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 F2009-10, 2009 Nov; :1-13
On January 2, 2009, a 57-year-old male career fire fighter (the victim) was fatally injured when he was backed over while spotting an apparatus on the fire scene. The victim was the acting captain the night of the incident and responded in an engine with a crew of three to a reported working structure fire. While enroute, the engine had received a radio message to forward lay and supply water for an elevated master stream. Due to the location of the fire structure and hydrant the crew had to lay the supply line beneath a highway overpass. Upon arrival, the engine chauffeur had to drive around a police cruiser and tow truck in order to position the engine to an available hydrant. The engine then dropped off a fire fighter at the hydrant to prepare a forward lay when the incident commander advised them to do a reverse lay. The victim then exited the engine to guide the chauffeur while he backed the engine around the police cruiser and tow truck. The victim walked down the officer's side of the engine and positioned himself at the rear on the officer's side. The fire fighter positioned himself at the driver's side front bumper. The chauffeur was able to negotiate the engine around the police cruiser and tow truck without incident before straightening up to position a feeder line into the scene. The victim walked backwards keeping eye contact with the chauffeur via the officer's side mirror. While backing, the chauffeur noticed the tow truck drive past him toward the scene. He focused his attention on the tow truck momentarily when he felt the truck run over something. A police officer yelled to the chauffeur to stop the engine because something or someone was just run over. The victim was found underneath the engine just in front of the officer's side rear wheels. He was transported to a local metropolitan hospital where he was pronounced dead. The chauffeur was not cited in the fatal incident. Key contributing factors identified in this investigation include loss of direct communications between driver and spotter, driver distractions, possible loss of footing by the victim, and possible failure of the automatic reverse braking system. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should: 1. Ensure that standard operating procedures (SOPs) are developed, implemented, and enforced on safe backing of fire apparatus (e.g., visual and audio communication, use and position of spotter(s)) and include adequate training and testing methods (e.g. written and practical tests) to ensure fire fighter comprehension. 2. Consider evaluating current safety equipment used on fire apparatus to assist drivers during backing operations and consider supplementary safety equipment (e.g., additional mirrors, automatic sensing devices, and/or video cameras) for further assistance. 3. Implement proper procedures for inspection, use, and maintenance of safety equipment used to assist in the backing of fire apparatus to ensure the equipment functions properly when needed.