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 F2009-23, 2010 Mar; :1-47
On August 24, 2009, a 45-year-old male career lieutenant (Victim #1) died following a partial floor collapse into a basement fire, and a 34-year-old male career fire fighter (Victim #2) was fatally injured while attempting to rescue Victim #1. The career fire department was dispatched for "an alarm of fire" with reported civilian(s) entrapment. Arriving units discovered a heavily secured mixed commercial/residential structure with smoke showing. Following failed initial attempts to locate an entry to the basement, crews located a door on Side 2 that provided access down a flight of stairs to a basement entry door. Repeated attempts were made to force open this basement door in order to search for trapped civilians, but crews had difficulty gaining access through this door because it was made of steel and locked and dead-bolted on both sides. Other crews on scene performed primary searches of the 1st and 2nd floors with no civilians found. Approximately 30 minutes into the basement fire, command ordered all interior crews to exit the structure to regroup because crews were still unable to gain access into the basement from Side 2. Additional manpower was sent with special tools to assist in breaching the basement door on Side 2. Victim #1 and two fire fighters from his crew entered into the structure from Side 1 to verify all fire fighters had exited a 1st floor deli. Victim #1, following a hoseline into the structure, was well ahead of the other two fire fighters when the 1st floor partially collapsed beneath him. Victim #1 fell with the floor into the basement, exposing him to the basement fire. The other two fire fighters immediately exited the deli after fire conditions quickly changed and shelving and displays fell on them; they were unaware of what had just occurred. Victim #1 made several Mayday calls from within the structure and activated his PASS device. Confusion erupted exteriorly on scene when trying to verify who was calling the Mayday, their exact location, and how they got into the basement. The incident commander was aware that he had crews attempting to gain access into the basement from Side 2 but was unaware that there had been a floor collapse within the deli section of the structure. Simultaneously, Victim #2, a member of the fire fighter assistance and search team (FAST), was standing by outside Victim #1's point of entry when the Mayday calls came out. It is believed that Victim #2 knew where Victim #1 was since he had gone in the structure with him earlier in the incident. Victim #2 grabbed a tool, went on air, and rushed into the structure. The FAST and additional personnel on scene concentrated on Side 2 initially while other fire fighters followed an unmanned hoseline into the deli. Crews within the deli quickly discovered a floor collapse and reported hearing a PASS device alarming. Victim #1 was immediately identified as missing during the first accountability check, but Victim #2 was not accounted for as missing until the third accountability check, more than 50 minutes after Victim #1's Mayday. After the fire was controlled, both victims were discovered side-by-side in the basement where the 1st floor had partially collapsed. They were found without their facepieces on and with SCBA bottles empty. Victim #1's PASS device was still alarming. They were pronounced dead on scene. Four fire fighters and one lieutenant suffered minor injuries during the incident. No civilians were discovered within the structure. Key contributing factors identified in this investigation include working above an uncontrolled, free-burning basement fire; interior condition reports not communicated to command; inadequate risk-versus-gain assessments; and, crew integrity not maintained. NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should: 1. Ensure that all personnel are aware of the dangers of working above a fire, especially a basement fire, and develop, implement, and enforce a standard operating procedure (SOP) that addresses strategies and tactics for this type of fire. 2. Ensure that the incident commander (IC) receives interior status reports and performs/continues evaluating risk-versus-gain. 3. Ensure that crew integrity is maintained at all times on the fireground. 4. Ensure that the incident commander (IC) receives accurate personnel accountability reports (PAR) so that he can account for all personnel operating at an incident. 5. Ensure that a separate incident safety officer, independent from the incident commander, is appointed at each structure fire. 6. Ensure that fire fighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures. Additionally, manufacturers, equipment designers, and researchers should: 1. Conduct research into refining existing and developing new technologies to track the movement of fire fighters inside structures. 2. 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).