F2005

04

A summary of a NIOSH fire fighter fatality investigation June 13, 2006

Career Fire Fighter Dies While Exiting Residential Basement Fire -

New York

SUMMARY
On January 23, 2005, a 37-year-old male career NIOSH investigators concluded that, to minimize
fire fighter (the victim) died while exiting a the risk of similar occurrences, fire departments
residential basement fire. At approximately should:
1337 hours, crews were dispatched to a reported
residential structure fire. Crews began to arrive • ensure that the first arriving officer or
on the scene at approximately 1340 hours and incident commander (IC) conducts a
at approximately 1344 hours, the victim, a fire complete size-up of the incident scene
fighter and officer made entry through the front
door and proceeded down the basement stairwell • ensure that fire fighters conducting interior
to conduct a search for the seat of the fire using a operations provide progress reports to the
thermal imaging camera (TIC). At approximately Incident Commander
1346 hours, the victim and officer began to exit
the basement when they became separated on the • establish standard operating procedures
lower section of the stairwell. The officer reached (SOPs) regarding thermal imaging camera
the front stoop and realized that the victim had (TIC) use during interior operations
failed to exit the building. He returned to the
top of the basement stairs and heard a personal • ensure that MAYDAY procedures are
alert safety system (PASS) alarm sounding followed and refresher training is provided
in the stairwell and immediately transmitted annually or as needed
a MAYDAY for the missing fire fighter. The
victim was located at approximately 1349 hours, • ensure that a rapid intervention team (RIT)
and numerous fire fighters spent the next twenty is on the scene and in position to provide
minutes working to remove the victim from the immediate assistance prior to crews entering
building. At approximately 1413 hours, the a hazardous environment
victim was transported to an area hospital where
he was later pronounced dead.
The Fire Fighter Fatality Investigation and Prevention
Program is conducted by the National Institute for
Occupational Safety and Health (NIOSH). The purpose of
the program is to determine factors that cause or contribute to
fire fighter deaths suffered in the line of duty. Identification of
causal and contributing factors enable researchers and safety
specialists to develop strategies for preventing future similar
incidents. The program does not seek to determine fault or
place blame on fire departments or individual fire fighters.
To request additional copies of this report (specify the case
number shown in the shield above), other fatality investigation
reports, or further information, visit the Program Website at
www.cdc.gov/niosh/fire/
or call toll free 1-800-35-NIOSH
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Career Fire Fighter Dies While Exiting Residential Basement Fire - New York

• educate homeowners on the importance of 11,500 uniformed fire fighters that serve a
installing and maintaining smoke detectors population of about 8,000,000 in a geographic
on every level of their home and keeping area of approximately 321 square miles.
combustible materials away from heat
sources. Training and Experience
The department requires all fire fighters
Although there is no evidence that the following to complete the fire department’s 13-week
recommendation could have specifically Probationary Fire Fighter’s School. Candidates
prevented this fatality, NIOSH investigators must be Certified First Responders to become
recommend that fire departments should: probationary fire fighters. Probationary fire
fighters are instructed in hydraulics and learn
• ensure that fire fighting teams check each the basics of fire suppression systems and fire-
other’s personal protective equipment (PPE) fighting tactics.
for complete donning.
The victim had 10 years of experience with this
INTRODUCTION department and had completed an extensive
On January 23, 2005, a 37-year-old male career fire list of training courses which included: Fire
fighter (the victim) died while exiting a residential Suppression and Control, Building Construction
basement fire. On January 25, 2005, the U.S. and Firefighter Safety, Tactical Roof Operations,
Fire Administration notified the National Institute Hazardous Material Operations, Ladder Company
for Occupational Safety and Health (NIOSH) of Chauffeur and Tactical Private Dwelling Fire.
this incident. On March 23, 2005, three Safety
and Occupational Health Specialists from the Equipment and Personnel
NIOSH Fire Fighter Fatality Investigation and 1337 hours dispatch - Initial dispatch
Prevention Program investigated this incident. included:
Meetings were conducted with the Chief Officers Engine 290 (Officer, fire fighter/driver, Fire
assigned by the department to investigate this Fighter #4, Fire Fighter #5 and two other fire
incident and representatives from the Uniformed fighters);
Firefighters Association and the Uniformed Fire Ladder 103 (Officer, fire fighter/driver, victim,
Officers Association. Interviews were conducted Fire Fighter #1, Fire Fighter #2 and Fire Fighter #3);
with officers and fire fighters who were at the Engine 332 (Officer, fire fighter/driver and four
incident scene. The investigators reviewed the fire fighters);
victim’s training records, autopsy report, and Ladder 175 (Officer, fire fighter/driver and four
death certificate. NIOSH investigators also fire fighters);
reviewed the department’s fireground standard Engine 236 (Officer, fire fighter/driver and four
operating procedures (SOPs)1, a transcription of fire fighters);
Squad 252 (Officer, fire fighter/driver and four
the dispatch tapes, and the department’s report of
this incident. The incident site was visited and fire fighters);
photographed. Rescue 2 (Officer, fire fighter/driver and five fire
fighters);
Fire Department and Battalion 44 (Battalion Chief and fire
This career department consists of approximately fighter/driver).

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Career Fire Fighter Dies While Exiting Residential Basement Fire - New York

1338 hours dispatch - not significantly delay response times. The

Engine 231 (Officer, fire fighter/driver and four approximate temperature at the time of the
fire fighters). incident was 20 degrees Fahrenheit with an
estimated wind chill of 0 degrees Fahrenheit.
1340 hours dispatch – The average wind speed was 24 miles per hour
Ladder 107 (Officer, fire fighter/driver, and three (mph) with gusting winds reaching 48 mph from
fire fighters); the north.
and Battalion 58 (Battalion Chief and fire
fighter/driver). INVESTIGATION
On January 23, 2005, a 37-year-old male career
1341 hours dispatch – fire fighter (the victim) died while exiting a
DC 15 (Deputy Chief and fire fighter/driver). residential basement fire. At approximately
1337 hours, crews were dispatched to a reported
Additional units were dispatched; however, only residential structure fire. At approximately
those units directly involved in the operations 1340 and 1341 hours, Engine 290 and Ladder
preceding the fatal event are discussed in the 103 arrived on the scene, respectively. The
investigation section of this report. officer from Engine 290 was informed by the
resident of the structure that the fire was in the
Structure basement. The officer verified the location of the
The incident site was a detached two family, fire as being in the basement when he opened the
two story, wood frame structure measuring interior basement door. The Engine 290 crew
approximately 25-feet wide and 50-feet in began stretching a 1 ¾-inch handline toward the
length. The entrances to the first and second floor front of the building. Ladder 107, Engine 332,
residences were located in the front of the building Engine 236, Ladder 175 and Battalion 44 arrived
at the top of a concrete staircase approximately on the scene. At approximately 1343 hours, the
5-feet above grade level. There was an external officer, victim and Fire Fighter #1 from Ladder
below-grade entrance to the basement located 103 donned their SCBA face masks at front door
in the rear (Side 3) of the structure (Diagram “B” as the Ladder 107 crew made entry through
1). There were security bars on the basement front door “A” to conduct a primary search for
and first floor windows, and security gates on occupants on the second floor (Photo 1). Fire
both of the front door entrances (Photo 1) and Fighter #2 and Fire Fighter #3 from Ladder 103
the rear basement entrance. Door “A” allowed proceeded to the rear (Side #3) of the structure
access only to the second floor residence. Door (Photo 2 and Diagram 1) as Engine 231 arrived
“B” only allowed access to the basement and on the scene.
first floor residence. The interior stairwell to the
basement was located approximately 3-feet from At approximately 1344 hours, the Ladder 103
the first floor entranceway (Door “B”). officer, victim and Fire Fighter #1 made entry
through front door “B” and proceeded down the
Weather basement interior stairwell to conduct a search
A recent snow storm had deposited 12 to 18 for the seat of the fire (Diagram 2). The officer
inches of accumulated snow. The department’s carried a thermal imaging camera (TIC). Fire
report stated that the snow had slowed, but did Fighter #1 stopped on the stairwell’s half-landing

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while the victim and Ladder 103 officer continued scene and observed fire venting from the basement
toward the basement. The Engine 290 officer and window on Side #2 and the officer from Ladder
Fire Fighter #4 advanced a 1 ¾-inch handline 107 observed fire and heavy smoke venting from
down the interior stairwell, until they reached the the basement door and window on Side #3. The
half-landing. Fire Fighter #5 remained at the top officer radioed the Battalion 44 Chief Officer
of the stairs and assisted in feeding the handline and requested that a handline be brought to Side
down the interior stairwell. Note: The Engine 290 #3. The Battalion 44 Chief Officer ordered the
officer’s helmet was knocked off of his head by Engine 332 crew to take their handline to Side #3.
a large loop of hose in the handline. His helmet His plan was to utilize the basement entrance on
fell down the stairs and he operated without it Side #3 as the point of access for the attack line
for the duration of the interior operations and (Engine 332 handline).
received first and second degree burns to his
forehead while working on the half-landing. Fire The Engine 290 Officer ordered Fire Fighter #2
Fighter #2 and Fire Fighter #3 from Ladder 103 and Fire Fighter #3 to exit the stairwell. The
forced open the exterior basement door on Side Ladder 103 Officer, standing near the victim
#3. A second 1 ¾-inch handline was stretched in the basement, approximately 10 feet from
from Engine 290 toward the front of the structure. the stairs, heard the crews on the half-landing
Fire fighters from Ladder 107 began removing operating their handline. Unable to see the screen
the window bars on the front basement window on the TIC due to the heavy smoke conditions,
(Side #1). Note: Several fire fighters reported the officer told the victim “Let’s go.” The victim
to NIOSH investigators that they had to don responded with an “Okay.” The Engine 290
their SCBA face masks while operating on Side Officer then ordered Fire Fighter #4 and Fire
#1 of the structure due to the heavy thick smoke Fighter #5 to exit the stairwell. As the Ladder
pushing out the front door. 103 Officer and victim reached the stairs they
heard the Engine 290 officer yell “Get out.” The
At approximately 1345 hours, the officer from officer and victim began ascending the lower
Engine 290 ordered Fire Fighter #4 to open the section of the interior stairwell. Fire Fighter
nozzle in an attempt to cool the stairwell area. #4 was knocked over while operating on the
Fire Fighter #4 hit the stairwell, leading down half landing. His face mask and helmet were
into the basement, with a short burst of water. dislodged as the members attempted to ascend
The officer ordered the nozzle to be opened again the stairwell. Fire Fighter #4 was forced to then
as the heat increased. Fire Fighter #2 and Fire place the nozzle on the stairwell to adjust his face
Fighter #3 from Ladder 103 made entry into the mask and helmet, and then exited the building.
basement on Side #3 as two fire fighters from The officer continued up toward the first floor,
Ladder 107 vented the middle and rear basement not knowing that the victim was not with him.
windows on Side #4 while they attempted to Two fire fighters from Ladder 107 vented the
remove the window bars (see Photo 2). basement window on Side #1 after removing the
window bars.
At approximately 1346 hours, a heavy fire
condition was observed in the basement by At approximately 1347 hours, the victim became
interior and exterior crews. The Battalion 44 separated from his officer while ascending the
Chief Officer (Officer in charge) arrived on the lower half of the interior stairwell. The Ladder

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103 officer exited the structure and found Fire Numerous fire fighters spent the next twenty
Fighter #1 out on the front stoop. The officer minutes working to remove the victim from the
quickly realized that the victim had failed to exit building. The narrow stairwell, objects on the
the building. half-landing and extremely high heat and zero
visibility conditions hampered the rescue effort
At approximately 1348 hours, the Ladder 103 (see Photo 3 and Photo 4). The hook at the end
officer returned to the interior front basement of the life rescue rope was attached to the victim’s
stairs where he heard a personal alert safety SCBA harness and stretched to the front lawn
system (PASS) alarm sounding in the stairwell. where fire fighters were able to assist with getting
The officer was unable to descend the stairs due the victim up the stairs. At approximately 1410
to the extreme heat conditions. He immediately hours, the victim was removed from the building.
transmitted a MAYDAY for the missing fire At approximately 1413 hours, the victim was
fighter. Note: The Battalion 44 Chief Officer transported to an area hospital where he was later
did not hear this transmission. Ladder 120, pronounced dead.
dispatched as the fire fighter assist and safety
team (FAST), equivalent to a rapid intervention INJURIES
team (RIT), arrived on the scene and heard the Nine members involved in the rescue effort were
MAYDAY transmission. The Battalion 58 Chief injured. Two members suffered from smoke
Officer also arrived on the scene at this time. The inhalation and seven members received burn
Engine 290 officer, standing next to the Ladder injuries.
103 officer at the front door, pulled the handline
up the stairs and had members begin spraying CAUSE OF DEATH
water down the stairwell in order to protect the The autopsy report listed the victim’s cause of
Ladder 103 officer and Fire Fighter #1 as they death as smoke inhalation (Carboxyhemoglobin
descended the stairs. level was 24% saturation) and burns of the head,
torso and upper extremities (third degree burns on
The officer followed up with a second MAYDAY approximately 63% of body surface area).
transmission at approximately 1349 hours when
he found the victim. Note: Numerous crews RECOMMENDATIONS/DISCUSSION
on the fireground believed that the MAYDAY Recommendation #1: Fire departments should
was made by the fire fighter in distress. The ensure that the first arriving officer or incident
Battalion 44 Chief Officer heard this MAYDAY commander (IC) conducts a complete size-up of
transmission and immediately radioed a request the incident scene.
for a second alarm. The victim’s upper body
was lying on the half-landing; his facemask was Discussion: The initial size-up conducted by
dislodged, and the rest of his body was on the the first arriving officer or incident commander
lower half of the stairs (Photo 3). The victim’s (IC) allows the officer to make an assessment
PASS was in full alarm. The Division 15 of the conditions and to assist in planning the
Chief Officer arrived on the scene and assumed suppression strategy. The following general
command (Incident Commander) after a brief factors are important considerations during a
exchange of information from the Battalion 44 size-up: occupancy type involved, potential for
Chief Officer. civilians in the structure, smoke conditions, type

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of construction, age of structure, exposures, and usually provides the only vent to the below grade
time considerations such as time of incident, time fire exposing fire fighters to smoke, heat and
fire was burning before arrival, and time fire was flame venting up the stairwell. Taking a hose
burning after arrival.2 The evaluation of risk is line down a burning basement stairway makes
an assignment that the first arriving officer or this type of incident one of the most dangerous
Incident Commander is designated to conduct. jobs a fire fighter must perform.4
The Incident Commander or Officer in Charge
must perform a risk analysis to determine what A size-up report was not provided to Central
hazards are present, what the risks to personnel Dispatch or responding units. There were no
are, how the risks can be eliminated or reduced, reports of civilians inside the structure nor were
the chances that something may go wrong, and any civilians located in the building at anytime
the benefits to be gained.3 during or after the incident.

The fire department involved in this incident Recommendation #2: Fire departments should
has an established standard operating procedure ensure that fire fighters conducting interior
(SOP) on the requirements and purpose of operations provide progress reports to the
providing a preliminary report. The SOP Incident Commander.
defines a preliminary report as: The report of
the Incident Commander at a fire or emergency. Discussion: Frequent progress reports are
The preliminary report shall include a brief essential to the Incident Commander’s (IC’s)
description of the situation, the identity of the or Officer in Charge continuous assessment and
units at work and the status of the balance of size-up of the incident and are required as per the
the assignment.1 The preliminary report is fire department's standard operating procedures.1
transmitted to the dispatcher and provides Chief Interior crews and crews working in areas not
Officers and fire department officials with a clear visible to the IC are the eyes and ears of the IC.
and accurate sense of the conditions existing at Progress reports also provide everyone on the
the scene of the fire or emergency. fireground with information on other aspects
of the fire that relate to their own particular
The first arriving officer conducted a partial size- operations (e.g., ventilation, suppression, primary
up in terms of evaluating the conditions and type search, etc.).2
of building, the location of the fire (basement)
and exposures. A complete size-up would have The interior crews experienced high heat
involved a walk-around of the entire building conditions with zero visibility. The crew
allowing the officer to evaluate all four sides of advancing the handline down the interior stairwell
the building. The partial size-up only allowed the had difficulty in descending the narrow stairwell
officer to see Sides #1, #2 and #4, and not Side and never reached the basement level where the
#3 that had a basement level access. Entering seat of the fire was located. Progress reports
and attacking the fire on the basement level were not provided to the IC by the interior crews.
provides fire fighters with better access and less This information is needed by the IC in order to
exposure to high heat conditions and products establish a plan of action and continually assess
of combustion. In contrast, an interior stairwell the risk versus gain.

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Recommendations #3: Fire departments should would help fire fighters understand how the TIC
establish standard operating procedures (SOPs) can best be utilized to support and enhance basic
regarding thermal imaging camera (TIC) use fire fighting tactics.
during interior operations.
The Ladder 103 Officer utilized a TIC as part of
Discussion: The fire department involved the interior size-up as he entered the structure
in this incident did not have an established with the victim. The officer and victim entered
standard operating procedure (SOP) regarding the structure ahead of the crew advancing the
thermal imaging camera (TIC) use at structure handline, reached the basement level, but were
fires. The fire department had posted a training unable to see the screen on the TIC due to the
bulletin (October 26, 2000) regarding thermal zero visibility environment.
imaging camera use and maintenance prior to
the incident. The training bulletin addressed the Recommendation #4: Fire departments should
camera’s operating features (e.g. how temperature ensure that MAYDAY procedures are followed
variations appear on the screen) and when and refresher training is provided annually or
the camera is to be used to augment existing as needed.
department procedures for search and rescue. The
training bulletin listed some possible applications Discussion: As soon as fire fighters become lost
such as whenever a search rope is used, at high- or disoriented, trapped or unsuccessful at finding
rise fires, etc. their way out of a hazardous situation (e.g.,
interior of structure fire), they must recognize
There is no mention in the training bulletin of how that fact and initiate emergency traffic.5 They
the officer utilizing the TIC will coordinate their should manually activate their personal alarm
assignment (e.g., size-up, primary search, etc.) safety system (PASS) device and announce a
with other crews operating in their vicinity. SOPs “MAYDAY” over the radio. A “MAYDAY” call
would provide a basis for operations involving will receive the highest communications priority
the use of a TIC in conjunction with other crews from Central Dispatch, Incident Command, and
operating on the fireground. For example, if the all other units. Information regarding last known
TIC is to be utilized in conjunction with the initial location, crew assignments, and identity of the
attack line, the user of the TIC must be within the lost fire fighter provides the RIT with important
vicinity of the nozzle operator. This serves two clues in locating the missing/lost member. The
purposes: 1) The handline would be in a position sooner Incident Command is notified and the
to provide protection for the TIC operator and RIT is activated, the greater the chance of the fire
crew members operating in the vicinity of the fighter being rescued.6
nozzleman, and 2) The operator of the TIC could
guide the nozzleman in stream placement after The steps included in the department’s standard
pointing out the hot spots, the seat of the fire, and operating procedures require that “If possible, the
any high heat conditions that may pose a hazard officer will immediately press his/her emergency
to crews operating in the vicinity. alert button, and then contact the Incident
Commander in the following format: “MAYDAY-
Fire departments should also provide training on MAYDAY-MAYDAY. Ladder 103 to Battalion
the proper use and the limitations of TICs. This 44, MAYDAY.”1 The SOPs also require that

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the person transmitting the MAYDAY identify “At least one dedicated rapid intervention crew/
who they are, what the MAYDAY is for, and the company shall be standing by with equipment
victim's location. to provide for the rescue of members that are
performing special operations or for members
Investigators were unable to determine, through that are in positions that present an immediate
interviews, whether the victim had manually danger of injury in the event of equipment failure
activated his PASS device or if the device had or collapse.”7
gone into alarm mode. Investigators were also
unable to determine if the victim had attempted at A fire fighter assist and safety team (FAST),
any time to transmit a “MAYDAY.” The victim’s equivalent to a rapid intervention team (RIT) or
officer radioed “MAYDAY” when he heard a PASS rapid intervention crew (RIC), was assigned and
alarm sounding in the stairwell where he believed en route to this incident. Ladder 120 was the
the victim was located. The victim’s location designated FAST and arrived on the scene when
and his identity were not provided in the first the initial “MAYDAY” was transmitted. Fire
“MAYDAY” transmission and the “MAYDAY” fighters standing by on the front lawn were the first
was not received or acknowledged by the IC, the to assist the Ladder 103 Officer and Fire Fighter
FAST team, or Central Dispatch. The victim’s #1 with the victim. The narrow stairwell, high
officer transmitted a second “MAYDAY” upon heat/low visibility environment and objects on
finding the victim (approximately 1 minute after the stairwell landing made it difficult to move the
initial “MAYDAY”) that was heard by the IC and victim up the stairwell. Numerous fire fighters, in
the FAST team staged on the front lawn. an attempt to assist with the rescue effort, blocked
the area on the landing to the front door making it
Recommendation #5: Fire departments should difficult for fire fighters entering and exiting the
ensure that a rapid intervention team (RIT) is on front door during the rescue attempts. The RIT
the scene and in position to provide immediate must have an unobstructed entry/egress point in
assistance prior to crews entering a hazardous order to facilitate the rescue effort. Assigning a
environment. Chief Officer to monitor the entry/egress point
would ensure that the area would remain clear
Discussion: Fire departments should have a and unobstructed and that only those members
rapid intervention team (RIT) standing by during assigned to the rescue assignment are working
any fire to rescue a trapped, injured, or missing in the area.
fire fighter.5 NFPA 1500, 8.5.5 states “In the
early stages of an incident, which includes the Recommendation #6: Fire departments should
deployment of the fire department’s initial attack educate homeowners on the importance of
assignment, the rapid intervention crew/company installing and maintaining smoke detectors on
shall be in compliance with 8.4.11 and 8.4.12 every level of their home and keeping combustible
and be either one of the following: 1) On-scene materials away from heat sources.
members designated and dedicated as rapid
intervention crew/company, or 2) On-scene Discussion: When fire breaks out, the smoke
members performing other functions but ready alarm, functioning as an early warning system,
to re-deploy to perform rapid intervention crew/ reduces the risk of dying by nearly 50 percent.8
company functions.”7 NFPA 1500, 8.5.7 states In the event of a fire, properly installed and

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maintained smoke alarms will provide an early Recommendation #7: Although there is no evi-
warning signal to occupants. This allows for dence that the following recommendation could
early reporting to emergency services and a have specifically prevented this fatality, NIOSH
quicker response by fire department personnel investigators recommend that fire departments
allowing fire fighters to reach and attack the should ensure that fire fighting teams check
fire in an earlier growth stage. Homeowners each other’s personal protective equipment
should follow the manufacturer’s installation (PPE) for complete donning.
instructions.8
Discussion: The key to proper and effective use
Witness statements provided to investigators of PPE is the development of good habits that
from the Fire Marshal’s Office mention that include fast, proper and complete donning of the
there were two smoke detectors and one fire appropriate PPE ensemble. Fire fighting teams
extinguisher located in the basement. However, should check each others’ PPE to help ensure that
there were no statements regarding whether the the equipment is fully and completely donned.
smoke detectors were operational at the time This team check will help prevent burn or injury.
of the fire. There were no reports of anyone To minimize the risk of burn injuries to the head
hearing a smoke detector alarming at anytime. region, it is important to ensure that the hood is
The homeowners were in the kitchen and dining donned correctly to provide maximum protec-
room area of the first floor when they first noticed
tion to the ears, neck and face (not protected by
the smell of smoke. One of the residents opened the SCBA face mask). Care must be taken to
the door leading down to the basement and ensure that the hood does not interfere with the
observed smoke in the stairwell. He got the fire face-to-face seal. Collars must be turned up to
extinguisher from the kitchen and attempted to protect the wearer’s neck and throat (the front of
descend the stairs but was turned back due to the the collar must be fastened to protect the throat
high volume of smoke. He closed the basement area). The ear flaps on the helmet must be pulled
stairwell door and evacuated his family from down to protect the back of the neck and the ears.
the house while calling 911. The fire had been The chin strap on the helmet must be fastened
burning for an undetermined time prior to the around the chin without obstructing the SCBA’s
family discovering and reporting the fire. This regulator hose to ensure that the helmet stays in
delayed report of the fire may have led to the place upon impact.6
fire growing to a more advanced stage making it
more difficult and dangerous for the fire fighters REFERENCES
to establish an initial attack. 1. New York fire department [2005]. Standard
operating procedures.
The fire was listed by the fire investigators as being
accidental in nature as a result of combustibles 2. Klaene BJ and Sanders RE [2000]. Structural
in close proximity to a portable electric heater. fire fighting. Quincy, MA: National Fire Protection
Fire departments can provide public service Association, pp. 57-63.
announcements educating the residents of their
communities on the hazards of storing flammable 3. Kipp JD and Loflin ME [1996]. Emergency
materials close to ignition sources (e.g., portable incident risk management. New York: Van
electric heaters). Nostrand Reinhold, p. 253.

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4. Dunn V [1999]. Command and control of program. Quincy, MA: National Fire Protection
fires and emergencies. Saddle Brook, NJ: Fire Association.
Engineering Books & Videos, p. 257.
8. U.S. Fire Administration [2006]. Smoke
5. Dunn V [1992]. Safety and survival on the alarms. Accessed January 30, 2006 at http://www.
fireground. Saddle Brook, NJ: Fire Engineering usfa.fema.gov/safety/alarms
Books & Videos, p. 131.
INVESTIGATOR INFORMATION
6. Fire Fighter’s Handbook [2000]. Essentials This incident was investigated by Mark McFall,
of firefighting and emergency response. New Virginia Lutz and Steve Berardinelli, Safety and
York: Delmar Publishers, pp. 130-131 and pp. Occupational Health Specialists, Surveillance
692-693. and Field Investigations Branch, Division of
Safety Research, NIOSH. The report was written
7. NFPA [2002]. NFPA 1500. Standard on fire by Mark McFall.
department occupational safety and health

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Diagram 1. Aerial view of incident scene

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Diagram 2. Aerial view of interior stairwell and basement

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Photo 1. View of Side 1 of incident building

Photo 2. Rear view of incident building (Side 3)

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Photo 3. View of interior stairwell half-landing

Photo 4. View of half-landing after removal of debris

Page 14
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