire suppression operations; 13. train fire fighters to communicate interior and exterior conditions to the incident commander as soon as possible and to provide regular updates; 14. ensure that crew integrity is maintained during fire suppression operations, 15. ensure that a rapid intervention crew (RIC) / rapid intervention team (RIT) is established and available to immediately respond to emergency rescue incidents; 16. ensure that fire fighters wear a full array of turnout clothing and personal protective equipment that is certified by NFPA and appropriate for the assigned task while participating in fire suppression and overhaul activities. Additionally, code setting organizations and municipalities should: 1. require the use of automatic ventilation systems in commercial structures, especially ones that have large void spaces and other unique life-safety hazards; 2. require that fire alarm systems installed in commercial structures incorporate heat and smoke detectors in large void spaces to improve life-safety; 3. require all commercial cooking operations to have periodic inspections of their kitchen exhaust systems and require all kitchen exhaust system installers to be certified to nationally recognized standards. Additionally, the National Fire Protection Association (NFPA) should consider developing more comprehensive training requirements for fire behavior to be required in NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA 1021 Standard for Fire Officer Professional Qualifications.