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 F2011-13, 2012 Mar; :1-34
On June 02, 2011, a 48 year-old career lieutenant and a 53 year-old fire fighter/paramedic died in a multi-level residential structure fire while searching for the seat of the fire. Note: The residential structure where the fatalities occurred was built on a significantly sloped hillside common throughout the city. The fire floor was one floor below street level. Six companies and three command chiefs were dispatched to a report of an electrical fire at a residential home. When Engine 26, staffed with a lieutenant, fire fighter/paramedic (the victims), and driver arrived at approximately 1048 hours, they noticed light smoke showing as they made entry through the front door, side A, street level, of the building. Minutes later, the incident commander (IC) tried contacting them over the radio, but received no response. A battalion chief (BC) assigned to "the fire attack group" followed the hoseline through the door and spoke to the victims on the street level floor. The lieutenant stated to the BC that the fire must be a floor below them. The BC stated they would attack the fire from the side B of the structure and exited the front door. The victims did not follow. A few minutes later the IC again tried to contact Engine 26 via radio with no response. The crew from Engine 24, assigned to back up Engine 26, and a split crew from Rescue 1 tried to make entry through the door in the garage but could not advance due to the heat. The BC went to the side B door, located one floor below street level, and forced the door with the Engine 11 crew on the hoseline. They immediately felt a blast of heat from the fully involved basement area. The Rescue 1 crew backed out of the garage and re-entered on side B after the Engine 11 crew knocked down the large room and contents fire. At about the same time, the Engine 24 crew also backed out of the garage and followed the Engine 26 crew's hoseline through the front door. In zero visibility conditions, separate members of the Engine 24 crew independently found a downed member of the Engine 26 crew. The Incident Commander was alerted of a downed fire fighter but, did not initially realize, until moments later that it was actually two downed fire fighters. Both victims were removed from the structure and immediate medical treatment was provided. The victims were transported to the local medical center where the lieutenant was pronounced dead and the fire fighter/paramedic died two days later. Contributing Factors: 1. Construction features of the house built into a steep sloping hillside; 2. Natural and operational horizontal ventilation; 3. Ineffective size-up; 4. Fire fighters operating above the fire; 5. Ineffective fire command communications and progress reporting; 6. Lack of a personnel accountability system. Key Recommendations: 1. Ensure that standard operating guidelines (SOGs) for coordinated operations are developed and implemented for hillside structures; 2. Ensure that an adequate size-up of the structure is conducted prior to crews making entry; 3. Ensure staffing levels are maintained; 4. Ensure that a personnel accountability system is established early and utilized at all incidents; 5. Ensure that fireground operations are coordinated with consideration given to the effect horizontal ventilation has on the air flow, smoke, and heat flow through the structure; 6. Ensure that the Incident Commander is provided a chief's aide at all structure fires; 7. Ensure that an incident safety officer is assigned to all working structure fires; 8. Ensure that fire fighters are trained in Mayday procedures and survival techniques. Additionally: 1. Continue research and efforts to improve radio system capabilities; 2. Adopt and enforce regulations for automatic fire sprinkler protection in new buildings and renovated structures.