REPORT F2020-10 • DATE 3/28/2022

Career Captain and Career Firefighter Die After Running Out of Air
During a Search in a Public Library – California
Executive Summary
On February 18, 2020, a 35-year-old career captain and a
25-year-old career firefighter died searching for a reported
civilian using a walker in a public library. At 1616 hours,
the communication center dispatched Engine 71, Engine
72, Truck 73, and Battalion 77 to a commercial structure
fire at the library caused by arson. A minute later, a city
police officer arrived, made entry, and reported the first
floor was clear. At approximately 1618 hours, Engine 71
arrived with a captain, firefighter, and engineer from the
fire station. The rear of the fire station shares a common
wall with the rear of the library. The captain reported
heavy smoke from Side Alpha. Battalion Chief 70 also
responded from the adjacent fire station. A bystander
informed a second police officer that a woman with a
walker was on the second floor. The Engine 71 crew made
entry without a hoseline and without informing Battalion
Chief 70. At approximately 1621 hours, Battalion 77
arrived on scene, assumed command, and advised everyone Fire Structure Side Alpha
go to Channel 2. Battalion 77 saw Engine 71 in front of the (Photo Courtesy of City Building
building and tried to contact the Engine 71 captain on Inspector)
Channel 2 to confirm they were in the building. A minute
later, the Engine 71 captain contacted Battalion Chief 77 on Channel 1 and reported they cleared Division 2
and were headed to the stairwell for Division 1. At 1626 hours, fire conditions had worsened, and Battalion
Chief 77 declared a defensive attack and attempted multiple times to radio the Engine 71 captain on
Channels 1 and 2 with no response. At 1631 hours, a rapid intervention team (RIT) was assembled and
made entry to locate the Engine 71 crew. A minute later, the fire chief arrived, and the Engine 71 captain
called a Mayday from Division 2. The Engine 71 captain stated that he and his firefighter were running low
on air in the banquet room and were trying to locate the stairs. At 1638 hours, the RIT reported no fire and
zero visibility in the stairwell to the second floor. The RIT could hear activated PASS alarms. The Engine
71 captain was located in a bathroom and handed off to a second RIT because the first RIT was low on air.

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The captain was removed from the building and later died at the hospital. Several more RIT attempts were
made to locate the Engine 71 firefighter. Efforts were suspended due to progressing fire conditions and
collapse of the building. The Engine 71 firefighter was located by an urban search and rescue team (USRT)
late the next day and was extricated from the building the following morning by the USRT and his fire
department members.

Contributing Factors
• Air management factors at the task and tactical level
• Risk assessment/size up difficulties
• Primary search without a tagline or hoseline in a large commercial occupancy
• Large area search in an occupied structure (public library)
• Ineffective Mayday procedures and survival techniques
• Residential tactics in a commercial structure
• Crew integrity lost during search
• Radio/communication difficulties
• Lack of sprinkler system
• Rapid fire growth.

Key Recommendations
• Fire departments should ensure all firefighters are trained on and actively practice air management
principles.
• Fire departments should use risk management principles at all structure fires.
• Fire departments should ensure that primary search crews and RIT advance with a hoseline or
tagline in commercial or complex structures.
• Fire departments should ensure all firefighters are trained in large area search procedures.
• Fire departments should ensure firefighters are trained in situational awareness, personal safety,
and accountability.
• Fire departments should ensure firefighters are trained in Mayday procedures and survival
techniques.
• Fire departments should develop and implement standard operating procedures/guidelines to define
fireground strategies and tactics for commercial structures.
• Fire departments should ensure all members engaged in emergency operations receive annual
proficiency training and evaluation on fireground operations, including operations within
commercial structures.
• Fire departments should ensure crew integrity is properly maintained by voice or radio contact
when operating in an atmosphere that is immediately dangerous to life and health (IDLH).
• Fire departments should ensure all firefighters are trained on radio discipline and proper use,
including using the emergency alert button (EAB) on their portable radio.
• Fire departments should ensure firefighters and officers are trained in understanding fire
development and growth during size-up, and that incendiary fires can rapidly develop and grow
beyond predictions.

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• Fire departments should incorporate the principles of command safety into the incident management
system during the initial assumption of command to ensure strategic-level safety responsibilities are
incorporated into the command functions throughout the incident.

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine
deaths of firefighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these
incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations
are intended to reduce or prevent future firefighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any
other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to
develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH
summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and
recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

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Career Captain and Career Firefighter Die After Running Out of

Air During a Search in a Public Library – California
Introduction
On February 18, 2020, a 35-year-old career captain and a 25-year-old career firefighter died searching
for a reported civilian using a walker in a public library. On February 20, 2020, the U.S. Fire
Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this
incident. On February 23 - March 3, 2020, a general engineer, two occupational safety and health
specialists, and a technical information specialist from the NIOSH Fire Fighter Fatality Investigation
and Prevention Program traveled to California to investigate this incident. The NIOSH investigators
met with fire department officials, including the fire chief, battalion chiefs, captains, and firefighters
involved in the incident. The NIOSH investigators also met with representatives of the International
Association of Fire Fighters local, representatives from the city manager’s office, the buildings and
inspection services inspector, and local police. The NIOSH investigators visited the city’s dispatch
center and obtained a copy of the fireground audio; visited the incident site; and conducted interviews
with the fire department officers and firefighters directly involved in the incident, which included
several mutual aid fire departments. The NIOSH investigators inspected and photographed the victims’
personal protective clothing and the self-contained breathing apparatus. They also reviewed fire
department training records and standard operating procedures.

Fire Department
The combination fire department provides fire protection and life safety services to an area
encompassing 18.7 square miles and a population greater than 60,000. The city encompasses a diverse
range of structures from populated multi-family dwellings, single-family residential occupancies, 25
schools, a college, 4 nursing homes, a hospital, numerous hotels, commercial structures, churches, and
a municipal airport. Additionally, the fire department provides automatic and mutual aid within the
county totaling 405,348 residents.

The fire department operates six engines, a ladder truck, a rescue vehicle, three patrol vehicles
(wildland brush trucks), five command vehicles, and several utility vehicles out of three fire stations.
The fire department is staffed by 42 career and 15 volunteer uniformed personnel that provide
firefighting for structural and wildland fires, rescue and hazardous materials operations, and basic life
support services. The minimum daily staffing is 10 front line personnel and a Battalion Chief (BC).

The fire department responded to a total of 5,359 incidents (including 369 fires and 100 hazardous
material incidents) during 2019. The fires involved 40 structures, 32 vehicles, 112 vegetation, and 185

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other classified fires. The first alarm structure fire response consists of two engines, a ladder truck, a
patrol vehicle, a BC, and a county mutual aid engine driven by a firefighter.

The fire department has written policies and procedures which are available to all department members
within their stations. These policies and procedures have been implemented and some were in various
stages of revision at the time of this incident.

Training and Experience

The operations division has primary responsibility for emergency response and preparedness within the
city. The division includes a training captain responsible for management of the department’s annual
training programs and coordination of emergency management response and preparedness activities
with city staff. Daily supervision and leadership of the division is provided by the battalion chief of
operations. Fire department personnel participate in drills and classes throughout the year, including
basic firefighter skills, emergency medical technician skills, hazardous materials response, technical
rescue, and disaster management.

The department also has a regional training facility that hosts courses providing instruction to students
from the region and the state. These courses range from state fire training courses, a national fire
academy course, public works courses, and police officer special weapons and tactics. The Fire
Department’s training division is also responsible for the city’s National Incident Management System
(NIMS) compliance program.

The state requires all firefighters be 18 years of age, have a valid driver’s license, and complete
California Fire Fighter 1 certification which contains three levels of professional qualifications set by
the National Fire Protection Association (NFPA). The three levels are:

• NFPA 1001: Fire Fighter 1

• NFPA 1051: Wildland Fire Fighter 1
• NFPA 1072: Hazardous Material Awareness and Operations

These qualifications are documented in the Fire Fighter 1 Certification Training Standards (CTS). The
State Fire Training agency coordinated the development of the CTS guide, certification, and associated
curriculum. The Statewide Training and Education Advisory Committee and the State Board of
Fire Services recommended these standards and qualifications for adoption by the Office of the State
Fire Marshal for all new firefighters.

The recruit academy is based on the firefighter professional qualifications contained in NPFA 1001.
The academy runs for a total of 16 weeks. The first 3 weeks focus on Emergency Medical Technician
(EMT) training (120 hours) followed by 13 weeks of fire operations training (520 hours).

The fire department hiring process for the fire recruit position requires that applicants have a valid
EMT certification from the state of California or from the National Registry of Emergency Medical
Technicians before being hired. Applicants are tested in the disciplines of reading, math, video
scenarios, and the national testing network’s mechanical aptitude test as it pertains to the firefighter

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position. Based on the results of the test, the most successful applicants are scheduled to perform a
Physical Ability Test. The Physical Ability Test consists of completing typical firefighting tasks in a
timely manner while wearing safety equipment, turnout gear, breathing apparatus, helmet, and
structural firefighting gloves. Candidates are then selected to participate in potentially two rounds of
interviews, the first with the fire department’s fire captains and the second with the fire department’s
chief officers. Based on the results of the interviews, candidates receive a conditional job offer and
then receive background checks and medical and psychological testing.

The firefighter that was fatality injured was a reserve firefighter for the department in 2014, became
part-time in 2016, and full-time in 2017. The firefighter received his Fire Fighter II certification in
October 2019.

The captain that was fatality injured was hired in 2007, promoted to engineer in 2016, lieutenant in
2018, and captain in 2019. The captain had 13 years of firefighting experience.

Equipment and Personnel

On February 18, 2020, the city dispatched the local combination fire department for a commercial structure
fire. Five minutes after dispatch, the incident commander requested a second alarm which called in all off-
duty personnel and a mutual aid engine and mutual battalion chief. Table 1 identifies the apparatus and
staff dispatched on the first-alarm assignment. All resources in Table 1 were dispatched at 1616 hours.
Engine 71 arrived on scene at 1618 hours. All other resources arrived at 1621 hours.

Table 1: First alarm Apparatus

Resource Designation Staffing

Engine 71 captain, engineer, and firefighter
Battalion chief 77 shift battalion chief
Truck 73 captain, engineer, probationary firefighter
Engine 72 captain and engineer
Patrol 72 2 firefighters

Notes: A local police officer was first on scene at 1617 hours, made initial entry into the fire structure,
and verified the first floor was clear. Battalion Chief 70 (administrative battalion chief) self-dispatched
and arrived approximately at 1618 hours, responding from his office at the fire department
headquarters and assumed command prior to Battalion Chief 77 arrival.

The dispatch center is in the city and employed 13 dispatchers at the time of the incident. Each
dispatcher works three 12-hours days and one 8-hour day. The dispatch center also dispatches for the
city police department and a neighboring city’s fire, police, and EMS. The dispatch center answers
over 20,000 emergency calls annually.

Training for new dispatchers includes:

• Working with a field training officer during probation.
• Completing 6 months on-the-job training.

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• Shadowing as a probationary dispatcher and dispatching animal control calls initially.
• Completing the California Public Safety Dispatcher’s Basic Course within 12 months.

Personal Protective Equipment

At the time of the incident, the captain and firefighter were wearing their station uniform, turnout coat
and pants, gloves, hood, helmet, boots, and self-contained breathing apparatus with integrated PASS
devices. They both carried portable radios and flashlights assigned by the fire department. The NIOSH
investigators examined and photographed the personal protective clothing and equipment at the fire
department’s headquarters facility. The firefighters’ turnout gear and equipment were not considered to
be a contributing factor in this incident.

Weather and Road Conditions

The weather was clear with an approximate temperature of 67°F, winds WNW at 7 mph, and the
relative humidity was 47%. Weather was not considered to be a factor in this incident.

Structure
The non-sprinklered, 2-story commercial structure was originally built in 1953, with major additions in
1957 and 1974. It totaled 19,000 square feet at the time of the incident. The two-story structure had a
concrete slab, concrete block wall exterior, light steel trusses, and composition flat roof. Additions in
1957 and 1974 were made of 2x4 stud walls, plaster exterior, wood truss framing with plywood
sheathing, and steel beams. The area after the 1957 addition was approximately 220 feet wide, 396 feet
long, and 15 feet high and the 1974 addition was approximately 231 feet wide, 440 feet long, and 27
feet 5 inches high (this included a second floor). The floor plans are shown per Diagrams 1 and 2.
Typical fuel load of a library is depicted in pre-fire photo (see Photo 1).

The library and the fire station share the same city block and a common Side C wall (see Diagram 3 on
page 13).

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Diagram 1: First floor layout

Courtesy of city manager’s office

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Diagram 2: Second floor layout

Courtesy of city manager’s office

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Photo 1: First floor of the library pre-fire. Note the stairwell where the RIT operation occurred.
Courtesy of the fire department.

Timeline
The following timeline is a summary of events that occurred as the incident evolved on February 18,
2020. Not all incident events are included in this timeline. The times are approximate and were
obtained by studying the dispatch records, audio recordings, witness statements, and other available
information. This timeline lists the changing fire behavior indicators and conditions reported, as well
as fire department response and fireground operations. All times are approximate and rounded to the
closest minute.

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Fire Behavior Indicators & Conditions Time Response & Fireground Operations

911 call received 1616 Engine 71, Engine 72, Truck 73, and
Battalion 77 were dispatched to
commercial structure fire.
Local police officer on scene and
1617
cleared first floor of structure.
Engine 71 captain reported heavy smoke Engine 71 arrived on scene; Battalion
1618
from Side Alpha. Battalion Chief 70 Chief 70 arrived on scene; police
confirmed heavy smoke Side Alpha and officer informed Battalion Chief 70
requested traffic control, notified there’s no one in the building;
utilities, and staged ambulance. Battalion Chief 70 directed Captain 71
to initiate fire attack; and bystanders
informed second police officer that
there was a woman upstairs with a
walker.
Second police officer informed Engine
1619
71 captain and firefighter that there was
a woman with walker on second floor.
They entered Side Alpha without a
hoseline and did not inform command;
Truck 73 established water supply on
Side Delta; and Battalion Chief 70
established Command.

Third police officer advised Engine 71

1620
engineer that she searched the second
floor and the woman with a walker was
out of the building.
Battalion Chief 77 called for a second
1621 Battalion 77 arrived on scene and
alarm and assumed command.
confirmed working fire and requested
all radio traffic go to Channel 2 per
policy; Battalion Chief 77 directed
Truck 73 to initiate the fire attack
through Side Delta windows; Engine
72 arrived on scene; and Battalion
Chief 77 met with Engine 71 engineer.

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Fire Behavior Indicators & Conditions Time Response & Fireground Operations

1623 Battalion Chief 77 called Engine 71

captain on radio and asked for status
report and received no response.

1624 Engine 71 captain contacted Battalion

Chief 77 on Channel 1 and informed
command that they cleared Division 2
and were moving to Division 1.
Captain asked command to confirm if
the woman with a walker was out,
command believed so but would
confirm.
Engine 73 captain requested laddering
1626 Battalion Chief 77 radioed Engine 71
the roof to vent but Battalion Chief 77
captain on Channel 2, Captain 71
declared a defensive fire attack until fire
responded but Battalion Chief 77 did
under control.
not acknowledge.

1627 Battalion Chief 77 attempted to contact

Engine 71 captain first on Channel 1
then Channel 2 and the captain replied
but Battalion Chief 77 did not
acknowledge.

1628 Battalion Chief 77 attempted to contact

Engine 71 captain on Channel 2 with
no response; Truck 73 captain
informed command that they had good
knockdown on the fire, wanted to
access the roof, and cut a hole along
the Side Delta wall working towards
the center.

1631 Battalion Chief 77 ordered the training

Captain 70 to form a RIT to locate
Engine 71 crew.

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Fire Behavior Indicators & Conditions Time Response & Fireground Operations

1632 Fire chief arrived on scene and met

with Battalion Chief 77; Engine 71
captain called a Mayday on Channel 1,
reported they were in banquet room
trying to locate stairwell, low on air
and activating PASS; Battalion Chief
77 responded and sent in RIT.

1634 Battalion Chief 77 and fire chief

requested hold on Channel 1 for
Mayday. All other traffic on Channel 2.

1635 Fire chief assumed command and made

Channel 3 Fireground tactical channel
(TAC). Battalion Chief 77 stayed in
command of the Mayday.

1636 Battalion Chief 70 assigned himself as

Delta command. Battalion Chief 70
sent Engine 73 captain and two
firefighters to Division 2 by accessing
the enclosed external stairwell on Side
Delta, to attempt to locate Engine 71
crew

1637 The Side Delta crew searched the

banquet room; fire chief established a
staging area near Engine 71.

1638 RIT team led by training captain

radioed command that they made it to
the inside stairwell and could hear
PASS alarms. There was no fire and
zero visibility conditions.

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Fire Behavior Indicators & Conditions Time Response & Fireground Operations

1640 RIT team located Engine 71 captain in

the Division 2 bathroom and requested
additional manpower. RIT got Engine
71 captain halfway out the building and
had to pass him off to second RIT
because they were low on air.

1650 Engine 71 captain extricated from the

building. Several other RIT attempts
were made to locate Engine 71
firefighter without success.
RIT operations halted and defensive
1745
operations called.
2015 Urban Search and Rescue Team
located Engine 71 firefighter the next
2/19/20
night.

0400 Engine 71 firefighter removed from

structure by Urban Search and Rescue
2/20/20
team and fire department members
early morning the following day.

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Investigation
On February 18, 2020, a 35-year-old career captain and a
25-year-old career firefighter died searching for a reported
civilian using a walker in a public library. At 1616 hours,
the communication center dispatched Engine 71, Engine
72, Truck 73, and Battalion 77 to a commercial structure
fire (see Photo 2). A minute later, a city police officer
arrived, made entry, and reported that the first floor was
clear. At approximately 1618 hours, Engine 71 arrived
with a captain, firefighter, and engineer from the fire
station. Side Charlie of the fire station and Side Charlie of
the library share a common wall.
Photo 2: Fire structure Side Alpha
The captain reported heavy smoke from Side Alpha. (Photo by NIOSH )
Engine 71 had been informed by dispatch that the reported fire was in the back of the building. The
Engine 71 crew laid a 1¾-inch hoseline to the front door. Battalion Chief 70, the administrative
battalion chief, was in his office at the station and responded. Upon arriving at the scene, Battalion
Chief 70 reported heavy smoke from Side Alpha. A bystander informed a second police officer that a
woman with a walker was on the second floor. The police officer relayed this information to the
Engine 71 captain and firefighter. The Engine 71 crew made entry without a hoseline and did not
inform Battalion Chief 70.

Battalion Chief 70 assumed command and instructed Truck 73 to connect to the hydrant at the
Alpha/Delta corner of the block to establish a water supply. Truck 73, the second arriving apparatus,
connected to the hydrant and was laying a 4-inch supply line to Engine 71, but Engine 71 was already
laying their own supply line. Truck 73 supplied their own truck. A third police officer informed the
Engine 71 engineer that the woman with the walker from the second floor was out of the building and
in the parking lot.

At approximately 1621 hours, Battalion Chief 77 arrived on scene, assumed command, and advised
everyone to go to Channel 2. Battalion Chief 70 was on Side Delta when Battalion Chief 77 arrived
and on his way to brief Battalion Chief 77 when he heard Engine 71 captain say something on radio
Channel 1. Battalion Chief 77 assumed command and instructed the Engine 71 captain to go to
Channel 2. About this time, Side Delta’s windows self-vented and Battalion Chief 70 blocked the Side
Delta alley with his vehicle as he briefed Battalion Chief 77. Battalion Chief 77 asked for the location
of Engine 71 captain and tried to contact Engine 71 captain on Channel 2 to confirm if they were in the
building. Battalion Chief 77 confirmed with the Engine 71 engineer that his captain and firefighter
were inside the fire structure. Truck 73 pulled a 1¾ -inch and a 3-inch hoseline to Side Delta (see
Diagram 3). The Truck 73 captain informed his engineer to go to Channel 2 but to scan Channel 1.
Engine 72 had arrived and parked behind Truck 73. The Engine 72 captain and firefighters set up mini-
monitors (500-1000 gallon per minute flow rate) on the ground at the Alpha/Delta corner.

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Diagram 3: First alarm apparatus and hoseline placement.

A minute later, the Engine 71 captain announced on Channel 1 that they cleared Division 2 and were
headed to the stairwell for Division 1. The Engine 71 captain requested confirmation that the lady with
the wheelchair (there was some confusion whether the lady was in walker or wheelchair) was still in
the building. Battalion Chief 77 responded that he thought she was out but would confirm. Battalion
Chief 77 reminded the captain to go to Channel 2. At 1626 hours, Battalion Chief 77 radioed the
Engine 71 captain on Channel 2 and the captain responded but Battalion Chief 77 did not acknowledge
at that time. The Truck 73 captain wanted to place a ladder to the roof to vent but fire conditions had
worsened, and Battalion Chief 77 declared a defensive attack. Battalion Chief 77 attempted multiple
times to radio the Engine 71 captain on Channel 1 but did not get a response. Battalion Chief 77
radioed the Engine 71 captain on Channel 2 but received no response.

At 1628 hours, Truck 73 captain informed Battalion Chief 77 that Side Delta was sufficiently knocked
down and that they were able to place a ladder to the roof. At 1631 hours, Battalion Chief 77 had the
training captain assemble a three-man RIT consisting of the Engine 72 captain, Engine 72 engineer,
and himself to locate the Engine 71 crew. A minute later, the fire chief arrived on scene at the same
time that the Engine 71 captain called a Mayday on Channel 1 from Division 2. The Engine 71 captain

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stated that he and his firefighter were running low on air in the banquet room and trying to locate the
stairs. Battalion Chief 77 advised he was sending in a RIT. At the Side Alpha doors, the Engine 71
engineer had a 1¾-inch hoseline and stopped flowing water as the initial RIT team made entry with a
RIT bag that contained a 45-minute cylinder and facepiece. Upon entry, the initial RIT had no hoseline
or tagline and only 10 feet of visibility.

The Engine 71 captain repeated they were low on air, and they were manually activating their PASS
devices. Battalion Chief 77 had all units hold traffic on Channel 1 due to the Mayday and directed all
other fireground communications to Channel 2. At 1635 hours, the fire chief assumed incident
command and had Battalion Chief 77 run the Mayday. Incident command changed the incident tactical
channel to Channel 3. The initial RIT team had made it to the stairs in the middle of the first floor
where there was no fire but zero visibility. Then the Engine 72 captain headed towards the front door
because he thought more people were needed. On his way back, he ran into the off-shift Engine 72
captain from C-shift (Engine 72C captain), who was the fourth man on a second RIT team and
followed him back to the stairs where they searched underneath the stairs.

A minute later, on Side Delta, the Battalion Chief 70 assembled a Side Delta RIT crew of three led by
the Truck 73 captain to access the Side Delta enclosed external stairwell near the Charlie/Delta corner.
The Truck 73 engineer, Truck 73 probationary firefighter, and Patrol 72 firefighter forced the Side
Delta stairs door. As smoke pushed out, the Truck 73 captain with a thermal imager, firefighter with a
1¾-inch hoseline, and probationary firefighter went to the second floor. The probationary firefighter
stayed at the Side Delta exterior second door feeding the hoseline to the Truck 73 captain and
firefighter. The Truck 73 captain informed the Battalion Chief 70 that they were in the banquet area
searching in heavy smoke with 10-inch visibility while scanning with the thermal imager. The
Battalion Chief 70 advised them to come back to the landing at the top of the Side Delta stairs. At 1637
hours, the fire chief established a staging area.

The initial RIT team led by the training captain took the Engine 72 engineer and started ascending the
stairs. He requested the Engine 72 captain remain at the bottom of the stairs. At 1638 hours, the
training captain reported that they made it to the second floor and there was no fire but zero visibility.
They could hear PASS alarms sounding. The Engine 72 captain’s low-air alarm was going off, and he
exited to get a fresh bottle. Two minutes later, the training captain located the Engine 71 captain
behind the door in a bathroom (see Diagram 4). The training captain noticed the Engine 71 captain had
no mask on. He tried to grab the drag rescue device in the Engine 71 captain’s turnout coat but
couldn’t locate it, so he grabbed the SCBA shoulder strap and started moving the captain towards the
door. The training captain’s low air alarm activated, and he yelled for the Engine 72 engineer to help
him get the Engine 71 captain to the stairs. As they started down the stairs, the Engine 71 captain’s
mask mounted regulator became caught in the railing and his PASS alarm was still going off.

The Engine 72C captain showed up on the stairs as the training captain exited to get a fresh bottle. The
Engine 72 engineer turned off the Engine 71 captain’s PASS alarm while the Engine 72C captain got
the mask mounted regulator freed. The two RIT firefighters control-rolled the Engine 71 captain down
the stairs. Their low-air alarms had been going off and the Engine 72C captain only had about a minute
of air left when the training captain showed back up with a mutual aid RIT crew of four. The Engine

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72C captain grabbed the training captain’s hand and put it on the Engine 71 captain’s SCBA strap. The
Engine 72C captain made it to the exit by unclipping his mask mounted regulator and taking breaths of
smoke-filled air as he exited the fire structure. The training captain and crew were turning the corner
near the computer room with the Engine 71 captain. They were accompanied by the Engine 72
engineer, (who was running out of air), and got the RIT crew headed in the right direction as the
engineer exited with her mask reportedly starting to collapse to her face as she had also run out of
breathing air.

Diagram 4: RIT locating Engine 71 captain on second floor in women’s bathroom.

At 1640 hours, the Engine 71 captain was extricated and taken by ambulance to the hospital and later
pronounced dead. An off-duty Engine 71 captain C-shift (Engine 71C) was asked by Battalion Chief
77 to assemble a RIT to look for the Engine 71 firefighter. The Engine 71C captain teamed up with the
Patrol 73 engineer and a county firefighter. They gathered the RIT and rope bags along with thermal
imagers to make entry. Prior to entry, the RIT captain spoke with the training captain to verify that the
Engine 71 firefighter’s last known location was second floor bathroom.

Upon entry, the RIT team were using their thermal imagers and a tagline in the zero visibility
conditions, but obstacles hampered their ingress and they mistakenly made entry into the computer
room. Once out of the room and headed towards the stairs, the captain noticed heavy soot on his mask
and the county firefighter mentioned he could hear a PASS alarm in the distance. Command called for
a status update and the captain replied they were having difficulty but could hear a PASS alarm
sounding. The captain was struck by falling ceiling materials, which caused him to lose his thermal

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imager. While the captain was searching for the thermal imager, he inadvertently found the Engine 71
captain’s helmet. Due to worsening conditions and collapsing ceiling they decided to back out. In
doing so they ran into another RIT crew led by mutual aid Engine 19 captain and three other
firefighters, who were told to back out by the exiting RIT crew. One additional RIT attempt was made
to locate the Engine 71 firefighter but due to fire conditions and building collapse along the Side
Charlie wall, efforts were suspended, and fire operations went fully defensive. Truck 73’s ladder was
put up on Side Delta and directed water through the vented roof. Mini-monitors were flowing water on
Sides Alpha and Delta. The Engine 71 firefighter was located by a USRT late the next day. The Engine
71 firefighter was extradited from the building the following morning by the USRT and his fire
department members.

Contributing Factors
Occupational injuries and fatalities are often the result of one or more contributing factors or key
events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH
investigators identified the following items as key contributing factors in this incident that ultimately
led to the fatalities:

• Air management factors at the task and tactical level

• Risk assessment/size up difficulties
• Primary search without a tagline or hoseline in a large commercial occupancy
• Large area search in an occupied structure (public library)
• Ineffective Mayday procedures and survival techniques
• Residential tactics in a commercial structure
• Crew integrity lost during search
• Radio/communication difficulties
• Lack of sprinkler system
• Rapid fire growth.

Cause of Death
According to the death certificate, the medical examiner listed the captain’s and the firefighter’s cause
of death as asphyxiation and smoke-inhalation. Both the captain and firefighter had moderate soot
throughout their lungs. The captain had no significant blunt force trauma and the firefighter had first
degree burns on the front of his body and post-mortem charring on his back.

Recommendations
Recommendation #1: Fire departments should ensure all firefighters are trained on and actively
practice air management principles.

Discussion: Air management is a program that the fire service can use to ensure that firefighters have
enough breathing air to complete their primary mission and to escape an unforeseen emergency.
Retired fire chief Bobby Halton notes, “If you run out of air in a working fire today, you are in mortal
danger. There is no good air at the floor anymore, no effective filtering methods, no matter what others

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may say to the contrary.” The only protection for firefighters in the toxic smoke environments in
today’s fires is the air they carry on their backs. Like SCUBA divers, firefighters must manage their air
effectively to leave enough reserve air to escape in case of unforeseen occurrences while inside a
structure fire. They should leave IDLH atmosphere before the low-air alarm activates, which will also
eliminate the noise of a low-air alarm from the fireground [Gagliano et al. 2008].

NFPA 1404 Standard for Fire Service Respiratory Protection Training states that firefighters should
exit from an IDLH atmosphere before the consumption of reserve air supply begins; a low-air alarm is
notification that the individual is consuming the reserve air supply and activation of the reserve air
alarm requires immediate action of the individual and the firefighting team [NFPA 2018a]. It is critical
that firefighters understand that the initial 67% of the air supply is the "working and exiting air"
[NFPA 2018a]. This includes air used for gaining access, working toward the tactical objectives, and
exiting the hazard zone.

A low-air alarm is a fireground emergency and should be treated accordingly. A crew of firefighters
who enter an IDLH environment together can be expected to run low on air in rapid sequence as
experienced in this incident by the initial search crew for the civilian and the RIT team. A low-air
emergency for one crew member should be treated as an emergency for the entire team, requiring the
entire team to exit simultaneously, maintaining crew integrity.

Generally, fire crews are able to search structures quickly, put out the fire, and exit the hazard zone on
their initial 67% air supply. Multiple points of egress are usually close by if a rapid retreat to the
exterior becomes necessary. However, high-rise apartment buildings, commercial structures, and large
open floor plans present additional challenges that firefighters must consider, such as building
contents, building materials, limited ingress/egress, and void spaces.

Company officers should frequently assess their crew's air consumption rates and estimate the crew's
exit time based on the individual with the greatest assumed air consumption rate. It is the individual
firefighter's responsibility to continually assess and report their air consumption to their company
officer.

In this incident, the Engine 71 captain and Engine 71 firefighter ran out of air before they were able to
exit the second floor of the structure. In addition, numerous RIT crew members ran out of air while
they exited the structure and had to remove their masks. Findings from NIOSH investigations have
indicated that the Heads-Up Display (HUD) is often over-looked and when the End-of-Service-Time-
Indicator (EOSTI) activates, it may be the first time that firefighters may notice critical milestone
indicators. Fire departments need to reinforce proper air management training and proper use of the
HUD.

The NFPA 1981 (SCBA) Technical Committee is currently soliciting input on another alert
mechanism that stimulates a second human sense, such as a unique sound in addition to the milestone
flash at 50%, to make the firefighter more aware of their air supply. Also, upgrading SCBAs to the
latest edition of NFPA 1981 will increase the EOSTI from 25 +/- 2% to 35% that provides more
emergency reserve air by activating the EOSTI sooner. Additionally, increasing the cylinder size from

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a 30-minute [1200 liter] cylinder to a 45-minute cylinder [1800 liter] (discussed in a later
recommendation) will provide additional emergency reserve air and increase a crew’s work time,
especially in a commercial size structure.

Recommendation #2: Fire departments should use risk management principles at all structure fires.

Discussion: Established fire service risk management principles are based on the philosophy that
greater risks will be assumed when there are lives to be saved and the level of acceptable risk to
firefighters is much lower when only property is at stake. Interior offensive firefighting operations can
increase the risk of traumatic injury and death to firefighters from structural collapse, burns, and
asphyxiation. Established risk management principles suggest that more caution should be exercised in
abandoned, vacant, and unoccupied structures and in situations where there is no clear evidence that
people are trapped inside a structure and can be saved. Fire departments should establish a standardized
method or approach to assess the risks encountered at each incident, especially structure fires.
Structure fires are very dynamic and fast paced operations with little room for error or miscalculations
of the significance of the risk encountered.

NFPA 1500 Standard on Fire Department Occupational Safety, Health, and Wellness Program,
Chapter 8.4 addresses the use of risk management principles at emergency operations. Chapter 8.4.4
states, “Risk management principles shall be routinely employed by supervisory personnel at all levels
of the incident management system to define the limits of acceptable and unacceptable positions and
functions for all members at the incident scene”.

The incident commander is responsible for managing risk at the incident. However, one person cannot
be expected to apply these principles to an incident if the organization has not integrated a standard
approach to risk management into its standard operating procedures (SOPs)/standard operating
guidelines (SOGs) and its organizational culture. To be effective, risk management principles should
be integrated into the entire operational approach of the fire department organization. They should be
incorporated within the duties and responsibilities of every officer and member. The single most
important reason to establish an effective incident management system is to ensure that operations are
conducted safely. Every individual assigned to the incident is responsible for monitoring and
evaluating risks and for keeping the Incident Commander (IC) informed of any factor that causes the
system to become unbalanced. Continuous risk assessment should be done as every benchmark or task
is completed until the incident ends.
A standardized evaluation of the situation should occur at each incident starting with the first arriving
officer or member of the department arriving on scene of the incident. This evaluation starts with the
scene size-up. The first arriving unit should look at the entire incident scene versus focusing on a small
part of the situation. During the size-up, incident commanders need to consider the following incident
priorities:

• Life safety
• Continuous firefighter safety
• Incident stabilization

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• Property conservation [Rubin 1996]

The risk management plan should also consider the following:

• Risk nothing for what is already lost—choose defensive operations.

• Extend limited risk in a calculated way to protect savable property—consider offensive
operations.
• Extend very calculated risk to protect savable lives—consider offensive operations.

In incidents where occupant survival isn’t possible, the IC should evaluate conditions based upon the
risk to firefighters and revise the strategy and Incident Action Plan (IAP). In these situations, the IC
should take a more cautious approach to fireground operations. Fire control should be obtained before
proceeding with the primary and secondary search efforts [Morris 2011].
A fire in a building today is not what it was 40 years ago. Yet, fireground tactics have not changed to
be consistent with the effects of fire conditions on today’s modern furnishings. As a result of the
increased use of plastics in our buildings, today’s fires are hotter and flashover occurs more quickly
than in the past, releasing extreme levels of toxins. Fire models reflect that flashover can occur in less
than five minutes and reach a temperature of more than 1,100°F. When exposed to fire, plastics burn
hotter and produce highly toxic gases. For example, a pound of wood when burned produces 8,000
British thermal units (BTUs). On the other hand, a pound of plastic can produce 19,900 BTUs when
burned. The human limit for temperature tenability is 212 degrees. On many occasions, flashover can
occur as the first fire companies are arriving on the scene. In such circumstances, the survivability of
any victims in the affected compartment can be very limited or nonexistent [Marsar 2010].
Additionally, the effects of carbon monoxide poisoning on a victim are well known to the fire service.
Carbon monoxide blocks oxygen absorption to hemoglobin within the bloodstream. Due to the
increased use of plastics and synthetic materials, carbon monoxide is produced in very high
concentrations and very quickly in structure fires. As a result, victims die sooner than in the past.
Burning synthetic materials also release hydrogen cyanide, creating a risk of cyanide poisoning.
Cyanide kills the body’s organs. A low concentration of 135 parts per million (PPM) of cyanide and
carbon monoxide will kill a person in 30 minutes. At 3,400 PPM, it can kill in less than one minute.
It’s not uncommon for a fire in today’s buildings to produce 3,400 PPM of hydrogen cyanide. A
person may be resuscitated from the effects of carbon monoxide poisoning, but they may not survive
the organ damage caused by cyanide poisoning [Marsar 2010].
Research findings by the Underwriters Laboratories (UL) show that modern furnishings in a fire
environment can contribute to flashover occurring up to 8 times faster than with legacy furnishings. An
experiment was conducted with two side by side living room fires to understand the difference
between modern (today’s petroleum-based furniture) and legacy (wood, cotton, and silk furniture of 40
years ago) furnishings and how they contribute to fire growth. Both rooms contained similar amounts
of like furnishings. Both rooms were ignited by placing a lit candle on the right side of the sofa. The
fires were allowed to grow until flashover. The modern room transitioned to flashover in 3 minutes and
30 seconds and the legacy room at 29 minutes and 30 seconds [Underwriters Laboratories Firefighter

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Safety Research Institute 2020]. For these reasons, the conditions within a fire compartment become
untenable much sooner than in the past, and victims die quicker.

The IAFC Rules of Engagement for Firefighter Survival and the Incident Commander’s Rules of
Engagement for Firefighter Safety stress the need to determine the occupant survival profile. This
action is ranked as the second most important action to take on the fireground, behind completion of
the initial size-up [IAFC 2021] (See Diagram 6 on page 24).

In this incident, the first arriving crews were met with a rapidly developing fire in an occupied library
and an immediate need to remove civilians. The Engine 71 captain reported heavy smoke from Side
Alpha. Engine 71 had been informed by dispatch that the reported fire was in the back of the building.
The Engine 71 crew laid a 1¾-inch hoseline to the front door. Battalion Chief 70, the administrative
battalion chief, was in his office at the station and responded.

Upon arriving at the scene, Battalion Chief 70 reported heavy smoke from Side Alpha. A bystander
informed a second police officer that a woman with a walker was on the second floor. The police
officer relayed this information to the Engine 71 captain and firefighter. A third police officer informed
the Engine 71 engineer that the woman with the walker from the second floor was out of the building
and in the parking lot, however the Engine 71 crew had already made entry without a hoseline and did
not inform Battalion Chief 70.

Recommendation #3: Fire departments should ensure that primary search crews and RITs advance
with a hoseline or tagline in large commercial or complex structures.

Discussion: Hoselines can be the last line of defense, and the last chance for a lost firefighter to find
egress from a burning building. The basic techniques taught during entry level firefighting programs
describe how to escape a zero-visibility environment using only a hoseline. However, as years elapse
from the time of basic training, firefighters may overlook this technique. Exiting a structure in zero
visibility should be faster and easier for a firefighter with a hoseline. A firefighter operating on a
hoseline should search along the hose until a coupling is found. Once found, the firefighter can “read”
the coupling and determine the male and female ends [USFA 2003]. The International Fire Service
Training Association (IFSTA) manual titled, “Essentials of Fire Fighting” teaches that the female
coupling is on the nozzle side of the set and the male is on the water side of the set (see Diagram 5)
[IFSTA 2019]. In most cases, the male coupling has lugs on its shank while the female does not.

There are a number of ways that a fire hose can be marked to indicate the direction to the exit,
including the use of raised arrows and chevrons that provide both visual and tactile indicators. Fire
departments may use a variety of techniques to train firefighters on how to identify hoseline couplings
and the direction to the exit, based on the model of hose used by the department. The training needs to
be repeated often so that firefighters are proficient in identifying the direction to the exit in zero
visibility conditions while wearing gloves, when the hose is entangled, and there are various
obstructions present.

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An attack fire hose can also be marked in a number of ways that will indicate the direction to the exit,
including the use of raised arrows or chevrons that provide both visual and tactile indicators. Fire
departments may use a variety of techniques to train fire fighters on how to identify hose line
couplings and the direction to the exit, based on the model of the hose used by the department. This
training should be conducted and repeated often so that fire fighters are proficient in identifying the
direction to the exit in zero-visibility conditions while wearing gloves, when the hose is entangled, and
with various obstructions present.

Manufacturers of attack fire hoses should consider marking their attack hoses (1½”, 1¾”, 2” and 2½”)
at the coupling point with raised chevrons indicating away from the male thread which will point in the
direction of the exit. Manufacturers should also consider developing retro fitting indicators for current
unmarked attack fire hose sizes.

A charged back-up hoseline of equal or greater size should also be established to cover the primary
search crews. This cover line can also be used for a tactical withdrawal while continuing water
application or as a lifeline to be followed to egress the building.

Diagram #5. Hose couplings can indicate the direction toward the exit. Adapted from IFSTA
Essentials of Fire Fighting, 7th Edition.

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Deploying a tagline (sometimes referred to as a search line) is a difficult but sometimes necessary task
to search a complex or large area. Regardless of the reason for deployment, if not trained with the line,
it can be more of a hinderance than it will be an aid [Fire Engineering 2014]. It is important for fire
fighters to be proficient using a tagline during a large area search and that proficiency begins with the
basic training and repetitive skill training.

There are many important considerations when choosing a tagline to complete a search operation. For
example, positive communication and understanding between crew members completing the search,
maintaining a tagline and keeping it taught throughout the operation to avoid confusion for the crew
and to help from becoming tangled with other objects encountered throughout the occupancy [Fire
Engineering 2014].

Recommendation #4: Fire departments should ensure all firefighters are trained in large area
search procedures.

Discussion: The mission of search and rescue crews is to find victims in a fire as quickly as possible.
However, before beginning any type of search, there needs to be a high probability of survivors. If the
risk is too great, entry cannot be made. First arriving crews need to complete a 360 size-up, notifying
command, and enter with a charged a hoseline or tagline.

For commercial structures, it becomes a low frequency/high risk event and training is essential. Fire
conditions in a large structure can change rapidly and the search team should either have a hoseline or
a tagline to facilitate exiting the structure if required. A back-up hoseline should also be established to
cover the primary search crews. During a large-area search, a safety officer should be posted outside
the building to time members operating inside.

A primary search is one of the most critical and dangerous tasks a firefighter can perform, thus training
should be a top priority [Firehouse 2017]. Search skills should be continually practiced (to achieve an
over-learned muscle memory response for SCBA controls) and include SCBA emergency maneuvers,
such as low air recognition, emergency communications and procedures for buddy breathing.
Instructions on emergency air replenishment (trans-fill) for a downed fire fighter through an
RIC/UAC* (rapid intervention crew/universal air connection) should be provided.

When looking for a large area for training, consider large commercial structures that are vacant and
may be designated for demolition (but safe enough to conduct the training exercise). Often permission
can be obtained with reasonable limitations. Goals of the training should be to exercise and measure
IC, air management, Mayday procedures, RIT, company officer decision making, communications,
accountability, searching with an attack line, and victim/downed firefighter removal [Fire Engineering
2007].

*Note—Use of the SCBA RIC/UAC is intended for emergency situations. Recharging air cylinders
during routine operations and training should follow applicable safe filling practices outlined in, but
not limited to NFPA 1500, 1852 and manufacturing instructions [NFPA 2018c, 2018d, 2021].

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Recommendation #5: Fire departments should ensure firefighters are trained in situational
awareness, personal safety, and accountability.

All firefighters operating at an incident should maintain situational awareness and conduct
a continuous risk assessment throughout the incident, reporting unsafe or changing conditions to the
incident commander. Firefighters need to understand the importance of situational awareness and
personal safety on the fireground. The fireground dangers and hazards can and do change as the
incident becomes larger and the event duration increases [IFSTA 2019].

Situational awareness is the ability to perceive and understand what is happening in

the environment around you, in relation to how time is passing, and then using your understanding of
the situation to accurately predict future events in time to prevent bad outcomes [Gasaway 2019].

Situational awareness is defined as a process with 3 levels:

• Level 1. Perception, perceive the situation around us.
• Level 2. Comprehension, apply our knowledge and past experiences to our perception and
develop an understanding of the meaning of the situation.
• Level 3. Application, taking our understanding of the situation and applying it to the future,
thereby predicting how and when the situation will change and what action is appropriate on
our part.

Level 1. Perception, also considered as sensing or observing, is often correlated in the fire service with
size-up. While size-up is most often focused on visual observations, it is important to understand that
effective perception should involve all 5 senses (hearing, taste, touch, sight, and smell) as applicable.
Those senses should also be enhanced through the use of technology when possible. An example
would be the use of a thermal imaging camera (TIC) to enhance the sense of sight. This first level in
the situational awareness process must be deliberate, accurate, and continually ongoing.

Level 2. Comprehension, also considered as understanding, it can be part of a forgone conclusion that
perception will always lead to comprehension. Unfortunately, that does not always happen and there is
a potential for misinterpretation to occur. In order to fully understand the critical things that we are
perceiving, firefighters and officers must have the proper knowledge which comes from education and
training and also ability, which comes from experience. If they have any doubts about what they are
comprehending, they should re-evaluate the process and when possible, seek the input of others.
Firefighters and officers should also not just dismiss someone who has a different understanding of
what others are perceiving. Comprehending different things can indicate that there is a
misinterpretation or potentially multiple understandings for what is being perceived. Having a shared
understanding on the fireground at the task, tactical, and strategic level is critical for success.

Level 3. Application, also considered as projecting or forecasting, is the final critical level that is only
as successful as the outcomes from the first two levels. Given the fireground is a constantly changing
and evolving place, plans must not only be based on what is currently taking place, but also based on
what will happen in the immediate future. Firefighters and officers’ ability to forecast future events
will also rely heavily on their knowledge and ability. It is critical to recognize when we lack the

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necessary knowledge and/or ability for a given situation as it can negatively impact the ability to
forecast. In those situations, firefighters may use another contingency such as seeking input from
someone else who has the necessary knowledge and ability for the situation. Effectively utilizing level
3 forecasting can allow planning and actions to take place proactively, versus being forced to respond
reactively, which increases the overall chances for success [Gasaway 2013, 2017, 2022].

Even though a safety officer may be designated for an incident, it is the obligation of all personnel to
remain alert to their immediate surroundings [Clark 2008]. One of the most critical aspects of
coordination between crews is maintaining situational awareness. The opposite of situational
awareness is tunnel vision where the firefighters become so focused on firefighting or other operational
assignments that they fail to sense changes in their environment. Firefighters must maintain their
situational awareness by looking up, down, and around themselves, as well as listening for new or
unusual sounds and feeling vibrations or movement. constantly working through the 3 levels until the
incident is over. Firefighters and officers should communicate any key changes in their situational
awareness to other members in their environment as well as to the incident commander.

The rules of engagement for structural firefighting have been developed to assist both the firefighter
and the incident commander as well as command team officers in risk assessment and “Go” or “No-
Go” decisions (See Diagram 6). These rules provide a recommended best practice model which fire
departments can adopt and apply to enhance fireground safety [IAFC 2021]. The fireground creates a
significant risk to firefighters, and it is the responsibility of incident commanders and command
organization officers to minimize firefighter exposure to unsafe conditions and stop unsafe practices.
The rules of engagement can assist the incident commander, company officers, and firefighters who
are at the highest level of risk in assessing their situational awareness. One principle applied in the
rules of engagement are that firefighters and the company officers are the members most exposed to
the risk for injury or death and will be the first to identify unsafe conditions and practices. The rules
integrate the firefighter into the risk assessment/decision-making process. These members should be
the ultimate decision makers as to whether it is safe to proceed with assigned objectives. Where it is
not safe to proceed, the rules allow a process for that decision to be made while still maintaining
command unity and discipline.

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Diagram 6: The IAFC’s Rules of Engagement for Firefighter Survival and the IC’s Rules of
Engagement for Firefighter Safety [IAFC 2021]

Recommendation #6: Fire departments should ensure firefighters are properly trained in
Mayday procedures and survival techniques.

Firefighters need to be trained to recognize when they are in trouble, know how to call for help, and
understand how incident commanders and others need to react to a responder in trouble [Jakubowski
and Morton 2001]. A Mayday declaration is such an infrequent event in any firefighter’s career that
they need to frequently train to recognize when to declare the Mayday and what steps to take to
improve their survival chances.

Calling a Mayday is a complicated behavior that includes the affective, cognitive, and psychomotor
domains of learning and performance [Grossman and Christensen 2008; Clark 2005]. Any delay in
calling a Mayday reduces the chance of survival and increases the risk to other firefighters trying to
rescue the downed firefighter.

Firefighters should be 100% confident in their competency to declare a Mayday for themselves. Fire
departments should ensure that any personnel who may enter an IDLH environment meet the Mayday
competency standards of the authority having jurisdiction throughout their active-duty service.
Presently, there are no national Mayday standards for firefighters and most states do not have Mayday

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standards. A RIT will typically not be activated until a Mayday is declared. Any delay in calling the
Mayday reduces the window of survivability and also increases the risk to the RIT [IAFF 2010, 2022 ;
Clark 2005, 2008; USFA 2006].

There are no mandates on when a firefighter must call a Mayday, and Mayday training is not included
in the job performance requirements in NFPA 1001 [NFPA 2019]. It is up to each authority having
jurisdiction to develop parameters and performance standards for a firefighter to call a Mayday.

The National Fire Academy Mayday courses present specific parameters for when a firefighter should
call a Mayday. Course number Q133, Firefighter Safety: Calling the Mayday, is a 2-hour online
program covering the cognitive and affective learning domain of the firefighter Mayday doctrine. The
course was based on the military methodology used to develop and teach fighter pilots ejection
doctrine [Clark 2005; USFA 2006]. The courses may help fire departments in developing and teaching
Mayday procedures for firefighters. The IAFC’s rules of engagement for structural firefighting include
rule #11: Declare a Mayday as soon as you think you are in danger (see Diagram 6).

The IAFF Fireground Survival program is another resource fire departments can use. It was
developed to ensure that training for Mayday prevention and Mayday operations are consistent among
all firefighters, company officers, and chief officers [IAFF 2010, 2022; NIOSH 2014].

Any Mayday communication must provide the location of the firefighter in as much detail as possible
and, at a minimum, should include the division (floor) and quadrant. It is imperative that firefighters
know their location when in IDLH environments at all times to effectively give their location in the
event of a Mayday. Once in distress, firefighters must immediately declare a Mayday. The following
example uses LUNAR (Location, Unit, Name, Assignment/Air, Resources needed) as a prompt:
"Mayday, Mayday, Mayday, Division 1 Quadrant C, Engine 71, Smith, search/out of air/vomited,
can't find exit." When in trouble, a firefighter's first action must be to declare the Mayday as accurately
as possible. Once the incident commander and RIT know the firefighter's location, the firefighter can
then try to fix the problem, such as clearing the nose cup, while the RIT is in route for rescue [USFA
2006; NIOSH 2014].

A firefighter who is breathing carbon monoxide (CO) quickly loses their cognitive ability to
communicate correctly and can unknowingly move away from an exit and other firefighters before
becoming unconscious. Without the accurate location of a downed firefighter, the speed at which the
RIT can find them is diminished, and the window of survivability closes quickly because of lack of
oxygen and high CO concentrations in an IDLH environment [Clark 2005, 2008].

Firefighters also need to understand the psychological and physiological effects of the extreme level
of stress encountered when they become lost, disoriented, injured, trapped, or run low on air during
rapid fire progression. Most fire training curriculum does not include discussion of the psychological
and physiological effects of extreme stress, such as encountered in an imminently life-threatening
situation, nor do they address key survival skills necessary for effective response. Understanding the
psychology and physiology involved is an essential step in developing appropriate responses to life-
threatening situations. Reaction to the extreme stress of a life-threatening situation, such as being

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trapped, can result in sensory distortions, and decreased cognitive processing capability [Grossman and
Christensen 2008].

In the book Stress and Performance in Diving, the author notes: "We know that under conditions of
stress, particularly when rapid problem-solving is crucial, overlearning responses is essential. The
properly trained individual should have learned coping behavior so well that responses become
virtually automatic requiring less stop and think performance" [Bachrach and Egstrom 1987].

One of the most difficult situations a firefighter can face is when they realize they need to declare a
Mayday. The word “Mayday” is designated to identify when a member is in a life-threatening situation
and in need of immediate assistance [FIRESCOPE 2015, NIOSH 2014]. Recognizing that they are or
about to be in a life-threatening situation is the first step in improving the firefighters’ chances to
survive a Mayday event. Many fire departments do not have a simple procedure for what to say when a
firefighter gets into trouble—a critical situation where communications must be clear [NIOSH 2010,
NIOSH 2014].

Firefighters must understand that when they are faced with a life-threatening emergency, there is a
very narrow window of survivability. Training frequently is limited to breathing apparatus
emergencies, egress through small openings, and emergency window egress. It is necessary to place
additional emphasis on appropriate procedures for tactical withdrawal under worsening fire conditions
and structural collapse situations. Firefighter training programs should include training on such topics
as air management and emergency communications; familiarity with their SCBA, radio, and personal
protective equipment; crew integrity; reading smoke, fire dynamics and fire behavior; entanglement
hazards; building construction; and signs of pending structural collapse.

Firefighters must act promptly when they become lost, disoriented, injured, low on air, or trapped
[FIRESCOPE 2015; IAFF 2010, 2022; LAFD 2016; TFRD 2012]. After quickly assessing the
sustainability of their location, a firefighter should transmit a Mayday following these procedures:

• Activate the emergency alert button (EAB) on the portable radio pushing the button for 1 to 3
seconds to activate Note: All fireground radios should be equipped and programmed with
EABs [NIOSH 2023]
• Declare the Mayday announced on the radio as “MAYDAY, MAYDAY, MAYDAY” followed
by the unit designation, then a brief and concise statement of essential information
• Ensure the message is acknowledged by command and/or the dispatcher
• Ensure their PASS device is activated

Firefighters must transmit a Mayday while still having the capability and sufficient air, noting their
location if possible. Firefighters may need to move away from untenable fire conditions before calling
the Mayday. The next step is to manually activate their PASS device. To conserve air while waiting for
rescue, firefighters should try to stay calm and focused on their situation and avoid unnecessary
physical activity.

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After initiating a Mayday, firefighters should survey their surroundings to get their bearings and
determine potential escape routes, such as windows, doors, hallways, changes in flooring surfaces, etc.,
and stay in radio contact with the incident commander and other rescuers. In addition, firefighters can
attract attention by maximizing the sound of their PASS device (e.g., by pointing it in an open
direction), pointing their flashlight toward the ceiling or moving it around, and using a tool to make
tapping noises on the floor or wall. A crew member who initiates a Mayday call for another person
should quickly try to communicate with the missing member via radio and, if unsuccessful, initiate
another Mayday providing relevant information on the missing firefighter’s last known location.
Emphasis on appropriate procedures for retreat/emergency evacuation under worsening fire conditions
and/or pending building collapse is necessary. An operational retreat is designed to quickly remove
firefighters from operations in an unsafe or potentially unsafe environment. Incident commanders need
to initiate an operational retreat whenever the operational area is deemed unsafe for emergency
personnel. All personnel operating in the unsafe area need to evacuate as the operational retreat
procedures are initiated. Operational retreat needs to begin with radio traffic announcing “emergency
traffic” with directions for all emergency personnel to evacuate the operational area. An emergency
egress signal should sound [IAFF 2010, 2022; LAFD 2016]. For example, repeat short air horn blasts
of approximately 10 seconds, followed by 10 seconds of silence. This sequence should be repeated
three times.

Upon hearing an operational retreat signal, all firefighters should immediately withdraw from any
operations they are performing and leave the operational area. All company officers should
immediately perform a personnel accountability report (PAR), of all personnel they are responsible for
and report the results to the incident commander.

If firefighters find themselves in a questionable position (dangerous or not), they must be able to
recognize this and know the procedures for when and how a Mayday should be called. A firefighter's
knowledge, skill, and ability to declare a Mayday must be at the mastery level of performance. This
performance level should be maintained throughout their career through training offered more
frequently then annually [IAFF 2010, 2022; Sendelbach 2003].

As part of emergency procedures training, firefighters need to understand that their PPE and SCBA do
not provide unlimited protection. PPE that is not properly donned, worn, or activated may provide
reduced protection or no protection at all.

Training should include situations dealing with uncontrolled SCBA emergencies, egress through small
openings, emergency window egress, building collapse, and other situations that are possibly
encountered during a Mayday situation.

Recommendation #7: Fire departments should provide a Mayday tactical worksheet for incident
commanders in the event of a Mayday.

Discussion: When a Mayday is transmitted, incident commanders have a very narrow window of
opportunity to locate the lost, trapped, or injured member(s). The incident commander will need to
restructure the strategy and tactics to include a priority rescue [NFPA 2020a].

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A Mayday tactical worksheet serves as a guide and a tailored checklist to any fire department’s
Mayday procedures such as a reminder to prompt the firefighter to activate his/her EAB [emergency
alert button] for priority radio transmissions and other important items such as PASS activation, air
status and location information.

A Mayday tactical worksheet can be easily located the back of a tactical worksheet to assist incident
commanders in ensuring the necessary steps are taken to clear the Mayday as quickly and safely as
possible. This process is too important to operate from memory and risk missing a vital step that could
jeopardize the outcome of the rescue of a firefighter who is missing, trapped, or injured. An example
worksheet is provided in Appendix A, Incident Commander’s Tactical Worksheet for Mayday [IAFF
2010, 2022].

Recommendation #8: Fire departments should develop and implement SOPs/SOGs to define
fireground strategies and tactics for commercial structures.

Discussion: Fireground SOPs define the initial strategy and tactics for the coordinated deployment of
departmental resources for specific incidents and occupancies. SOPs are based on factors including
department staffing; deployment capabilities; knowledge/familiarity and skill levels the firefighting
assets in those assigned protection areas; apparatus, tools, and equipment; building information
including height, area, construction class, and type of occupancy; and potential life hazards (some
examples could be nursing homes and/or assisted living occupancies, restricted ingress/egress
properties such as mental health and other facilities designed to provide high security that limit
firefighter access and occupant egress).

The first arriving resource will assume command and control of the incident. This ensures initial
responding units determine the strategy (offensive or defensive), develop operational objectives, and
deploy tactics at incidents with or without a chief officer on the scene. The intent is to maximize
efficiencies while minimizing confusion and duplication of effort. The incident commander develops
strategy and tactics based upon scene size-up and the risk assessment, including the factors listed
above. This is a process that should be completed in a short period of time for a dynamic and fluid
situation. Most importantly, the strategy and tactics should include an observation and/or report from
all sides of the structure. The goals of effective fireground procedures are to increase the safety of the
members, eliminate confusion, and prevent the loss of life [NIOSH 2014a].

Construction types/classes of construction define how the building is constructed with either
combustible or non-combustible materials. Fire departments must consider numerous factors that affect
operations when developing these SOPs. This will ensure essential strategic, tactical- and task level
functions are performed by the incident commander, division/group supervisors, company officers, and
firefighters. Additionally, this process compliments the defined knowledge, skills, abilities,
competencies, and fireground experience to assist:

• The incident commander to plan and implement an effective strategy and Incident Action Plan
• Division/group supervisors to formulate and follow tactics

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• Company officers to successfully carry out assigned tasks
• Individual members to effectively perform their duties [FDNY 2009a; FDNY 2009b; FIRESCOPE
1994]

The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and
situational report by the first arriving officer. If physical barriers make the 360-degree size-up
impractical for the first arriving officer, the size-up of Side Bravo, Side Charlie, and Side Delta may be
delegated to another fire department resource. The priority is to get a fire department resource to the
rear of the structure Side Charlie. Unless an obvious life safety issue exists (e.g., visible victims
requiring immediate assistance), interior fire-fighting operations should not commence until a report
from Side Charlie is received. A radio report of conditions, including those on Side Charlie, should be
transmitted over the assigned tactical channel to the incident commander and the dispatch center. The
transmission should include the following information:

• Smoke and fire conditions, with an emphasis on identifying the seat of the fire. The initial radio
report from the first arriving unit for a structural fire should include the signal for a working fire, the
number of stories, type of occupancy, and location of fire. This lays the foundation for additional
reports and serves as notification to responding units as to the type of tactics to implement.
• If there was critical building description information through the incident dispatch system for the
address, then this information would aid in implementing or adjusting SOPs. Critical incident dispatch
systems may contain information that would necessitate alternative action to fulfill operational goals,
including:

o Building features (e.g., number of stories)

o Basement access and type
o Any other life or safety hazards.

Any change to operational priorities or responsibilities based on the above size-up should be clearly
communicated to command, all responding units, and the dispatch center via the assigned tactical radio
channel [Township of Spring Fire Rescue 2013; FDNY 2011]. Command is then obligated to re-
broadcast and receive acknowledgement from all operating companies.

The procedures developed for fireground operations should be flexible enough to allow for change if
any of the following issues occur or are present:

• Life hazard (must be given first priority)

• Problems with water supply and water application
• Volume and extent of fire requires large caliber streams
• Location of the fire makes it inaccessible for hand-line operations
• Materials involved in the fire and/or explosion potentially compound the problem
• Exposure problems where further fire spread would be a major concern
• Stability of the structure, which would be dependent on the condition of the structural components of
the building and the intensity and duration of the fire [ISFSI 2013]

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Personnel should recognize small commercial fires (structures around 10,000 square feet) are different
from residential fires. Personnel should focus on identifying modern fire behavior, utilizing
commercial construction techniques, and knowing if their resources and equipment match the fire
situation. The types of construction and building features will pose different challenges, and the
internal spaces in commercial fires are much larger. Fire departments are generally knowledgeable
about small compartment fires (i.e., house and apartment fires). Knowing how fire behaves in larger
spaces, in void spaces, and in various attic or cockloft spaces is information firefighters need to have
training on.

Understanding fire indicators from an initial size-up is essential in determining not only strategy and
tactics but also risk-benefit decisions. Observing smoke “push” is faster in one location over another
generally provides direction to the origin of the fire. Observing gray smoke becoming darker indicates
more fuel being burned, more incomplete combustion, and a general deterioration of survivable
conditions. Dark smoke turning lighter can indicate water is getting on the fire, fuel is becoming
consumed, or the fire is going into decay or to an under ventilated stage and creating a very dangerous
time to enter because of the potential for delayed flashover, explosive growth stage, or backdraft. Fire
exiting a roof or under eaves indicates fire in attic area, and exterior smoke can indicate the fire origin
as well as the stage of the fire. Smooth or laminar flowing smoke that becomes turbulent is a warning
that ignition is imminent. Remember that commercial structure fires typically pose a low life hazard
for civilians, yet a high loss hazard for firefighters [Fire Engineering 2018].

Building construction techniques are always evolving. SOPs/SOGs should include specific recuring
training on issues related to building construction and commercial structures.

A common issue for small commercial occupancies is rapid fire spread, which causes early collapse.
Typically, these structures have large open spaces and common attic or cockloft spaces that are
generally open and undivided, allowing rapid lateral fire to spread above. These structures generally
have high ceiling spaces with one or more false or drop ceilings that can hide smoke and fire on entry.
They generally have higher fire loads than single-family dwellings, which means hotter and faster
burning fires. The presence of overhangs or facades are common and dangerous in fire conditions.
Couple these issues with potential access/egress issues, an irregular and unfamiliar layout, and aisles of
stocked items or highly combustible contents, and it becomes evident why fighting fires in these types
of buildings is dangerous [Fire Engineering 2018].

Recommendation #9: Fire departments should ensure all members engaged in emergency
operations receive annual proficiency training and evaluation on fireground operations, including
operations within commercial structures.

Discussion: To ensure the proficiency and competency of fire department members, fire departments
should conduct annual skills evaluations to verify minimum professional qualifications. This annual
evaluation should address the qualifications specific to the member’s assignment and job description.
Evaluation of skills should take place on a recurring cycle with the goal of preventing the degradation
of skills and abilities and ensuring the safety of members. Proficiency evaluation and training provides

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an opportunity to ensure that all fire officers and firefighters are competent in fireground operation
knowledge, skills, and abilities. This process should include annual live fire training.

NFPA 1500, Standard for a Fire Department Occupational Safety, Health, and Welfare Program,
requires a fire department to establish and maintain a training, education, and professional
development program with the goal of preventing occupational deaths, injuries, and illnesses. This
ensures member competencies are maintained to execute all responsibilities effectively, efficiently, and
safely [NFPA 2021]. This process is consistent with the organizational statement that establishes the
existence of the fire department, the services the fire department is authorized and expected to perform,
the fire department’s organizational structure, and the job descriptions and functions of fire department
members [NFPA 2021]. As members progress through various job duties and responsibilities, the
department should ensure the necessary knowledge, skills, abilities, and the required ability to
demonstrate competencies for the defined position. The training and education process also should
provide the ongoing development of existing skills [NFPA 2021].

NFPA 1410, Standard on Training for Initial Emergency Scene Operations, defines basic evolutions,
which are adaptable to local conditions and serve as a method for the evaluation of minimum
acceptable job performance during initial fireground operations [NFPA 2020a]. Proficiency training
for fireground operations and emergency incidents should occur annually. This training should include
scene size-up, situational awareness, use of an incident management system, personnel accountability
system, strategy and tactics, search and rescue, hoseline operations, ladder operations, ventilation,
thermal imaging cameras, fireground communications, use of RITs, and Mayday operations.

Over the past few years, fire service members have emphasized the importance of adopting strategies
and tactics specifically designed and proven to work effectively at commercial fires [Fire Engineering
2017]. An article from Firefighter Nation highlights important training considerations for commercial
vs. residential fire attack and search and rescue issues in commercial structures:

Commercial vs. Residential

There are three main reasons why we must approach commercial fires differently than
residential fires.

Building construction: The average house has many compartments and at least some fire
protection for the ceiling support members in the form of the drywall ceiling. In contrast, most
modern commercial structures include lightweight open bar joist trusses that span a large,
open area designed for retail or office use. Because commercial buildings lack the
compartmented features of a house, the fire has the potential to grow much larger, much faster.

Consider this: In a 2,000-square-foot house with one or two involved rooms, the walls may
limit fire spread to a few hundred square feet. In a 2,000-square-foot commercial building
without such “compartments,” a small fire is more likely to grow at a much faster rate. Hence,
buildings of the same overall size may produce vastly different sized fires. Add to this the open

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nature of many commercial roof assemblies, which are often unprotected from direct flame
contact, and you get buildings that will fail faster than residential structures.

Hidden fire: The second major difference between residential and commercial structures is that
moderate or large commercial structures can conceal a large fire without showing the classic
indications of a working fire. One example: A fire in a 1,000-square-foot house will probably
fill the house with a smoke layer that’s close to the floor. The same size fire in a 5,000-square-
foot commercial structure may present with smoke only at the ceiling level. It’s the same
amount of smoke; it’s simply dispersed over a larger area. We tend not to feel threatened by
smoke that’s 12 feet above us; however, the roof assembly is directly exposed, increasing the
potential for collapse.

This example shows why we cannot treat a commercial building the same way we treat a house.
Moderate smoke showing from a 3,000-square-foot house may lead us to take an offensive
approach. The same presentation from a commercial structure probably indicates a much
larger and more dangerous fire. If we use the same offensive approach, we’re likely to get into
serious trouble. Add to that the inherent difficulties in finding and attacking the fire in a large
building, and you can see where the risk becomes compounded. It takes more personnel with
longer, larger lines a greater amount of time to attack the fire. Plus, the bigger the fire and the
longer it burns, the more likely it is to bring down the structure.

Access, egress & ventilation: The third significant difference between residential and
commercial structures is the ease at which we can access, egress and ventilate the buildings.
Doors in commercial buildings are grouped in a way that benefits the retailer in their effort to
control the customer. They are typically located in a single area and are designed for easy
egress only once you reach them. They are not evenly spaced around the structure. Have you
ever been out the back door of a Wal-Mart? Although the exits are required to be large enough
for the customer traffic, they were never intended to be spaced evenly enough for firefighting
access or egress.

As for ventilation, even the most well-staffed fire departments will find it a challenge to cut
holes large enough or fast enough to keep up with the volume of smoke produced by a
significant working fire in a commercial structure [Firefighter Nation 2009].

Recommendation #10: Fire departments should ensure crew integrity is properly maintained by
voice or radio contact when operating in an atmosphere that is IDLH.

When an engine company enters a structure, the members should stay in contact by visual (eye-to-eye),
verbal (radio or face-to-face), or direct (touch) contact. NFPA 1500 Standard on Fire Department
Occupational Safety and Health Program, 8.5.5, states, “Crew members operating in a hazardous area
shall be in communication with each other through visual, audible, or physical means or safety guide
rope, in order to coordinate their activities.” Section 8.5.4 states, “Members operating in hazardous
areas at emergency incidents shall operate in crews of two or more.” Additionally, NFPA 1500 8.5.6
states, “Crew members shall be in proximity to each other to provide assistance in case of an
emergency” [NFPA 2021].

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All firefighters should maintain unity of command by always operating under the direction of the
incident commander, division/group supervisor, or their company officer. The ultimate responsibility
for crew integrity and ensuring no members become separated or lost rests with the company officer.
While operating in a hazard zone, the officer should maintain constant contact with their assigned
members by visual observation, voice, or touch. They should ensure members stay together as a
company or crew. If any of these elements are not adhered to, crew integrity is lost, and firefighters are
placed at great risk.

NFPA 1500, 8.4.4–8.4.6 states:

• The incident commander shall maintain an awareness of the location and function of all companies or
crews at the scene of the incident.

• Officers assigned the responsibility for a specific tactical-level management component at an incident
shall directly supervise and account for the companies and/or crews operating in their specific area of
responsibility.

• Company officers shall maintain an ongoing awareness of the location and condition of all company
members [NFPA 2018b].

If a firefighter becomes separated and cannot immediately get reconnected with his/her crew, the
firefighter must attempt to communicate via radio with the company officer. If reconnection is not
accomplished after three radio attempts or reconnection does not take place within 1 minute, a Mayday
should be declared. If conditions are rapidly deteriorating, the Mayday should be declared
immediately. As part of a Mayday declaration, the firefighter should next activate the radio’s
emergency alert button, followed by manually turning on the PASS alarm. Similarly, if the company
officer or the firefighter’s partner recognizes they have a separated member, they should immediately
attempt to locate the member by using their radio or by voice. If contact is not established after three
attempts or within 1 minute, a Mayday must be declared immediately [IAFC 2021].

Recommendation #11: Fire departments should ensure all firefighters are trained on proper use of
radios, including discipline and use of the EAB on their portable radio.

Discussion: In addition to issuing a radio to every firefighter, training should be conducted to improve
fireground communication. The fireground radio frequency can become congested, especially during
the early stages when the incident is not yet under control. Radio discipline and proper use are
important and radio transmissions should be limited to those of an important tactical nature
(Conditions-Actions-Needs or a CAN report), personnel accountability report (PAR), and fireground
emergencies (Mayday).

Training should also encompass circumstances when an incident commander opts to change radio
frequencies. This is a potentially dangerous action and should only be undertaken in the most extreme
circumstances given the possibility of “losing” personnel in the movement from one channel to

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another. After switching frequencies, command should conduct a PAR to confirm that the appropriate
units are operating on the correct channel. When channels are changed, dispatch should make a formal
announcement.

Fire departments need to ensure firefighters, officers and dispatchers are trained on fireground
communications and especially emergency communications such as Mayday and priority traffic.
Dispatchers need to inquire if their systems are capable of “pinging” a down firefighter’s radio or
remotely enabling a fire fighters EAB. Different radio systems have different features, but firefighters,
officers, and dispatchers need to train on and practice emergency fireground communications. NIOSH
has recently released a Safety Advisory on the importance of understanding and training on the
portable radio emergency alert button (EAB) during a Mayday [NIOSH 2023].

Recommendation #12: Fire departments should incorporate the principles of command safety into
the incident management system during the initial assumption of command. This ensures strategic-
level safety responsibilities are incorporated into the command functions throughout the incident.

Discussion: The purpose of command safety is to provide incident commanders with the necessary
guidance on how to use, follow, and incorporate safety into the incident management system at all
incidents. Command safety is incorporated into the eight functions of Command developed by Fire
Chief Alan V. Brunacini. The principles of command safety describe how the incident commander
should use the regular, everyday command functions to complete the strategic-level safety
responsibilities during incident operations. Using the command functions creates an effective way to
ensure a close connection between incident safety and incident management.

The eight functions of command are:

• Deployment
• Assume, confirm, and the positioning of command
• Situation evaluation
• Strategy/incident action planning
• Communications
• Organization
• Review, evaluate, revise
• Continue, support, and terminate command [Brunacini 2002; NFPA 2020]

A vital command function involves the IC accounting for the initial scene size-up, critical factors
(building type, occupancy, life safety, fire conditions, and available resources), the standard risk
management plan, the forecast of incident conditions, and a standardized decision-making process. The
incident’s overall strategy is based on the incident’s critical factors weighed against the risk
management plan. The choice of strategy (offensive or defensive) is independent of location (inside or
outside) as it relates to the hazard area or hazard zone. The strategy may change over the course of an
incident, but only one of the two strategies is used at any one time [Blue Card 2018]. Any strategy
should include a simple understandable plan that describes how close the emergency responders will
get to the incident’s hazards.

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The initial radio report should:

• Announce to everybody the overall incident strategy

• Eliminate any question on where firefighters will operate on the incident scene and inside the
structure [Blue Card 2018]

Once the overall incident strategy is determined and the IAP developed, the incident commander
should manage the completion of the tactical priorities for the chosen strategy. Each strategy has a
different set of tactical priorities to complete. The IAP should be short and simple as a complicated
IAP tends to break down during this critical time.

In general, the IC tries to achieve the same basic objectives at every incident. Tactical priorities offer a
regular set of tools, which the incident commander can utilize for tactical activities to develop a
standard approach to solving incident problems. With this standard approach, incident commanders
can manage the basic work sequence at every incident in the same manner.

Dispatch centers should contact the IC every 10–15 minutes on the assigned fireground tactical
channel with elapsed-time reminders. These 10–15-minute notification reminders serve as cues for the
IC to re-evaluate conditions, restate the current strategy, and consider the length of time firefighters
operate in the hazard zone. Incident commanders develop the strategy and the IAP based on the initial
size-up of the incident’s critical factors. These critical factors are very dynamic. Incident operations
either get better or worse. They never stay the same. The incident conditions drive the strategy, IAP,
and risk management plan [Blue Card 2018; NFPA 2021].

An integral part of the personnel accountability system is to ensure all assigned resources working in
the hazard zone are initially accounted for. Throughout the incident, it is necessary to conduct a PAR
periodically to ensure that all assigned resources are accounted for by the accountability officer or
resource status officer.

The accountability officer also should request a PAR from each division or group supervisor whenever
a change in conditions occurs that could cause unsafe operation, such as an “emergency traffic”
announcement to “all companies evacuate the building.” When a division or group supervisor is
requested to conduct a PAR, the supervisor is responsible for reporting on the accountability of all
companies or members working within their area of responsibility [NFPA 2020]. With a strategic
mode change, a PAR should occur to ensure that all assigned resources are accounted for and are out
of the hazard zone. Defensive operations should not start until the PAR is completed and all members
are accounted for by resource status.

The eight functions of command serve as the foundation for addressing command safety issues.
Incident commanders should follow each of these functions in order without skipping or missing any
function. Automatically connecting and integrating safety with command becomes an essential way
that the incident management system protects assigned resources at an incident. These functions serve
as a practical performance foundation for how the incident commander fulfills the responsibility as the

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strategic-level incident manager and the overall incident safety manager [Brunacini and Brunacini
2004].

In this incident, the incident commanders experienced several command safety issues. The fire
department reported that they are increasing training (including command training) as part of its
recovery process. Issues were identified in the areas of fireground communications, establishment of a
stationary command post, personnel accountability, use of a tactical worksheet that compliments
personnel accountability and crew integrity, and a continuous scene size-up and risk assessment.

Recommendation #13: Fire departments should ensure all company operations follow the
assignments given by the incident commander to ensure tactical priorities are met.

Discussion: The IAP is a methodical process that ensures life safety, incident stabilization, and
property conservation. Assigning the tactics in the order of accomplishment will aid in the
coordination of the fireground activities [USFA 2006]. Assigning tactics also limits the amount of
radio traffic needed to implement the IAP, allows companies to react immediately to unforeseen or
changing conditions, and reduces the demands placed on the incident commander. Companies should
communicate their progress reports on the tactical objectives given them by Command to complete the
tactical priorities. This keeps the operation focused on making sure everyone is out and okay,
potentially eliminating an incident problem, and reducing property damage. Incident operations are
conducted around the completion of the tactical priorities, and incident communications should mirror
this. This will help keep communications short and effective. It also maximizes the available free
airtime. Incident commanders should structure unit assignments around:

• Addressing the incident’s critical factors

• Completing the tactical priorities
• Having tactical reserves

The incident commander should consider the following structure when assigning any unit into the
hazard zone:

• Tasks
• The location of these tasks
• The objectives of these tasks [Blue Card 2018]

An assigned tactic provides a direction to a company, which serves as the basis for feedback to the
incident commander as to whether the tactic is completed. If a company is unable to complete the
assignment, the incident commander needs to know as soon as possible to adjust the IAP. The incident
commander also needs to understand why the company is not capable of completing its assigned tactic,
such as no water, unanticipated conditions, or conditions that have deteriorated since the original
assignment [USFA 2006].

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When units arrive on the scene, they should announce that they are staged. Dispatch should not
acknowledge any staged units over the tactical channel. Command should contact the staged units and
assign them based on the IAP.

Orders to first-alarm-staged units should follow a Task-Location-Objective format:

• Tasks
• Location of the tasks
• Objectives of the tasks

Location of those tasks should include:

• What floor to operate on

• What occupancy/exposure to operate in
• What side to make entry on
• What side to operate on (defensive)

When assigning a unit to deploy a hoseline, the incident commander should designate the following:

• What the company needs to do with their apparatus

o Lay a supply line
o Pump a supply line
o Park the apparatus out of the way (manpower only)
• Where the company will get the handline from
o Their own company
o Another forward pumper designated by Command

The task objectives should focus on the completion of the tactical priorities (objective = completion
benchmark):

• Search/rescue = primary and secondary “all clear”

• Fire control = “under control”
• Loss control = “loss stopped” [Blue Card 2018]

When assigning companies to areas that already have units assigned, incident commanders should
inform the newly assigned unit of whom it will report to/work under. The incident commander also
should inform the division/group supervisor of the newly assigned company(s).

Recommendation #14: Fire Departments should ensure firefighters and officers are well trained in
understanding fire development and growth during size up, and that incendiary fires can rapidly
develop and grow beyond predictions.

Discussion: As part of a scene size-up, firefighters and officers need to predict fire growth and
development based on a number of factors. This size-up allows the officer to perform a risk assessment

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on the specific incident and begin to plan actions that will save lives and stop loss while minimizing
the risk to the first responders. Those factors include:

• Fire location, size and intensity (where is it now and where is it going?)
• Life hazard (number and location of civilians, employees, remove the fire or remove the
civilians?)
• Building type and occupancy (type, age and use and built-in protection systems)
• Fire department assets (on-scene resources and additional assets and response times)
• Current fire department actions/effectiveness
• If arson or incendiary conditions are suspected, a defensive approach should be considered due
to unexpected fire growth considerations

This size-up should include an observation and/or report from all sides of the structure and risk
assessment should continue throughout the incident to increase the safety of the members, eliminate
confusion, and prevent the loss of life.

Recommendation #15: States and municipalities should consider adopting and enforcing
regulations for automatic fire sprinkler protection when renovating structures, including self-
closing doors.

Fire development beyond the incipient stage is one of the greatest hazards that firefighters face in
today’s combustible environment. Fire development can be dramatically reduced when fires are
controlled or extinguished by automatic sprinkler systems. NFPA statistics show that most fires in
sprinklered buildings are controlled prior to fire department arrival by the activation of one or two
sprinkler heads. The presence of automatic fire sprinklers also reduces the exposure risk to firefighters
in rescue situations by allowing the safe egress of building occupants before the fire department arrives
on-scene. Finally, the exposure to hazards such as building collapse and overhaul operations are
greatly reduced, if not eliminated, when fire development is arrested and controlled.

The State of California requires the installation of automatic fire sprinkler systems in all newly built
commercial buildings with a fire area that exceeds 5,000 square feet, after any remodeling or
renovation that extends the fire area beyond 5,000 square feet, or any single tenant expansion requiring
a new certificate of occupancy that increases the fire area beyond 12,000 square feet [Mee Design
Services 2020]. The building code requiring sprinkler systems (when built or renovated) did not apply
to this structure.

Recommendation #16: Fire departments should ensure a respiratory protection plan includes
consideration for using larger-volume SCBA cylinders in areas that may require longer-duration
work times (e.g., commercial structures, large area residential structures etc.).

Discussion: A typical 30-minute (1200L) SCBA may not provide an effective quantity of breathing air
for firefighters working in high-rise buildings, commercial structures, large area residential structures,
or large, complex structures.

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The 1200L cylinder in an SCBA will last an average firefighter, actively engaged in suppression
activities, about 15–18 minutes. SCBA ratings are based on a 40 liter per minute breathing rate,
however working firefighters (dragging hose lines down hallways, hooking ceilings, dragging heavy
objects, rescuing civilians, etc.) can regularly breath at rates approaching 100 liters per minute.
Therefore, considerations need to be given to increase the liter volume of SCBAs to achieve a desired
work period of air plus the firefighter’s emergency reserve air (EOSTI). Modern editions of SCBA are
available in higher pressures that increase the available liter volume but are also smaller in overall size
and weight.

NFPA 1852 Standard on Selection, Care and Maintenance of Open-Circuit Self-Contained Breathing
Apparatus for Emergency Services A.5.1.5(18) states, during extreme exertion, for example, actual
service time can be reduced by 50% or more. In addition to the degree of user exertion, other
conditions that effect the SCBA service time include:

• Physical condition of the firefighter

• Emotions of the firefighter, such as fear or excitement that can increase the user’s breathing
rate
• Degree of training or experience the firefighter has had with such equipment
• Whether or not the cylinder is fully charged at the beginning of use
• Facepiece fit
• Use in a pressurized tunnel or caisson [at two atmospheres of pressure (29.4 psig), the duration
is one-half the duration obtained at one atmosphere]
• Condition of the SCBA
• SCBA dead space [A volume proportional to the carbon dioxide (CO2) concentration in the
inhaled breathing gas. An increase of CO2 in the inhalation air leads to increased ventilation
and, consequently, shorter service time for a given air supply. Reducing CO2 in the inhalation
air by using, for example, a well-fitting nose cup, has been demonstrated to give longer service
time].

Fire departments should ensure that firefighters have enough air in their SCBA’s to complete the
mission in their areas. The firefighters should have enough air, by volume, to effectively provide a
work period inside an IDLH atmosphere and still contain enough air volume to exit the IDLH with
their reserve air intact. This can be accomplished by assessing structures to identify areas in a
jurisdiction that demand additional breathing air due to the type of occupancy or hazard, and
companies assigned to those areas can be equipped with the larger cylinders. A modern SCBA cylinder
is made of significantly lighter materials and contains higher pressure, greater volume, and a smaller
profile.

SCBA manufacturers are now offering these SCBA cylinders, and some manufacturers are offering
higher pressure (5500 psi) SCBA, which reduce the weight and increase the volume over existing
SCBA. Currently, many fire departments perform a needs assessment for hazards, such as tunnel
rescues, and provide those specialty companies with closed circuit SCBA (re-breathers) to increase the
amount of time firefighters have to complete an assignment.

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The most important part of the needs assessment is to identify the areas of the jurisdiction that need the
increased air volumes and then provide the equipment and training to those companies that respond or
could be called upon to respond to incidents in those areas.

NFPA 1852 Standard on Selection, Care and Maintenance of Open-Circuit Self-Contained Breathing
Apparatus for Emergency Services, provides fire departments with basic criteria for evaluation and
selecting open-circuit SCBA [NFPA 2018c].

Additionally, the latest editions of NFPA 1981 have a higher EOSTI setting that will alarm at
approximately 35% remaining volume vs 25% +/-2% in editions prior to 2013. In this incident the
department was using 1200-liter (30 minute rated) cylinders but has since upgraded to 1800-liter
cylinders [NFPA 2018d].

Recommendation #17: Fire departments should develop and implement a SOP/SOG on the
deployment and use of RITs, including the use of a RIT bag and air supply for trapped or downed
firefighter(s).

Discussion: Although there is no evidence that the following recommendation would have prevented
this fatality, it is being provided as a reminder of best safety practice for the fire service. To ensure
compliance with 29 CFR 1910.134 Respiratory Protection [OSHA 1998], fire departments must
maintain a RIT or company when members are operating in an IDLH or potentially IDLH atmosphere
[NFPA 2021]. In some organizations, they can be known as a RIT or a firefighter assist and search
team (FAST).

The RIT function should be incorporated into the department’s incident management and personnel
accountability systems [NFPA 2020b]. The needs of critical fireground operations and staffing should
be continuously evaluated in regard to firefighter safety. Resource assignments should be made with
the goal of having the RIT function in place at all times. When the incident commanders need
additional resources, the consideration of deploying the RIT for an operational assignment without
additional resources on scene to function as the RIT should be carefully assessed [NFPA 2020b].

The following restrictions regarding the use of RIT should be considered by incident commanders
during fireground operations:

• The RIT is dedicated to assist and, if necessary, rescue members who become lost, trapped,
distressed, or involved in other serious life-threatening situations

• The RIT should not be used to provide relief for operating companies until the fire/incident has been
declared “under control” by Command

• If assigned by a superior officer to other than RIT duties, the RIT unit officer should remind such
officer of RIT designation [Toledo Fire & Rescue Department 2012; TSFRS 2014]

If the incident commander orders the RIT to work, the incident commander should immediately assign
another on scene company to stand by as the RIT. At a minimum, the incident commander should

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request an additional alarm and designate a company or companies to function as RIT. The remainder
of the companies should report to staging. If no units are available, the incident commander should
assign at least two members to act as a RIT while awaiting a special-called RIT to arrive. An engine
company may be designated as the RIT pending arrival of an additional ladder company or rescue
company. This ensures compliance with OSHA’s “2 In/2 Out” rule under 29 CFR 1910.134,
Respiratory Protection [OSHA 1998].

Many fire departments have a defined response plan for the dispatch of an additional company (engine,
truck, squad, rescue, and/or command officer) to respond to an incident and stand by as the RIT. Based
upon the complexity, magnitude, configuration of the structure, or geographical layout of the incident,
the incident commander may deploy additional RIT by sector/division. Upon arrival or upon
appointment, the RIT officer should confer with the incident commander. The RIT officer should
establish an area to stage the RIT and the necessary RIT equipment.

It is important to stage all necessary RIT equipment in an expedient manner. The RIT officer,
accompanied by one member of the RIT, should perform an incident scene survey while the remaining
RIT members assemble the RIT equipment. If the size of the structure negates a 360-degree survey of
the building, this fact should be relayed to the incident commander as soon as possible. This should be
a benchmark for Command to designate another RIT in order to effectively cover all sides of the
building.

During this survey, the RIT officer and members should look for ways in and out of the structure,
including window configurations, fire escapes, and construction features. The RIT officer should note
the feasibility for placement of ground ladders for rescue or escape purposes. The RIT officer should
also be responsible for setting up and securing a suitable secondary egress for interior crews. This may
include laddering multiple sides of the structure. Once the RIT has determined the need for an egress
ladder, the window glass should be removed. This should only be done after conferring with Command
that the removal of the window will not affect firefighting operations. Once approved by Command,
the egress ladder should be placed at the window. The location of the egress ladder(s) shall be
announced over the radio by the RIT officer [Toledo Fire & Rescue Department 2012].

After the above tasks are completed, the RIT officer should inform Command that a 360-degree survey
is complete and the RIT is ready to intervene if necessary. Once RIT equipment is in place, the entire
RIT should be located in an area immediately accessible to the building for rapid deployment and
maintain radio contact with Command. The RIT officer should brief all members of the RIT as to the
results of his/her incident scene survey. The RIT should operate as one unit. Additional crews may be
added to or in support of the team as necessary. When more than one company is added as part of the
RIT, a rescue group should be formed with a rescue group supervisor [Toledo Fire & Rescue
Department 2012]. Another consideration for Command is to request the response of an advanced life
support (ALS) engine company or truck company as a component of the RIT Group. The members of
an ALS company are trained to operate in an IDLH atmosphere and can function as part of the RIT,
plus they can provide ALS care to affected firefighters [FDNY 2011].

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The RIT officer and RIT members will coordinate with Command to formulate rescue plan
contingencies and continue to monitor the radio and fireground conditions. RIT protection is not a
passive assignment. This is a process of ongoing information gathering and diligent scene monitoring
until the unit is released by the incident commander. The RIT function is a critical component for
firefighter safety.

To ensure firefighters and fire officers are properly trained to conduct RIT operations, they should
meet the requirements of NFPA 1407, Standard for Training Fire Service Rapid Intervention Crews
[NFPA 2020a].

RIT should consider the following tools and equipment for use:

• Thermal imagers
• Additional RIT Kits/Escape Canisters or a RIT SCBA Kit that consists of:
o Nylon bag with sling and carrying handles, 60-minute air bottle, first stage pressure reducer
with 20-feet of intermediate pressure hose, facepiece, second stage regulator, 150-feet of drop
bag line, flashlight, and escape canister.
• Quartz lights to entrances and windows identified as possible exits
• Apparatus rechargeable lights to entrances and exits of the structure
• Lightweight forcible entry tools (axe, pike pole, hook, Halligan Bar)
• Rotary saws
• Chalk
• Inside ladder (12-foot or 14-foot)
• Lighted rescue lines
• A 2½-inch hoseline with straight tips to penetrate and knockdown the fire
• Mattress carrier
• Strobe lights
• Cyalume© light sticks
• Extra SCBA cylinders
• Litter basket or stokes (can be used to carry up equipment to the access point)
• Fans for ventilation when positive pressure ventilation is indicated and there is sufficient time
available to reduce noise
• Tool staging tarp
• Rescue SCBA (RIT pack)
• 150-foot rope for search and rescue
• Wire cutters
• Rebar cutter
• Life belt.
• Elevator keys for buildings with elevators [FDNY 2011; LAFD 2016; TSFRS 2012]

Note: This list of considerations is not comprehensive. It is intended to be a starting point. Fire
departments should constantly strive to upgrade rapid intervention team equipment and tactics.
Company officers should ensure that the rapid intervention team equipment is in a state of readiness
and is appropriate for the potential rescue situation.

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Rapid intervention operations can only be successful when skills are practiced, and swift intervention
tactics are employed. Sound fireground tactics can help prevent the need to deploy rapid intervention
operations. Based on these considerations, the importance of company accountability,
communications, risk versus gain evaluations, and firefighter safety cannot be overstated.

As part of the recovery process, the fire department involved in this incident is evaluating their annual
proficiency training and RIT training requirements for all members.

Recommendation #18: Fire departments should consider appointing shift safety officers.

Discussion: Although there is no evidence that the following recommendation would have prevented
this fatality, it is being provided as a reminder of best safety practice for the fire service. NFPA 1561
Standard on Emergency Services Incident Management System and Command Safety, states in
paragraph 5.3.1 that “The Incident Commander shall have overall authority for management of the
incident.” NFPA 1561 paragraph 5.3.2 states, “The incident commander shall ensure that adequate
safety measures are in place” [NFPA 2020b]. With the advent of the Incident Command System (ICS),
the goal is to ensure that the incident commander is responsible for the safety and welfare of all
members and other first responders that are on scene at an incident.

Based upon the size and complexity of an incident, the incident commander should delegate some
responsibilities that include safety. The ICS can expand to include functions necessary to effectively
command and control an incident. Though the incident commander still is responsible for the safety
and welfare of all members and first responders on the scene, some responsibilities can be delegated to
the safety officer. A predesignated safety officer responds automatically to incidents defined by the fire
department. Upon arrival at the incident, the safety officer should meet with the incident commander to
confirm the safety officer assignment and become integrated into the personnel accountability system.

Upon confirmation, the safety officer should obtain the following information:

• Overall situation status, resource status, the strategy, and IAP

• Known hazards and concerns, plus the establishment of control zones
• Status of RITs
• Establishment of the rehabilitation group
• Confirmation of established radio communication channels (command channel, tactical channels)
[NFPA 2020b]

Once the information above is obtained, the safety officer should don PPE appropriate for the potential
hazards that the safety officer could face. The safety officer also should wear a vest or helmet for quick
identification purposes. The safety officer should perform a reconnaissance of the incident and begin
initiating functions of this position. If the safety officer must enter the hazard zone, they must go with
another firefighter or fire officer. Based upon the size and complexity of the incident, the safety officer
may request the appointment of assistant safety officers.

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Types of incidents that might require expansion of the safety officer role include the following:

• Incidents covering a large geographical area (e.g., high-rise structure) that include numerous
branches, divisions, or groups
• Incidents where significant acute or chronic responder health concerns require coordination and input
to the planning section (responsible for accounting for the organizational structure availability of
resources, deployment of resources, and the situation status reports)
• Incidents requiring interface with local, state, federal, or other health and safety representatives
• Multi-agency incidents where Unified Command is established
• Incidents where Area Command is established

Assistant safety officers assigned to branches, divisions, or groups are addressed according to their
area of responsibility. For example, an assistant safety officer assigned to Division Alpha is addressed
as Division Alpha assistant safety officer. The assistant safety officers assigned to branches, divisions,
or groups report to and follow direction from the safety officer of the Command staff. The assistant
safety officer works with the supervisory person in the assigned branch, division, or group to assure
that safety conditions are met [FIRESCOPE 2015; NIMSC 2008; NFPA 2020b; NIOSH 2012b].

NFPA 1561 defines the role of the safety officer at an incident scene and identifies duties such as
reconnaissance of the fireground and reporting pertinent information back to the incident commander;
ensuring the department’s accountability system is in place and operational; monitoring radio
transmissions and identifying barriers to effective communications; and ensuring that established
safety zones, collapse zones, hot zones, and other designated hazard areas are communicated to all
members on scene [NFPA 2020b].

Larger fire departments should consider having one or more full-time dedicated safety officers who are
on duty and can routinely respond to working fires (e.g., full-time shift safety officers). In smaller
departments, every officer should have the ability to function as the safety officer when assigned by
the incident commander. The presence of a safety officer does not diminish the responsibility of
individual firefighters and fire officers for their own safety and the safety of others.

The safety officer serves as a key figure on fireground operations (not tactics) by gathering a broad
overall perspective of the fireground and acting as extra eyes and ears for incident commanders. Since
incident commanders are tasked with strategic objectives and may not have time to give full attention
to every safety detail, the safety officer can assist the incident commander. A safety officer should
have training beyond that of a company level officer, with increased focus on safety issues such as:

• Fire department incident safety officer training

• Fire department health and safety officer training (acute and chronic threats to firefighter health)
• Fire ground risk assessment
• Risk management
• Accountability
• Fire ground hazards and hazard recognition, evaluation, mitigation, and elimination
• Building construction and collapse

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• Fire behavior
• Fire ground tactics and strategy
• PPE use, capabilities, and limitations
• Firefighter rehabilitation [NFPA 2020b]

Fire departments should establish a training and education program for safety officers. This ensures
that officers who are appointed on scene as the safety officer have the necessary knowledge, skills, and
abilities to effectively function in this position. For large scale incidents, such as this incident,
departments should consider appointing assistant safety officer(s).

Recommendation #19: Fire departments should ensure a communication SOP/SOG is in place for
dispatchers to support fireground operations and the incident commander.

Discussion: Although there is no evidence that the following recommendation would have prevented
this fatality, it is being provided as a reminder of best safety practice for the fire service. Effective
fireground radio communication is an important tool to ensure fireground command and control and
help enhance firefighter safety and health. The radio system must be dependable, consistent, and
functional to ensure that effective communications are maintained, especially during emergency
incidents. Fire departments should have a “Communications” SOP that outlines the communication
procedures for fireground operations. This SOP should be periodically reviewed and updated. Fire
departments should ensure that the communication or dispatch center is part of this revision process.
Another important aspect of this process is an effective education and training program for all
members of the department and the dispatchers [Kunadharaju, Smith, and DeJoy 2010].

NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety
provides basic requirements for fireground communications in Chapter 6, “Communications and
Information Management.” The chapter addresses the key components for effective fireground
communications, such as the requirements for a dispatch radio channel, a command radio channel, and
a tactical radio channel; use of plain text for transmitting strategic modes of operation and situational
reports; emergency traffic including a Mayday; and dispatcher support [NFPA 2020b].

One of the contributing factors in multiple line-of-duty death investigation reports is incident
commanders becoming overwhelmed with fireground radio communications. This is especially true if
the incident commander has to monitor the dispatch channel and the fireground tactical channel. Fire
departments should ensure that the fireground radio communication system is designed and operated to
take this issue into account. An incident commander may miss messages because they are engaged in
face-to-face communications, operating the command board and tactical worksheet, reviewing, or
preparing incident documentation. They may be unable to hear messages due to ambient noise
conditions, their radio being turned down, radio failure, simultaneous transmissions on separate
channels, or simply being distracted with other tasks [NFPA 2020b; Varone 2003].

There are several ways to ensure that incident commanders can effectively manage fireground
communications. The best solution is to have a trained dispatcher monitoring the fireground radio
channel. Dispatchers should meet the requirements of NFPA 1061, Professional Qualifications for

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Public Safety Telecommunications Personnel [NFPA 2018b]. The dispatcher is in a secure
environment, isolated from fireground distractions and noise. The dispatcher should have access to
playback technology with the ability to listen to hard-to-understand messages. The dispatcher should
also have access to "identifier" information, which identifies the portable radio making the
transmission. Like any other aspect of the fire service, all personnel need to be properly trained before
being assigned to a critical task. In the world of fireground operations today, effective radio
communications are essential, and the dispatcher is one of the most critical components in the radio
communications system. Dispatchers need a thorough understanding of the incident management
system, fireground strategy and tactics, and firefighting terminology. Most important, the dispatcher’s
responsibilities during emergency operations should include fireground benchmarks, notifying the
incident commander of elapsed time intervals for a PAR, emergency traffic, Maydays, roll calls, and
building evacuations. Dispatchers should understand the critical role they play in the incident
management system [NFPA 2020b; Varone 2003].

Another important function for the dispatcher is to communicate with the incident commander about
critical incident benchmarks. A dispatcher should ensure that a PAR is conducted every 10–15 minutes
during the incident. The dispatcher should prompt the incident commander every 10–15 minutes to
conduct a PAR. Other critical benchmarks that should be communicated during the incident include a
complete scene size-up with a declared strategy, water is on the fire, a primary search is completed
with outcome, command is being transferred, a Mayday has occurred, and a request has been made for
additional tactical channels and emergency traffic, fire is knocked down, and fire is out. This is not an
all-inclusive list, but an idea of critical fireground benchmarks [NFPA 2020b]. The job of dispatching
should not be assigned to a new firefighter or to a police dispatcher who does not have adequate
training in fireground radio communications. Effective communication involves a thorough
understanding of the message. The sender (dispatcher) transmits a clear message, and the receiver
(incident commander) must acknowledge the transmission, so the sender (dispatcher) knows that the
transmission was understood. This process would work the same way if the incident commander
transmitted a message to the dispatcher (See Diagram 7).

Diagram 7. Communications loop between the dispatcher and the incident commander [NFPA
2020b].

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Dispatching is not a job that should be assigned to a sole individual who may be called away from
monitoring the fireground radio to field telephone calls or dispatch runs. Dispatchers who monitor a
fireground radio channel must be able to dedicate 100% of their concentration into listening for missed
messages and providing support to resources on scene. Ideally, one dispatcher should be assigned to
each fireground channel in use [Varone 2003]. Many fire departments assign a tactical radio operator
or dispatcher to the assigned fireground tactical channel. This dispatcher is assigned the incident until
command clears the tactical channel.

Another solution is to provide the incident commander with a staff assistant or incident command
technician. A battalion chief or district chief can monitor and comprehend radio traffic when in route
to the incident and then while on scene. Additionally, an incident commander should address
deployment issues, develop a strategy for the incident based upon communications from the first
arriving resource, and develop an IAP for the incident. An incident command technician or staff aide
can assist the incident commander with processing information without distraction. Once on scene, the
staff assistant or staff aide can maintain fireground communications with the dispatcher. For fire
departments that do not have a staff assistant or staff aide, another officer or firefighter can be
designated to function in this position [NFPA 2020b]. Every firefighter and company officer should
take responsibility to ensure their portable radio is turned on and is on the correct channel. It is a
company officer’s responsibility to ensure that all members of the crew comply with radio discipline
and fire department SOPs [IAFF 2010, 2022].

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USFA [2003]. Special Report: Rapid intervention teams and how to avoid needing them. USFA-TR-
123/March 2003. Emmitsburg, MD: U.S. Department of Homeland Security, U.S. Fire Administration,
National Fire Academy.

USFA [2006]. Mayday CD Q133 Firefighter safety: calling the Mayday and H134 Calling the
Mayday: hands on training. Emmitsburg, MD: U.S. Department of Homeland Security, U.S. Fire
Administration, National Fire Academy.

Varone C [2003]. Fire fighter safety and radio communication. Fire Engineering, March.

Investigator Information
This incident was investigated by Stephen T. Miles, Investigator/Safety and Occupational Health
Specialist, Matt E. Bowyer, Investigator/General Engineer, and Jeff Funke, Investigator/Safety and
Occupational Health Specialist (team lead) with the Fire Fighter Fatality Investigation and Prevention
Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located
in Morgantown, West Virginia.

Additional assistance with recommendations was provided by Michael Richardson, Investigator/Safety

and Occupational Health Specialist also with the Fire Fighter Fatality Investigation and Prevention
Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located
in Morgantown, West Virginia, and Robert Saunders, Technical Information Specialist with the Fire
Fighter Fatality Investigation and Prevention Program, Hazard Evaluations and Technical Assistance
Branch, Division of Field Studies and Engineering, NIOSH located in Cincinnati, Ohio.

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An expert technical review was provided by Jeff Cook, Assistant Chief, Tomball Fire Department. A
technical review was also provided by the National Fire Protection Association, Public Fire Protection
Division.

Disclaimer
Mention of any company or product does not constitute endorsement by the National Institute for
Occupational Safety and Health, Centers for Disease Control and Prevention. In addition, citations to
websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or
their programs or products. Furthermore, NIOSH is not responsible for the content of these websites.
All web addresses referenced in this document were accessible as of the publication date.

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Appendix A
Example of an Incident Commander’s Tactical Worksheet for Mayday, courtesy of the IAFF
Fireground Survival Program [IAFF 2010, 2022].

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