Fatality Assessment and Control Evaluation (FACE) Program

U.S. workplace deaths remain a public health crisis, with over 5,000 annual fatalities concentrated in high-risk sectors like construction, transportation, and agriculture. To address this under the OSH Act, NIOSH runs the Fatality Assessment and Control Evaluation (FACE) program, a non-regulatory initiative providing safety guidance through independent, non-enforcement investigations. Structurally, FACE operates as a unified effort split into two distinct, complementary branches: a centralized, national In-House program run directly by NIOSH, and a decentralized network of State FACE programs funded via cooperative agreements. While both share common goals and methods, they differ significantly in their organizational structure, authority, influence, and how they implement findings locally across diverse regional industries. Together, they generate extensive prevention resources and adapt to emerging workplace hazards.

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Line of Duty Death Report F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland

Loflin, Murrey E. ;

Attwood, Wesley R.

2025/06/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On August 11, 2021, a 46-year-old career captain died after falling into a basement while fighting a large area residential structure fire. Engine 251 had just cleared from an incident and responded as the first due company. After locating the driveway, Engine 251 dropped 500 feet of 4-inch supply line where the driveway split. Engine 251 drove up ...

Public Domain

Title : Line of Duty Death Report F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland Personal Author(s) : Loflin, Murrey E.;Attwood, Wesley R.;Reichard, Audrey A.;Austin, Emilee T.; Published Date : 2025/06/01 Pages in Document : 42 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257811
Loflin, M. E., Attwood, W. R., Reichard, A. A., & Austin, E. T. (2025). Line of Duty Death Report F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257811

Loflin, Murrey E., Wesley R. Attwood, Audrey A. Reichard, and Emilee T. Austin. Line of Duty Death Report F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257811.

Loflin, Murrey E., et al. Line of Duty Death Report F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257811.
Export RIS Citation Information. TY - Array AU - Loflin, Murrey E. AU - Attwood, Wesley R. AU - Reichard, Audrey A. AU - Austin, Emilee T. AB - On August 11, 2021, a 46-year-old career captain died after falling into a basement while fighting a large area residential structure fire. Engine 251 had just cleared from an incident and responded as the first due company. After locating the driveway, Engine 251 dropped 500 feet of 4-inch supply line where the driveway split. Engine 251 drove up the driveway to the house arriving on-scene at 16:51 hours. Engine 251A (E251A) provided the scene size-up. E251A stated, "Engine 251 is on-scene, large 3½, 2 ½-story single family. We do have a working fire. Go ahead and start rapid intervention team (RIT) and tanker task force." Engine 251 parked on the Side Alpha/Side Bravo corner of the house in the driveway. At 16:52 hours, the Emergency Communication Center (ECC) transmitted the RIT dispatch. Truck 23 arrived on-scene at 16:52 hours. At 16:53 hours, a tanker task force was dispatched for Box 23-11. At 16:55 hours, Chief 23 responded to Box 23-11, arrived on scene, and assumed command. At the same time, OPSAC900 (division's Operations Division Assistant Chief) arrived on-scene and went to Side Charlie. A minute later, Truck 23A told Command, "360 of the residence showing single floor in the back, heavy fire on Side Charlie." Immediately after, E251A told Command, that he was unable to complete the 360. From 16:56 hours to 16:59 hours, Command dealt with arrival assignments and water supply. At 17:00 hours, OPSAC900 and Engine 251B (driver/operator) had two lines in service. Engine 251B told Command that Engine 251 was almost out of water. At 17:00 hours, E251A (deceased firefighter) transmitted a Mayday stating "Mayday, Mayday, Mayday, Engine 251A has fallen through the floor in the fire room." E231, E152, and TR23 were immediately deployed to find the downed captain. At 17:08 hours, E251A transmitted, I think I'm in the Side Charlie corner. I had to retreat from the fire, now I'm stuck and I'm burning up." At 17:08 hours, a rapid intervention group entered the basement by the basement steps on the Side Charlie/Side Delta corner. At 17:09 hours, E251A transmitted, "Tell my family I love them." At 17:12 hours, Engine 231A, with the RIT, told Command they found E251A unconscious and were removing him from the basement. At 17:14 hours, E251A was out of the basement and in the backyard. Basic and advanced life support treatment was initiated. E251A was taken to a trauma hospital in Washington, D.C. via air ambulance where he was pronounced deceased. The fire at Box 23-11 was marked under control around 22:00 hours. The fire was declared out at 07:00 hours the next day. Contributing Factors: Low frequency/high risk incident; Incident management system; Crew integrity; Initial rapid intervention crew (IRIC); Professional development; Corrugated stainless-steel tubing (CSST) system. Key Recommendations - 1) For low-frequency, high-risk incidents, fire departments should ensure incident commanders (ICs) implement an incident management system that prioritizes personnel accountability and maintains effective incident communications. As a part of incident management system (IMS) oversight, the IC can: a) Conduct a thorough scene size-up and risk assessment. b) Develop a strategy and incident action plan specific to large-area residential structures that includes the eight functions of command. c) Anticipate and forecast incident progression. d) Implement a functional personnel accountability system. e) Establish and maintain effective incident communications. f) Assign a staff aide or incident command technician (ICT) to support the IC. 2) For low-frequency, high-risk incidents, fire departments should ensure all companies operating on the fireground maintain crew integrity throughout the incident. Companies can: a) Operate based on the assignment given by the IC Communicate critical incident benchmarks to the IC. b) Deploy to rescue members during the initial stages of an incident. c) Use a thermal imager during the scene size-up and while operating in the hazard zone. 3) Fire department standard operating procedures (SOPs)/standard operating guidelines (SOGs) are consistently updated to ensure adequate staffing and professional development opportunities to support skills and competencies to manage Type V and Type IV incidents. Possible opportunities and activities: a) Train all firefighters and fire officers in fireground survival procedures. b) Conduct training on rural water supply operations. c) Provide annual proficiency training and evaluation on fireground operations, including live fire training, to all members involved in emergency operations. d) Train all members and dispatchers on the safety features of portable radios including the emergency alert button (EAB). e) Train on awareness of Corrugated Stainless Steel Tubing (CSST) and the hazards associated with it. Governing municipalities (federal, state, regional, and local) should develop and implement legislation which prohibits the use of corrugated stainless-steel tubing in residential, commercial, and industrial structures. AN - cdc:257811 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 3; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Safety practices; Accident analysis; Training; Water supply; Communications equipment KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland UR - https://stacks.cdc.gov/view/cdc/257811 ER -
Line of Duty Death Report Report Slides F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland

Fire Fighter Fatality Investigation and Prevention Program (U.S.)

2025/06/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On August 11, 2021, a 46-year-old career captain died after falling into a basement while fighting a large area residential structure fire. Engine 251 had just cleared from an incident and responded as the first due company. After locating the driveway, Engine 251 dropped 500 feet of 4-inch supply line where the driveway split. Engine 251 drove up ...

Public Domain

Title : Line of Duty Death Report Report Slides F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland Corporate Authors(s) : Fire Fighter Fatality Investigation and Prevention Program (U.S.) Published Date : 2025/06/01 Pages in Document : 13 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257812
Fire Fighter Fatality Investigation and Prevention Program (U.S.) (2025). Line of Duty Death Report Report Slides F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257812

Fire Fighter Fatality Investigation and Prevention Program (U.S.). Line of Duty Death Report Report Slides F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257812.

Fire Fighter Fatality Investigation and Prevention Program (U.S.) Line of Duty Death Report Report Slides F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257812.
Export RIS Citation Information. TY - Array A2 - Fire Fighter Fatality Investigation and Prevention Program (U.S.) AB - On August 11, 2021, a 46-year-old career captain died after falling into a basement while fighting a large area residential structure fire. Engine 251 had just cleared from an incident and responded as the first due company. After locating the driveway, Engine 251 dropped 500 feet of 4-inch supply line where the driveway split. Engine 251 drove up the driveway to the house arriving on-scene at 16:51 hours. Engine 251A (E251A) provided the scene size-up. E251A stated, "Engine 251 is on-scene, large 3½, 2 ½-story single family. We do have a working fire. Go ahead and start rapid intervention team (RIT) and tanker task force." Engine 251 parked on the Side Alpha/Side Bravo corner of the house in the driveway. At 16:52 hours, the Emergency Communication Center (ECC) transmitted the RIT dispatch. Truck 23 arrived on-scene at 16:52 hours. At 16:53 hours, a tanker task force was dispatched for Box 23-11. At 16:55 hours, Chief 23 responded to Box 23-11, arrived on scene, and assumed command. At the same time, OPSAC900 (division's Operations Division Assistant Chief) arrived on-scene and went to Side Charlie. A minute later, Truck 23A told Command, "360 of the residence showing single floor in the back, heavy fire on Side Charlie." Immediately after, E251A told Command, that he was unable to complete the 360. From 16:56 hours to 16:59 hours, Command dealt with arrival assignments and water supply. At 17:00 hours, OPSAC900 and Engine 251B (driver/operator) had two lines in service. Engine 251B told Command that Engine 251 was almost out of water. At 17:00 hours, E251A (deceased firefighter) transmitted a Mayday stating "Mayday, Mayday, Mayday, Engine 251A has fallen through the floor in the fire room." E231, E152, and TR23 were immediately deployed to find the downed captain. At 17:08 hours, E251A transmitted, I think I'm in the Side Charlie corner. I had to retreat from the fire, now I'm stuck and I'm burning up." At 17:08 hours, a rapid intervention group entered the basement by the basement steps on the Side Charlie/Side Delta corner. At 17:09 hours, E251A transmitted, "Tell my family I love them." At 17:12 hours, Engine 231A, with the RIT, told Command they found E251A unconscious and were removing him from the basement. At 17:14 hours, E251A was out of the basement and in the backyard. Basic and advanced life support treatment was initiated. E251A was taken to a trauma hospital in Washington, D.C. via air ambulance where he was pronounced deceased. The fire at Box 23-11 was marked under control around 22:00 hours. The fire was declared out at 07:00 hours the next day. Contributing Factors: Low frequency/high risk incident; Incident management system; Crew integrity; Initial rapid intervention crew (IRIC); Professional development; Corrugated stainless-steel tubing (CSST) system. Key Recommendations - 1) For low-frequency, high-risk incidents, fire departments should ensure incident commanders (ICs) implement an incident management system that prioritizes personnel accountability and maintains effective incident communications. As a part of incident management system (IMS) oversight, the IC can: a) Conduct a thorough scene size-up and risk assessment. b) Develop a strategy and incident action plan specific to large-area residential structures that includes the eight functions of command. c) Anticipate and forecast incident progression. d) Implement a functional personnel accountability system. e) Establish and maintain effective incident communications. f) Assign a staff aide or incident command technician (ICT) to support the IC. 2) For low-frequency, high-risk incidents, fire departments should ensure all companies operating on the fireground maintain crew integrity throughout the incident. Companies can: a) Operate based on the assignment given by the IC Communicate critical incident benchmarks to the IC. b) Deploy to rescue members during the initial stages of an incident. c) Use a thermal imager during the scene size-up and while operating in the hazard zone. 3) Fire department standard operating procedures (SOPs)/standard operating guidelines (SOGs) are consistently updated to ensure adequate staffing and professional development opportunities to support skills and competencies to manage Type V and Type IV incidents. Possible opportunities and activities: a) Train all firefighters and fire officers in fireground survival procedures. b) Conduct training on rural water supply operations. c) Provide annual proficiency training and evaluation on fireground operations, including live fire training, to all members involved in emergency operations. d) Train all members and dispatchers on the safety features of portable radios including the emergency alert button (EAB). e) Train on awareness of Corrugated Stainless Steel Tubing (CSST) and the hazards associated with it. Governing municipalities (federal, state, regional, and local) should develop and implement legislation which prohibits the use of corrugated stainless-steel tubing in residential, commercial, and industrial structures. AN - cdc:257812 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 3; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Safety practices; Accident analysis; Training; Water supply; Communications equipment KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report Report Slides F2021-14: Captain Falls into the Basement and Dies While Fighting a Fire in a Large Residential Structure - Maryland UR - https://stacks.cdc.gov/view/cdc/257812 ER -
Line of Duty Death Report F2022-06: 31-Year-Old Firefighter Cadet Collapses During Academy Training Exercise and Dies - Alabama

Eisenberg, Judith S. ;

Wilkinson, Andrea

2025/06/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On July 25, 2022, at 0718 a 31-year-old, male Cadet was participating in Academy training which included an (air) Consumption Course. While attempting the course for the first time, the Cadet was unable to complete it complaining of dizziness, shortness of breath, and cramping; He was reported to have "nearly passed out". An on-site Paramedic asses ...

Public Domain

Title : Line of Duty Death Report F2022-06: 31-Year-Old Firefighter Cadet Collapses During Academy Training Exercise and Dies - Alabama Personal Author(s) : Eisenberg, Judith S.;Wilkinson, Andrea;Barger, Alexandra; Published Date : 2025/06/01 Pages in Document : 16 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257807
Eisenberg, J. S., Wilkinson, A., & Barger, A. (2025). Line of Duty Death Report F2022-06: 31-Year-Old Firefighter Cadet Collapses During Academy Training Exercise and Dies - Alabama. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257807

Eisenberg, Judith S., Andrea Wilkinson, and Alexandra Barger. Line of Duty Death Report F2022-06: 31-Year-Old Firefighter Cadet Collapses During Academy Training Exercise and Dies - Alabama. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257807.

Eisenberg, Judith S., et al. Line of Duty Death Report F2022-06: 31-Year-Old Firefighter Cadet Collapses During Academy Training Exercise and Dies - Alabama. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257807.
Export RIS Citation Information. TY - Array AU - Eisenberg, Judith S. AU - Wilkinson, Andrea AU - Barger, Alexandra AB - On July 25, 2022, at 0718 a 31-year-old, male Cadet was participating in Academy training which included an (air) Consumption Course. While attempting the course for the first time, the Cadet was unable to complete it complaining of dizziness, shortness of breath, and cramping; He was reported to have "nearly passed out". An on-site Paramedic assessed the Cadet's condition immediately and determined he needed further observation and evaluation. The Cadet's PPE was doffed, and he was hooked up to a cardiac monitor to assess his vitals. At approximately 0750, the Cadet was moved indoors to an air-conditioned classroom and advised to drink 1 liter of water. At 0803 the Cadet vomited the water he had consumed, and the Paramedic determined the Cadet's vitals were abnormal and the Captain on scene (Captain 1) called for EMS transport to the Emergency Department. After several hours of observation in the Emergency Department, the Cadet was admitted to the hospital, and then released the following evening. This incident was preceded by another event on July 11, 2022 where the Cadet experienced similar, but less serious symptoms and did not result in hospital referral. The Cadet received clearance from his physician to return to Academy activities on July 28, 2022. The same day (July 28, 2022), at 0930, the Cadet attempts the Consumption Course again, this time accompanied by Captain 2. During the course, Captain 2 notes that the Cadet's breathing was not good, but the Cadet states he is fine and finishes the course. The Cadet promptly collapses just outside of the building where the onsite Paramedic assesses him and documents he is awake, alert and oriented. The Cadet initially denies any medical complaints other than experiencing dyspnea (shortness of breath), but moments later, complains of hamstring and back pain. The Cadet was doffed out of structure fire PPE and moved into an air-conditioned classroom where he began to experience severe respiratory distress. The Cadet was hooked up to cardiac and oxygen monitors which revealed sinus tachycardia and hyperventilation. At approximately 0955, EMS transport was arranged via phone. At 1001, the Cadet was moved from a chair to the floor. Approximately 10 seconds after being moved to the floor, pulseless electrical activity (PEA) was shown on the cardiac monitor with a rate of 23 BPM, and no carotid pulse could be found so cardiopulmonary resuscitation (CPR) was initiated. Following 30-60 seconds of CPR, the carotid pulse was palpable, and he was breathing independently but remained unresponsive. Multiple intravenous lines (IVs) were attempted but line placement was unsuccessful. Upon arrival of EMS, a care report was given to the arriving Paramedic who attempted to place an IV but was also unsuccessful. The original on-site Paramedic simultaneously attempted to perform an endotracheal tube (ETT) placement but was unsuccessful. The Cadet was transferred from the ED to the Intensive Care Unit (ICU) where lifesaving efforts continued. Unfortunately, his clinical condition continued to decline rapidly, and he died later that day. Key Recommendations - NIOSH offers the following recommendations to reduce the risk of heat-related injury and death among firefighters at this and other fire departments across the country. Key Recommendation #1: Review policy on return-to-work medical evaluations as the candidate had 2 prior incidents within the previous 17 days that required medical attention. Key Recommendation #2: Ensure that medical evaluations for Members and Cadets be performed by a provider familiar with the physical and psychological demands of firefighting and the components of NFPA 1582: Standard on Comprehensive Occupational Medical Program for Fire Departments. Key Recommendation #3: Consider feasible options for exertional heat illness monitoring during training including temperature assessment and rapid cooling utilizing NFPA 1584: Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, and the National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. Key Recommendation #4: Have onsite staff (e.g., paramedics) assess Cadet's risk for heat-related illness prior to strenuous training, to include any training in full turnout gear; consider use of a checklist or other screening tool. AN - cdc:257807 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 4; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Medical fitness evaluation; Return to work; Heat stroke KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2022-06: 31-Year-Old Firefighter Cadet Collapses During Academy Training Exercise and Dies - Alabama UR - https://stacks.cdc.gov/view/cdc/257807 ER -
Line of Duty Death Report F2022-03: 35-Year Old Volunteer Firefighter Dies from Smoke Inhalation Injury Sustained During Initial Fire Attack - Kansas

Eisenberg, Judith S. ;

Saunders, Robert

2025/06/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On June 20, 2022, at about 2253 hours, a building fire was reported in a small rural city in Kansas. Personnel from two jurisdictions, the City and County Volunteer Fire Departments (FDs), were dispatched and arrived to find moderate smoke conditions in a commercial building. A 35-year-old firefighter (FF1) responded to the fire and was assigned to ...

Public Domain

Title : Line of Duty Death Report F2022-03: 35-Year Old Volunteer Firefighter Dies from Smoke Inhalation Injury Sustained During Initial Fire Attack - Kansas Personal Author(s) : Eisenberg, Judith S.;Saunders, Robert;Wilkinson, Andrea; Published Date : 2025/06/01 Pages in Document : 20 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257805
Eisenberg, J. S., Saunders, R., & Wilkinson, A. (2025). Line of Duty Death Report F2022-03: 35-Year Old Volunteer Firefighter Dies from Smoke Inhalation Injury Sustained During Initial Fire Attack - Kansas. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257805

Eisenberg, Judith S., Robert Saunders, and Andrea Wilkinson. Line of Duty Death Report F2022-03: 35-Year Old Volunteer Firefighter Dies from Smoke Inhalation Injury Sustained During Initial Fire Attack - Kansas. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257805.

Eisenberg, Judith S., et al. Line of Duty Death Report F2022-03: 35-Year Old Volunteer Firefighter Dies from Smoke Inhalation Injury Sustained During Initial Fire Attack - Kansas. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257805.
Export RIS Citation Information. TY - Array AU - Eisenberg, Judith S. AU - Saunders, Robert AU - Wilkinson, Andrea AB - On June 20, 2022, at about 2253 hours, a building fire was reported in a small rural city in Kansas. Personnel from two jurisdictions, the City and County Volunteer Fire Departments (FDs), were dispatched and arrived to find moderate smoke conditions in a commercial building. A 35-year-old firefighter (FF1) responded to the fire and was assigned to be part of the initial attack crew. Fire origin was thought to be on the 2nd floor, which was accessible by interior stairs. However, due to heavy smoke, the attack team had difficulty finding the stairs. The team exited the structure and received detailed directions to the stairs, retrieved a thermal imaging camera, and reentered the building at approximately 2319. FF1 fell backwards down the stairs and experienced a catastrophic loss of air pressure at 2322. Shortly afterwards, a Mayday was called for firefighter down. The rapid intervention team (RIT) found FF1 face down and unresponsive on the floor near the base of the stairs. FF1 was removed from the building and placed in the waiting ambulance. Once outside, it was noted that his mask was off. He had a pulse but was not breathing, so CPR was initiated. Soot was noted in his airway when he was intubated. Intraosseous access was obtained during EMS ground transport to a rendezvous location with EMS air transport at 2349. On the way to the emergency department (ED), he went into cardiac arrest. However, with resuscitation efforts, he regained spontaneous circulation. On arrival at the ED, at 2352, he was still unresponsive. Imaging done at the time of his admission to the ICU showed a severe anoxic brain injury. He did not exhibit any brain stem reflexes. A brain perfusion scan done the following day showed no cerebral blood flow. He was pronounced dead at 1205 on June 22, 2022. Key Recommendations: NIOSH offers the following recommendations to reduce the risk of smoke inhalation injuries and sudden cardiac arrest among firefighters at this and other fire rescue agencies across the country. Key Recommendation #1: Reinforce self-contained breathing apparatus (SCBA) training to include equipment familiarization and use in Immediately Dangerous to Life or Health (IDLH) environments, such as structure fires. Ensure firefighters keep their mask on when operating in IDLH environments to reduce the risk of inhaling hot gases and combustion products. Key Recommendation #2: Firefighters wearing full face masks should groom facial hair as to not impede the seal formed by the mask. This requirement is outlined in OSHA 29 CFR 1910.134 and NFPA 1404 Standard for Fire Service Respiratory Protection Training. Fit testing should also occur, at minimum, once per year, following guidelines from the NFPA 1500 Standard on Fire Department Occupational Safety, Health, and Wellness Program and OSHA 29 CFR 1910.134(k). Key Recommendation #3: Adopt and comply with OSHA mandatory record keeping components of a respiratory protection program and regular SCBA maintenance and recordkeeping. Key Recommendation #4: Encourage training of all firefighters on NFPA 1407 Standard for Training Fire Service Rapid Intervention Crews to promote safety and survival. AN - cdc:257805 KW - Fires KW - Firefighters KW - Safety KW - Smoke Inhalation Injury KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 7; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Smoke inhalation; Self contained breathing apparatus; SCBA; Training KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety KW - Smoke Inhalation Injury LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2022-03: 35-Year Old Volunteer Firefighter Dies from Smoke Inhalation Injury Sustained During Initial Fire Attack - Kansas UR - https://stacks.cdc.gov/view/cdc/257805 ER -
Line of Duty Death Report F2022-05: 58-Year-Old Driver/Engineer with Diabetes Dies from Heart Attack, Florida

Eisenberg, Judith S. ;

Saunders, Robert

2025/06/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On the morning of Sunday, June 5, 2022, a 58-year-old driver/engineer (ENG) with a history of diabetes left the fire station to return home after completing a routine 48-hour shift. He did not report feeling unwell to any of the staff at the station that weekend. During the early hours of Monday, June 6, 2022, he began to have chest pain and called ...

Public Domain

Title : Line of Duty Death Report F2022-05: 58-Year-Old Driver/Engineer with Diabetes Dies from Heart Attack, Florida Personal Author(s) : Eisenberg, Judith S.;Saunders, Robert;Wilkinson, Andrea;Barger, Alexandra; Published Date : 2025/06/01 Pages in Document : 12 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257806
Eisenberg, J. S., Saunders, R., Wilkinson, A., & Barger, A. (2025). Line of Duty Death Report F2022-05: 58-Year-Old Driver/Engineer with Diabetes Dies from Heart Attack, Florida. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257806

Eisenberg, Judith S., Robert Saunders, Andrea Wilkinson, and Alexandra Barger. Line of Duty Death Report F2022-05: 58-Year-Old Driver/Engineer with Diabetes Dies from Heart Attack, Florida. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257806.

Eisenberg, Judith S., et al. Line of Duty Death Report F2022-05: 58-Year-Old Driver/Engineer with Diabetes Dies from Heart Attack, Florida. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257806.
Export RIS Citation Information. TY - Array AU - Eisenberg, Judith S. AU - Saunders, Robert AU - Wilkinson, Andrea AU - Barger, Alexandra AB - On the morning of Sunday, June 5, 2022, a 58-year-old driver/engineer (ENG) with a history of diabetes left the fire station to return home after completing a routine 48-hour shift. He did not report feeling unwell to any of the staff at the station that weekend. During the early hours of Monday, June 6, 2022, he began to have chest pain and called 911. An EKG obtained by paramedics during transport was consistent with an acute heart attack. This was relayed to the Emergency Department (ED) staff resulting in their calling a "cath alert" (activating the cardiology staff and alerting those in the cardiac catheterization laboratory to an incoming critical patient). On arrival to the ED, he was being stabilized and prepared for transport to the cardiac catheterization laboratory when he went into cardiac arrest and was unable to be resuscitated. Key Recommendations - NIOSH offers the following recommendations to reduce the risk of heart attacks and sudden cardiac arrest among firefighters, including those with diabetes, at this and other fire departments across the country. Key Recommendation #1: Consider requiring annual medical evaluations. Although annual medical evaluations are not required by department policy, NFPA 1582 recommends annual medical evaluations of members [NFPA 2022]. [NFPA 2022]. Key Recommendation #2: Ensure that firefighters with insulin dependent diabetes (type 1 or type 2) meet the provisions set forth in NFPA 1582 to be able to engage in firefighting tasks safely without restriction. Key Recommendation #3: Phase in a mandatory comprehensive wellness and fitness program for firefighters following guidance from NFPA 1583, Standard on Health-Related Fitness Programs for Firefighters [NFPA 2015]. Key Recommendation #4: Ensure that firefighters undergo cardiovascular disease screening as recommended in NFPA 1582 [NFPA 2022]. Please note that although NFPA standards are updated periodically, it is our practice to cite the version in effect at the time of the fatality. In 2025, the NFPA standards 1581-1584 that we cite in this report were consolidated into a single standard designated as 1580. AN - cdc:257806 KW - Fires KW - Myocardial Infarction KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 4; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Cardiac arrest; Cardiovascular disease; Diabetes; Medical fitness evaluation KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Myocardial Infarction KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2022-05: 58-Year-Old Driver/Engineer with Diabetes Dies from Heart Attack, Florida UR - https://stacks.cdc.gov/view/cdc/257806 ER -
Construcción narración de muertes: instalador de techos cae 45 pies a través de un tragaluz.

Washington (State). Department of Labor and Industries

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

Un instalador de techos de 29 años de edad cayó 45 pies a través de un agujero en un techo, mientras instalaba tragaluces. Trabajó para su empleador, un contratista de techos residenciales y comerciales ligeros, durante 16 meses. Formaba parte de una cuadrilla que instalaba aislamiento para techos y tragaluces en un edificio industrial grande en co ...

Title : Construcción narración de muertes: instalador de techos cae 45 pies a través de un tragaluz. Corporate Authors(s) : Washington (State). Department of Labor and Industries Published Date : 2025/05/01 Pages in Document : 1 Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/246444
Washington (State). Department of Labor and Industries (2025). Construcción narración de muertes: instalador de techos cae 45 pies a través de un tragaluz. Washington State Department of Labor and Industries. https://stacks.cdc.gov/view/cdc/246444

Washington (State). Department of Labor and Industries. Construcción narración de muertes: instalador de techos cae 45 pies a través de un tragaluz. Washington State Department of Labor and Industries, 2025. https://stacks.cdc.gov/view/cdc/246444.

Washington (State). Department of Labor and Industries Construcción narración de muertes: instalador de techos cae 45 pies a través de un tragaluz. Washington State Department of Labor and Industries, 2025, Stacks. https://stacks.cdc.gov/view/cdc/246444.
Export RIS Citation Information. TY - Fact Sheet A2 - Washington (State). Department of Labor and Industries AB - Un instalador de techos de 29 años de edad cayó 45 pies a través de un agujero en un techo, mientras instalaba tragaluces. Trabajó para su empleador, un contratista de techos residenciales y comerciales ligeros, durante 16 meses. Formaba parte de una cuadrilla que instalaba aislamiento para techos y tragaluces en un edificio industrial grande en construcción. Se contrataron varios contratistas para el proyecto, que implicaba la instalación de 77 tragaluces. La cuadrilla de estructuras de madera de otro contratista había cortado un agujero desde una plataforma elevadora, debajo de la plataforma del techo. Después le indicaron a los instaladores de techos que llevaran una cubierta de tragaluz para cubrir un agujero. Seleccionaron una cubierta sin sujetadores, de aproximadamente cuatro. pies de anchura por ocho pies de longitud, y la levantaron desde extremos opuestos, con un compañero de trabajo sosteniendo el frente. Dieron medio paso al frente y el compañero de trabajo oyó caer el extremo que sostenía el instalador de techos. Volteó hacia atrás y no vio al instalador de techos; después se dio cuenta de que había caído por un agujero que no sabían que estaba debajo de la cubierta. El compañero de trabajo alertó a su capataz y ambos bajaron las escaleras corriendo. Encontraron al instalador de techos boca arriba, con lesiones graves e inconsciente, en donde había golpeado el suelo de gravilla después de caer 45 pies. Varios compañeros que estaban en el interior lo vieron caer, llamaron al 911 y empezaron a administrar RCP. El personal de respuesta a emergencias llegó pronto, pero no pudieron salvar su vida. Después del accidente, los investigadores determinaron que: Los instaladores de techos no tenían experiencia ni capacitación en la instalación de tragaluces. Se movían de un lado a otro para instalar aislamiento y tragaluces, lo que pudo haberlos confundido respecto a cuáles tragaluces estaban protegidos. La visibilidad en el techo estaba afectada por los rollos de aislamiento. Había líneas de precaución para protección contra caídas en los bordes del techo y alrededor de escotilla de acceso al techo con una escalera de mano, pero los instaladores de techo no usaban protección contra caídas dentro de las líneas, en donde había agujeros para tragaluces. La canastilla de la plataforma elevadora, que se había movido de abajo del agujero antes de que ocurriera la caída, se usaba como plataforma de detención de caídas. Esa práctica contravenía las directrices de seguridad del fabricante y las reglas estatales de protección contra caídas. El empleador, los supervisores y los trabajadores no comprendían completamente los requisitos estatales de protección contra caídas para los agujeros de tragaluces, ni cuándo es aceptable utilizar un monitor o una plataforma de detención de caídas. El plan de trabajo de protección contra caídas del empleador no identificaba a los agujeros de tragaluces como peligros de caída. [Description provided by NIOSH] AN - cdc:246444 KW - Coal KW - Ventilation KW - Risk Factors KW - Engineering KW - Respiratory Protective Devices KW - Dust KW - Risk Assessment KW - Safety KW - Coal Mining KW - Personal Protective Equipment KW - Occupational Health KW - Mining KW - Muertes; Educación sobre seguridad; Construcción; Techadores; Protección contra caídas; Industria de techado KW - Coal KW - Coal Mining KW - Dust KW - Engineering KW - Mining KW - Occupational Health KW - Personal Protective Equipment KW - Respiratory Protective Devices KW - Risk Assessment KW - Risk Factors KW - Safety KW - Ventilation PB - Washington State Department of Labor and Industries PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Construcción narración de muertes: instalador de techos cae 45 pies a través de un tragaluz. UR - https://stacks.cdc.gov/view/cdc/246444 ER -
Construction Fatality Narrative: Roofer Falls 45 Feet Through Skylight

Washington (State). Department of Labor and Industries

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

A 29-year-old roofer fell 45 feet through a hole in a roof while installing skylights. He worked for his employer, a residential and light commercial roofing contractor, for 16 months. He was on a crew installing roofing insulation and skylights on a large industrial building under construction. Multiple contractors were hired for the project, whic ...

Title : Construction Fatality Narrative: Roofer Falls 45 Feet Through Skylight Corporate Authors(s) : Washington (State). Department of Labor and Industries Published Date : 2025/05/01 Pages in Document : 1 Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/246443
Washington (State). Department of Labor and Industries (2025). Construction Fatality Narrative: Roofer Falls 45 Feet Through Skylight. Washington State Department of Labor and Industries. https://stacks.cdc.gov/view/cdc/246443

Washington (State). Department of Labor and Industries. Construction Fatality Narrative: Roofer Falls 45 Feet Through Skylight. Washington State Department of Labor and Industries, 2025. https://stacks.cdc.gov/view/cdc/246443.

Washington (State). Department of Labor and Industries Construction Fatality Narrative: Roofer Falls 45 Feet Through Skylight. Washington State Department of Labor and Industries, 2025, Stacks. https://stacks.cdc.gov/view/cdc/246443.
Export RIS Citation Information. TY - Report A2 - Washington (State). Department of Labor and Industries AB - A 29-year-old roofer fell 45 feet through a hole in a roof while installing skylights. He worked for his employer, a residential and light commercial roofing contractor, for 16 months. He was on a crew installing roofing insulation and skylights on a large industrial building under construction. Multiple contractors were hired for the project, which involved installing 77 skylights. Another contractor's framing crew had just cut a hole from a boom lift underneath the roof deck. They then hand signaled the roofers to carry a skylight lid to cover a hole. They Skylight hole and lid on roof. selected an unsecured, approximately four-foot wide by eight-foot long lid and lifted it at opposite ends with the coworker holding the front. They took a half step forward when the coworker heard the roofer's end drop. He looked back and did not see the roofer, realizing he had fallen through a hole they did not know was under the lid. The coworker alerted his foreman and they ran downstairs. They found the roofer on his back, seriously injured and unresponsive where he landed on gravel after falling 45 feet. Several workers inside saw him fall, called 911, and began CPR. First responders soon arrived but could not save his life. Following the incident, investigators found: 1) The roofers were not experienced nor trained in skylight installations. They were going back and forth between installing insulation and skylights, which may have confused them about which skylights were secured. Visibility on the roof was impacted by the bundles of insulation. 2) Fall protection warning lines were in place at the roof edge and around a roof ladder access hatch but no fall protection was being used by roofers inside the lines where skylight holes were present. The boom lift basket, which had been moved from below the hole before the fall occurred, was being used as a fall catch platform. This practice was against the manufacturer's safety guidelines and state fall protection rules. 3) The employer, supervisors, and workers lacked understanding of state fall protection requirements for skylight holes and when a monitor or catch is acceptable to be used. The employer's fall protection work plan (FPWP) did not identity skylight holes as fall hazards. [Description provided by NIOSH] AN - cdc:246443 KW - Construction Industry KW - Safety KW - Accidental Falls KW - Occupational Health KW - Mortality KW - Fatalities; Safety education; Construction; Roofers; Fall protection; Roofing industry KW - Accidental Falls KW - Construction Industry KW - Mortality KW - Occupational Health KW - Safety PB - Washington State Department of Labor and Industries PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Construction Fatality Narrative: Roofer Falls 45 Feet Through Skylight UR - https://stacks.cdc.gov/view/cdc/246443 ER -
Overhaul Inventory: Lithium-ion Battery-Powered Devices

National Institute for Occupational Safety and Health. Fire Safety Research Institute

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

Instructions: Lithium-ion (LI) batteries can experience thermal runaway, a situation where a battery cell enters a state of uncontrolled self-heating. This can occur minutes, hours, or days after the battery is damaged from mechanical stress or being exposed to fire. During the overhaul stage at a residential structure fire, it is important for fir ...

Public Domain

Title : Overhaul Inventory: Lithium-ion Battery-Powered Devices Corporate Authors(s) : National Institute for Occupational Safety and Health. Fire Safety Research Institute Published Date : 2025/05/01 Pages in Document : 2 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257794
National Institute for Occupational Safety and Health. Fire Safety Research Institute (2025). Overhaul Inventory: Lithium-ion Battery-Powered Devices. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257794

National Institute for Occupational Safety and Health. Fire Safety Research Institute. Overhaul Inventory: Lithium-ion Battery-Powered Devices. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257794.

National Institute for Occupational Safety and Health. Fire Safety Research Institute Overhaul Inventory: Lithium-ion Battery-Powered Devices. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257794.
Export RIS Citation Information. TY - Forms A2 - National Institute for Occupational Safety and Health. Fire Safety Research Institute AB - Instructions: Lithium-ion (LI) batteries can experience thermal runaway, a situation where a battery cell enters a state of uncontrolled self-heating. This can occur minutes, hours, or days after the battery is damaged from mechanical stress or being exposed to fire. During the overhaul stage at a residential structure fire, it is important for firefighters to locate and remove all LI battery-powered devices exposed to fire conditions. 1. Incident commanders and homeowners/occupants should use this inventory checklist to identify all LI battery-powered devices in the residence and their locations. 2. Give the completed checklist to operations or an assigned firefighter to locate the devices and check for exposure to fire. 3. Isolate and/or apply the appropriate extinguishment method to identified devices. 4. With the addition of LI batteries to the fuel loads in structure fires, it is more important than ever to perform a gross decon at the scene with soap, water, and a brush. Full structural personal protective equipment with a self-contained breathing apparatus should be used during overhaul when LI battery-powered devices may be present. AN - cdc:257794 KW - Safety KW - Checklist KW - Occupational Health KW - Batteries; Thermal reactions; Fire fighters; Fire safety; Safety practices KW - Checklist KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Overhaul Inventory: Lithium-ion Battery-Powered Devices UR - https://stacks.cdc.gov/view/cdc/257794 ER -
Line of Duty Death Report F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois

Loflin, Murrey E. ;

Attwood, Wesley R.

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On December 4, 2021, a 38-year-old lieutenant (the officer of Engine 6 North) died after falling into the basement when the floor collapsed at a residential structure fire. On December 3, 2021, at 23:04 hours, a Still Alarm for mutual aid box alarm system (MABAS) Box 30 was dispatched for a residential structure fire. The county dispatch center (Tw ...

Public Domain

Title : Line of Duty Death Report F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois Personal Author(s) : Loflin, Murrey E.;Attwood, Wesley R.;Austin, Emilee T.; Published Date : 2025/05/01 Pages in Document : 31 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257792
Loflin, M. E., Attwood, W. R., & Austin, E. T. (2025). Line of Duty Death Report F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257792

Loflin, Murrey E., Wesley R. Attwood, and Emilee T. Austin. Line of Duty Death Report F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257792.

Loflin, Murrey E., et al. Line of Duty Death Report F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257792.
Export RIS Citation Information. TY - Array AU - Loflin, Murrey E. AU - Attwood, Wesley R. AU - Austin, Emilee T. AB - On December 4, 2021, a 38-year-old lieutenant (the officer of Engine 6 North) died after falling into the basement when the floor collapsed at a residential structure fire. On December 3, 2021, at 23:04 hours, a Still Alarm for mutual aid box alarm system (MABAS) Box 30 was dispatched for a residential structure fire. The county dispatch center (TwinComm) dispatched Engine 48 (E48), Engine 41 (E41), Engine 6 North (E6N), Tender 1 North (T1N), Car 1 South, Car 1 North, Deputy Chief 2 South (DC2S), and Deputy Chief 2 North (DC2N). Car 1 South arrived on-scene at 23:14 hours and found a fire in the attached garage that had extended into the house. Car 1 South established himself as the incident commander (IC) on arrival. E48 arrived onscene at 23:14 hours. IC ordered E48 to stretch a 2½- inch and 1¾-inch hoseline towards the garage. As E6N arrived on-scene at 23:18 hours, E48 initiated an exterior attack on the garage. DC2S arrived onscene at 23:18 hours and was assigned as the accountability officer. E48 moved to Side Alpha to make entry through the front door. Upon entry, they noticed the entire attic space was involved in fire. The officer of E6N (E6NA) (deceased firefighter) and the officer of T1N (T1NA) joined E48 to enter the house. Car 1 North arrived at 23:21 hours and was assigned as Operations Section Chief/Division Alpha Supervisor. The two firefighters from E6N went to Side Charlie with a 1¾-inch hoseline to knock down the porch fire. At 23:28 hours, DC2N arrived on-scene and was assigned as Division Charlie Supervisor. At 23:29 hours, fireground operations were at 15 minutes. At this time E48, E6NA, and T1NA exited the structure together after their self-contained breathing apparatus (SCBA) end of service time indicators (EOSTIs) sounded. After a cylinder change, the crew from E48 reentered the structure through the front door on Side Alpha. E6NA and T1NA reentered the house through the front door, but split up and went to different rooms to pull ceilings. T1NA pulled ceiling until he was completely out of air. As he left the structure through the front door, he encountered two firefighters from E41. T1NA went to the rehabilition area and met a firefighter from E48, who was with him on the initial fire attack. During this time, the accountability officer had E6NA on a team with two other firefighters in the building. At 23:44 hours, fireground operations were at 30 minutes. A crew of three firefighters were then assembled and directed to enter the building and report to the E6NA for an assignment. Interior operations continued with firefighters from multiple departments rotating in and out of the structure. At 23:54 hours, Car 1 North advised IC that the fire was under control and major overhaul was underway. At approximately 23:59 hours, E6NA met face-to-face with the incoming firefighters and then headed towards the outside. Since his crew had already been sent to rehab, E6NA was alone at this point. Fireground operations were at 45 minutes at this time. At approximately 00:01 hours on December 4, a radio report was transmitted on MABAS Red of a partial floor collapse. As E6NA exited the building, he fell through a fire weakened portion of the floor into the basement near the Side Alpha/Side Delta corner of the family room floor. E6NA transmitted a Mayday at approximately 00:04 hours on the dispatch channel. Most crews were operating on the MABAS Red and did not hear the Mayday. Car 1 North declared emergency traffic and asked for the member who called the Mayday to repeat the message. There was no response. A personnel accountability report (PAR) was initiated at approximately 00:06 hours. A firefighter from Squad 1 (a part of Car 1 North) was initially thought to be the missing firefighter. This firefighter was found on Side Charlie. After approximately 10-12 minutes, a message was transmitted over MABAS Red stating, "We have PAR." Car 1 North advised IC that all interior crews were accounted for at this time. At approximately 00:37 hours, firefighters in the rehabilitation area could not locate E6NA. A search operation was initiated. During the search, IC advised the house had a full basement. The presence of a basement was unknown to initial responding units because all the basement windows were boarded up and painted over to match the siding of the structure. A crew went to the basement steps but could not enter because of debris from the 1st floor collapse. A crew from a mutual aid fire department entered a front bedroom/office and cut a hole in the 1st floor. A crew from mutual aid fire department Engine 6 (DCE6) used an attic ladder to enter the basement through the hole. DCE6 reported heavy smoke, no visibility, and no visible fire. Shortly after entering the basement, a crew member heard an SCBA personal alert safety system (PASS) alarm sounding. The crew located E6NA with his SCBA facepiece and regulator intact and his helmet on. DCE6 reported to IC that they found E6NA and requested emergency medical services (EMS) at approximately 00:52 hours. The third attempt to remove E6NA from the basement was successful. E6NA was transferred to EMS personnel for care at approximately 01:02 hours. He was transported by ambulance to a local trauma hospitial and was pronounced deceased at 01:41 hours. The fire was marked under control at approximately 02:00 hours by IC. The fire was declared out at approximately 06:45 hours. Contributing Factors: Scene size-up and risk assessment; Personnel accountability; Crew integrity; Basement fire; Professional development; Lithium-ion battery fire; Emergency communications; Unpermitted occupancy renovations. Fire departments should: 1) Ensure initial and ongoing size-ups and risk assessments are conducted throughout the incident. 2) Train ICs to provide ongoing accountability to include immediately establishing divisions/groups with a supervisor to communicate conditions and critical benchmarks. 3) Use a personnel accountability system to identify the location and function of all personnel operating at an incident. 4) Ensure company officers and firefighters maintain crew integrity. 5) Ensure fire department operations include Standard Operating Procedures (SOPs)/Standard Operating Guidelines (SOGs) for identifying basements and below-grade fires. 6) Ensure the implementation of a training, education, and professional development program is based upon each rank. 7) Raise awareness about the fire dangers of lithium-ion battery-powered products among community members through fire and life safety education programs. Public Safety Answering Points (federal, state, regional/county, and local) should: Ensure a communication SOP and equipment is in place for dispatchers to support fireground operations and the IC, including the ability to receive emergency alert button (EAB) signals from portable radios as well as monitor and record all radio traffic during fireground operations. Governing municipalities (federal, state, regional/county, and local) should: Ensure the applicable fire and life safety codes are enforced for renovations in residential occupancies and relevant information is shared with the fire department. AN - cdc:257792 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 5; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Structural failure; Safety practices KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois UR - https://stacks.cdc.gov/view/cdc/257792 ER -
Line of Duty Death Report Report Slides F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois

Fire Fighter Fatality Investigation and Prevention Program (U.S.)

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On December 4, 2021, a 38-year-old lieutenant (the officer of Engine 6 North) died after falling into the basement when the floor collapsed at a residential structure fire. On December 3, 2021, at 23:04 hours, a Still Alarm for mutual aid box alarm system (MABAS) Box 30 was dispatched for a residential structure fire. The county dispatch center (Tw ...

Public Domain

Title : Line of Duty Death Report Report Slides F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois Corporate Authors(s) : Fire Fighter Fatality Investigation and Prevention Program (U.S.) Published Date : 2025/05/01 Pages in Document : 19 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257793
Fire Fighter Fatality Investigation and Prevention Program (U.S.) (2025). Line of Duty Death Report Report Slides F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257793

Fire Fighter Fatality Investigation and Prevention Program (U.S.). Line of Duty Death Report Report Slides F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257793.

Fire Fighter Fatality Investigation and Prevention Program (U.S.) Line of Duty Death Report Report Slides F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257793.
Export RIS Citation Information. TY - Array A2 - Fire Fighter Fatality Investigation and Prevention Program (U.S.) AB - On December 4, 2021, a 38-year-old lieutenant (the officer of Engine 6 North) died after falling into the basement when the floor collapsed at a residential structure fire. On December 3, 2021, at 23:04 hours, a Still Alarm for mutual aid box alarm system (MABAS) Box 30 was dispatched for a residential structure fire. The county dispatch center (TwinComm) dispatched Engine 48 (E48), Engine 41 (E41), Engine 6 North (E6N), Tender 1 North (T1N), Car 1 South, Car 1 North, Deputy Chief 2 South (DC2S), and Deputy Chief 2 North (DC2N). Car 1 South arrived on-scene at 23:14 hours and found a fire in the attached garage that had extended into the house. Car 1 South established himself as the incident commander (IC) on arrival. E48 arrived onscene at 23:14 hours. IC ordered E48 to stretch a 2½- inch and 1¾-inch hoseline towards the garage. As E6N arrived on-scene at 23:18 hours, E48 initiated an exterior attack on the garage. DC2S arrived onscene at 23:18 hours and was assigned as the accountability officer. E48 moved to Side Alpha to make entry through the front door. Upon entry, they noticed the entire attic space was involved in fire. The officer of E6N (E6NA) (deceased firefighter) and the officer of T1N (T1NA) joined E48 to enter the house. Car 1 North arrived at 23:21 hours and was assigned as Operations Section Chief/Division Alpha Supervisor. The two firefighters from E6N went to Side Charlie with a 1¾-inch hoseline to knock down the porch fire. At 23:28 hours, DC2N arrived on-scene and was assigned as Division Charlie Supervisor. At 23:29 hours, fireground operations were at 15 minutes. At this time E48, E6NA, and T1NA exited the structure together after their self-contained breathing apparatus (SCBA) end of service time indicators (EOSTIs) sounded. After a cylinder change, the crew from E48 reentered the structure through the front door on Side Alpha. E6NA and T1NA reentered the house through the front door, but split up and went to different rooms to pull ceilings. T1NA pulled ceiling until he was completely out of air. As he left the structure through the front door, he encountered two firefighters from E41. T1NA went to the rehabilition area and met a firefighter from E48, who was with him on the initial fire attack. During this time, the accountability officer had E6NA on a team with two other firefighters in the building. At 23:44 hours, fireground operations were at 30 minutes. A crew of three firefighters were then assembled and directed to enter the building and report to the E6NA for an assignment. Interior operations continued with firefighters from multiple departments rotating in and out of the structure. At 23:54 hours, Car 1 North advised IC that the fire was under control and major overhaul was underway. At approximately 23:59 hours, E6NA met face-to-face with the incoming firefighters and then headed towards the outside. Since his crew had already been sent to rehab, E6NA was alone at this point. Fireground operations were at 45 minutes at this time. At approximately 00:01 hours on December 4, a radio report was transmitted on MABAS Red of a partial floor collapse. As E6NA exited the building, he fell through a fire weakened portion of the floor into the basement near the Side Alpha/Side Delta corner of the family room floor. E6NA transmitted a Mayday at approximately 00:04 hours on the dispatch channel. Most crews were operating on the MABAS Red and did not hear the Mayday. Car 1 North declared emergency traffic and asked for the member who called the Mayday to repeat the message. There was no response. A personnel accountability report (PAR) was initiated at approximately 00:06 hours. A firefighter from Squad 1 (a part of Car 1 North) was initially thought to be the missing firefighter. This firefighter was found on Side Charlie. After approximately 10-12 minutes, a message was transmitted over MABAS Red stating, "We have PAR." Car 1 North advised IC that all interior crews were accounted for at this time. At approximately 00:37 hours, firefighters in the rehabilitation area could not locate E6NA. A search operation was initiated. During the search, IC advised the house had a full basement. The presence of a basement was unknown to initial responding units because all the basement windows were boarded up and painted over to match the siding of the structure. A crew went to the basement steps but could not enter because of debris from the 1st floor collapse. A crew from a mutual aid fire department entered a front bedroom/office and cut a hole in the 1st floor. A crew from mutual aid fire department Engine 6 (DCE6) used an attic ladder to enter the basement through the hole. DCE6 reported heavy smoke, no visibility, and no visible fire. Shortly after entering the basement, a crew member heard an SCBA personal alert safety system (PASS) alarm sounding. The crew located E6NA with his SCBA facepiece and regulator intact and his helmet on. DCE6 reported to IC that they found E6NA and requested emergency medical services (EMS) at approximately 00:52 hours. The third attempt to remove E6NA from the basement was successful. E6NA was transferred to EMS personnel for care at approximately 01:02 hours. He was transported by ambulance to a local trauma hospitial and was pronounced deceased at 01:41 hours. The fire was marked under control at approximately 02:00 hours by IC. The fire was declared out at approximately 06:45 hours. Contributing Factors: Scene size-up and risk assessment; Personnel accountability; Crew integrity; Basement fire; Professional development; Lithium-ion battery fire; Emergency communications; Unpermitted occupancy renovations. Fire departments should: 1) Ensure initial and ongoing size-ups and risk assessments are conducted throughout the incident. 2) Train ICs to provide ongoing accountability to include immediately establishing divisions/groups with a supervisor to communicate conditions and critical benchmarks. 3) Use a personnel accountability system to identify the location and function of all personnel operating at an incident. 4) Ensure company officers and firefighters maintain crew integrity. 5) Ensure fire department operations include Standard Operating Procedures (SOPs)/Standard Operating Guidelines (SOGs) for identifying basements and below-grade fires. 6) Ensure the implementation of a training, education, and professional development program is based upon each rank. 7) Raise awareness about the fire dangers of lithium-ion battery-powered products among community members through fire and life safety education programs. Public Safety Answering Points (federal, state, regional/county, and local) should: Ensure a communication SOP and equipment is in place for dispatchers to support fireground operations and the IC, including the ability to receive emergency alert button (EAB) signals from portable radios as well as monitor and record all radio traffic during fireground operations. Governing municipalities (federal, state, regional/county, and local) should: Ensure the applicable fire and life safety codes are enforced for renovations in residential occupancies and relevant information is shared with the fire department. AN - cdc:257793 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 5; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Structural failure; Safety practices KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report Report Slides F2022-09: Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted Renovations - Illinois UR - https://stacks.cdc.gov/view/cdc/257793 ER -
Line of Duty Death Report F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut

Loflin, Murrey E. ;

Attwood, Wesley R.

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On May 12, 2021, a 30-year-old career firefighter died, a lieutenant was seriously injured, and two firefighters suffered minor injuries while fighting a fire in a two-story multi-family residential structure. At 00:46 hours, the city's fire dispatch center transmitted a box alarm assignment for Box 1501 for a residential structure fire. The first ...

Public Domain

Title : Line of Duty Death Report F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut Personal Author(s) : Loflin, Murrey E.;Attwood, Wesley R.;Funke, Jeffrey; Published Date : 2025/05/01 Pages in Document : 33 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257802
Loflin, M. E., Attwood, W. R., & Funke, J. (2025). Line of Duty Death Report F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257802

Loflin, Murrey E., Wesley R. Attwood, and Jeffrey Funke. Line of Duty Death Report F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257802.

Loflin, Murrey E., et al. Line of Duty Death Report F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257802.
Export RIS Citation Information. TY - Array AU - Loflin, Murrey E. AU - Attwood, Wesley R. AU - Funke, Jeffrey AB - On May 12, 2021, a 30-year-old career firefighter died, a lieutenant was seriously injured, and two firefighters suffered minor injuries while fighting a fire in a two-story multi-family residential structure. At 00:46 hours, the city's fire dispatch center transmitted a box alarm assignment for Box 1501 for a residential structure fire. The first Alarm dispatched was Car 34, Engine 15, Engine 9, Engine 6, Truck 4, Truck 1, Rescue 1, Special Operations Command (SOC) 1, and Emergency 2 (EMS 2). At 00:50 hours, the fire dispatcher alerted Car 34 there was an occupant still in the house on the 1st floor and the fire was in the basement. At 00:51 hours, Engine 15 advised this was a "working" fire. At 00:52 hours, Engine 9 indicated a female occupant was trapped in a bedroom on Side Delta and Side Charlie. Engine 6 arrived on-scene at 00:53 hours and backed down the street to Engine 15, which was the attack piece. Engine 6 Hydrant (deceased firefighter) took five lengths of 1¾-inch hoseline to Engine 15 and made the connection for fire attack. Engine 6 stretched the hoseline into the house to the 2nd floor. Engine 6 (PAR 3) got to the 2nd floor via the front stairs at 01:02 hours. Engine 6 Lieutenant (who was carrying a thermal imager), Engine 6 Pipe, and Engine 6 Hydrant also got to the 2nd floor using the front stairs. Engine 6 Lieutenant called for the hoseline to be charged and had Engine 6 Pipe cool down the front room (living room), which was also located on the 2nd floor. Engine 6 Lieutenant went into the Side Delta bedroom which was very hot. The End of Service Time Indicators (EOSTIs) for the Engine 6 firefighters began to sound and Engine 6 Lieutenant told Engine 6 Pipe and Engine 6 Hydrant that they needed to leave to change air cylinders. Engine 6 Pipe left the hoseline and exited the 2nd floor. Engine 6 Lieutenant and Engine 6 Hydrant became separated. In this confusion, Engine 6 Lieutenant's facepiece and helmet became dislodged. Eventually, Engine 6 Hydrant ran out of air, became disoriented, and was trying to get out of the room. Engine 6 Hydrant walked/crawled and got between a radiator and a couch in the living room underneath two windows on Side Alpha. He was running low on air and called a Mayday at 01:16 hours, which was acknowledged by the incident commander (IC). At 01:17 hours, Engine 6 Lieutenant called IC and said "I have a firefighter down on the 2nd floor." At 01:18 hours, Engine 6 Lieutenant called a Mayday. Engine 6 Lieutenant was located by Rescue 1 Hook. The firefighter found Engine 6 Lieutenant in the living room near the entrance to the kitchen. Engine 6 Lieutenant had his facepiece off and was standing when the firefighter found him. He said, "Help me," and then fell into the firefighter. Engine 6 Lieutenant's helmet was found in the Side Alpha/Side Bravo corner near Engine 6 Hydrant and his gloves were off. Rescue 1 Hook was trying to get Engine 6 Lieutenant to the stairs but ended up in a bedroom (Side Delta/Side Alpha corner) at approximately 01:20 hours. Rescue 1 Hook knocked the glass out of a window with a gloved hand. Firefighters from Engine 4 and Engine 9 got ground ladders to the windows. Rescue 1 Hook tried to get Engine 6 Lieutenant out the window, but he was too heavy. Rescue 1 Hook had to leave due to being low on air. Once he was on the ground, he advised Car 31 where Engine 6 Lieutenant was located. At approximately 01:21 hours, Rescue 1 Irons made his way into the living room. He found Engine 6 Hydrant lying prone near a couch with his facepiece on, but he was out of air. Rescue 1 Irons attempted to drag Engine 6 Hydrant to the front windows. The officer from Truck 1 climbed into the front window on Side Alpha at 01:23 hours. When he got into the front room (living room), he heard a personal alert safety system (PASS) alarm sounding. He found Rescue 1 Irons trying to get Engine 6 Hydrant out from between the couch and a radiator underneath the front windows. The firefighters tried to take Engine 6 Hydrant out through the front windows but were not able to do so. Rescue 1 Irons and the Truck 1 officer had to leave due to being low on air. Once outside, the Truck 1 officer described Engine 6 Hydrant's location to Engine 11. Engine 11 entered the building, went up the front stairs, and found Engine 6 Hydrant behind the couch. Engine 11 brought him down the front stairs to the outside at 01:33 hours. Firefighters from Engine 4 and Engine 9 got Engine 6 Lieutenant out of the house at at the same time. Both Engine 6 Lieutenant and Engine 6 Hydrant were transported to a local university trauma center at 01:36 hours. Engine 6 Hydrant was declared deceased at 02:12 hours. Engine 6 Lieutenant was later transferred to a trauma hospital with a hyperbaric chamber for treatment and recovery. The fire at Box 1501 was declared under control at 03:23 hours. Contributing Factors: Scene size-up and risk assessment; Crew integrity; Air management and firefighter survival; Basement/below-grade fire operations; Mayday management; Rapid intervention crew/team; Incident Safety Officer (ISO); Incident Command Technician (ICT); Professional development. Key Recommendations - Fire departments should ensure: Initial and ongoing size-ups and risk assessments are conducted throughout the incident. Company officers and firefighters maintain crew integrity when operating in the hazard zone. Fire officers and firefighters are properly trained and utilize the principles of air management and fireground survival procedures. Fire department operations include Standard Operating Procedures (SOPs)/Standard Operating Guidelines (SOGs) for operating at basements and below-grade fires. Fire officers and firefighters are trained in Mayday operations. A rapid intervention team/crew is dedicated, assigned, and in place before interior firefighting operations begin and throughout an incident. Response plans include a dedicated and trained ISO. Operational battalion chiefs are staffed with an ICT or staff aide. Implementation of a training, education, and professional development program that is based upon each rank. AN - cdc:257802 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 1; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Safety practices; Accident analysis; Communications equipment; Hazard recognition; Training KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut UR - https://stacks.cdc.gov/view/cdc/257802 ER -
Line of Duty Death Report Report Slides F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut

Fire Fighter Fatality Investigation and Prevention Program (U.S.)

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On May 12, 2021, a 30-year-old career firefighter died, a lieutenant was seriously injured, and two firefighters suffered minor injuries while fighting a fire in a two-story multi-family residential structure. At 00:46 hours, the city's fire dispatch center transmitted a box alarm assignment for Box 1501 for a residential structure fire. The first ...

Public Domain

Title : Line of Duty Death Report Report Slides F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut Corporate Authors(s) : Fire Fighter Fatality Investigation and Prevention Program (U.S.) Published Date : 2025/05/01 Pages in Document : 19 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257803
Fire Fighter Fatality Investigation and Prevention Program (U.S.) (2025). Line of Duty Death Report Report Slides F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257803

Fire Fighter Fatality Investigation and Prevention Program (U.S.). Line of Duty Death Report Report Slides F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257803.

Fire Fighter Fatality Investigation and Prevention Program (U.S.) Line of Duty Death Report Report Slides F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257803.
Export RIS Citation Information. TY - Array A2 - Fire Fighter Fatality Investigation and Prevention Program (U.S.) AB - On May 12, 2021, a 30-year-old career firefighter died, a lieutenant was seriously injured, and two firefighters suffered minor injuries while fighting a fire in a two-story multi-family residential structure. At 00:46 hours, the city's fire dispatch center transmitted a box alarm assignment for Box 1501 for a residential structure fire. The first Alarm dispatched was Car 34, Engine 15, Engine 9, Engine 6, Truck 4, Truck 1, Rescue 1, Special Operations Command (SOC) 1, and Emergency 2 (EMS 2). At 00:50 hours, the fire dispatcher alerted Car 34 there was an occupant still in the house on the 1st floor and the fire was in the basement. At 00:51 hours, Engine 15 advised this was a "working" fire. At 00:52 hours, Engine 9 indicated a female occupant was trapped in a bedroom on Side Delta and Side Charlie. Engine 6 arrived on-scene at 00:53 hours and backed down the street to Engine 15, which was the attack piece. Engine 6 Hydrant (deceased firefighter) took five lengths of 1¾-inch hoseline to Engine 15 and made the connection for fire attack. Engine 6 stretched the hoseline into the house to the 2nd floor. Engine 6 (PAR 3) got to the 2nd floor via the front stairs at 01:02 hours. Engine 6 Lieutenant (who was carrying a thermal imager), Engine 6 Pipe, and Engine 6 Hydrant also got to the 2nd floor using the front stairs. Engine 6 Lieutenant called for the hoseline to be charged and had Engine 6 Pipe cool down the front room (living room), which was also located on the 2nd floor. Engine 6 Lieutenant went into the Side Delta bedroom which was very hot. The End of Service Time Indicators (EOSTIs) for the Engine 6 firefighters began to sound and Engine 6 Lieutenant told Engine 6 Pipe and Engine 6 Hydrant that they needed to leave to change air cylinders. Engine 6 Pipe left the hoseline and exited the 2nd floor. Engine 6 Lieutenant and Engine 6 Hydrant became separated. In this confusion, Engine 6 Lieutenant's facepiece and helmet became dislodged. Eventually, Engine 6 Hydrant ran out of air, became disoriented, and was trying to get out of the room. Engine 6 Hydrant walked/crawled and got between a radiator and a couch in the living room underneath two windows on Side Alpha. He was running low on air and called a Mayday at 01:16 hours, which was acknowledged by the incident commander (IC). At 01:17 hours, Engine 6 Lieutenant called IC and said "I have a firefighter down on the 2nd floor." At 01:18 hours, Engine 6 Lieutenant called a Mayday. Engine 6 Lieutenant was located by Rescue 1 Hook. The firefighter found Engine 6 Lieutenant in the living room near the entrance to the kitchen. Engine 6 Lieutenant had his facepiece off and was standing when the firefighter found him. He said, "Help me," and then fell into the firefighter. Engine 6 Lieutenant's helmet was found in the Side Alpha/Side Bravo corner near Engine 6 Hydrant and his gloves were off. Rescue 1 Hook was trying to get Engine 6 Lieutenant to the stairs but ended up in a bedroom (Side Delta/Side Alpha corner) at approximately 01:20 hours. Rescue 1 Hook knocked the glass out of a window with a gloved hand. Firefighters from Engine 4 and Engine 9 got ground ladders to the windows. Rescue 1 Hook tried to get Engine 6 Lieutenant out the window, but he was too heavy. Rescue 1 Hook had to leave due to being low on air. Once he was on the ground, he advised Car 31 where Engine 6 Lieutenant was located. At approximately 01:21 hours, Rescue 1 Irons made his way into the living room. He found Engine 6 Hydrant lying prone near a couch with his facepiece on, but he was out of air. Rescue 1 Irons attempted to drag Engine 6 Hydrant to the front windows. The officer from Truck 1 climbed into the front window on Side Alpha at 01:23 hours. When he got into the front room (living room), he heard a personal alert safety system (PASS) alarm sounding. He found Rescue 1 Irons trying to get Engine 6 Hydrant out from between the couch and a radiator underneath the front windows. The firefighters tried to take Engine 6 Hydrant out through the front windows but were not able to do so. Rescue 1 Irons and the Truck 1 officer had to leave due to being low on air. Once outside, the Truck 1 officer described Engine 6 Hydrant's location to Engine 11. Engine 11 entered the building, went up the front stairs, and found Engine 6 Hydrant behind the couch. Engine 11 brought him down the front stairs to the outside at 01:33 hours. Firefighters from Engine 4 and Engine 9 got Engine 6 Lieutenant out of the house at at the same time. Both Engine 6 Lieutenant and Engine 6 Hydrant were transported to a local university trauma center at 01:36 hours. Engine 6 Hydrant was declared deceased at 02:12 hours. Engine 6 Lieutenant was later transferred to a trauma hospital with a hyperbaric chamber for treatment and recovery. The fire at Box 1501 was declared under control at 03:23 hours. Contributing Factors: Scene size-up and risk assessment; Crew integrity; Air management and firefighter survival; Basement/below-grade fire operations; Mayday management; Rapid intervention crew/team; Incident Safety Officer (ISO); Incident Command Technician (ICT); Professional development. Key Recommendations - Fire departments should ensure: Initial and ongoing size-ups and risk assessments are conducted throughout the incident. Company officers and firefighters maintain crew integrity when operating in the hazard zone. Fire officers and firefighters are properly trained and utilize the principles of air management and fireground survival procedures. Fire department operations include Standard Operating Procedures (SOPs)/Standard Operating Guidelines (SOGs) for operating at basements and below-grade fires. Fire officers and firefighters are trained in Mayday operations. A rapid intervention team/crew is dedicated, assigned, and in place before interior firefighting operations begin and throughout an incident. Response plans include a dedicated and trained ISO. Operational battalion chiefs are staffed with an ICT or staff aide. Implementation of a training, education, and professional development program that is based upon each rank. AN - cdc:257803 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 1; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Safety practices; Accident analysis; Communications equipment; Hazard recognition; Training KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report Report Slides F2021-11: Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family Residential Structure Fire - Connecticut UR - https://stacks.cdc.gov/view/cdc/257803 ER -
Line of Duty Death Report F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania

Loflin, Murrey E. ;

Attwood, Wesley R.

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On Sunday, July 4, 2021, a 35-year-old volunteer firefighter (Engine 21-2) died after becoming lost and transmitting a Mayday in the attic of a single-family dwelling. Box 34162 was transmitted at 22:33 hours with a report of a roof on fire. Ladder 21, Engine 21, Engine 26, Ladder 26, Engine 25-1, and Ladder 28 were dispatched. Ladder 21 arrived at ...

Public Domain

Title : Line of Duty Death Report F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania Personal Author(s) : Loflin, Murrey E.;Attwood, Wesley R.; Published Date : 2025/05/01 Pages in Document : 26 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257797
Loflin, M. E., & Attwood, W. R. (2025). Line of Duty Death Report F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257797

Loflin, Murrey E. and Wesley R. Attwood. Line of Duty Death Report F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257797.

Loflin, Murrey E., and Wesley R. Attwood Line of Duty Death Report F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257797.
Export RIS Citation Information. TY - Array AU - Loflin, Murrey E. AU - Attwood, Wesley R. AB - On Sunday, July 4, 2021, a 35-year-old volunteer firefighter (Engine 21-2) died after becoming lost and transmitting a Mayday in the attic of a single-family dwelling. Box 34162 was transmitted at 22:33 hours with a report of a roof on fire. Ladder 21, Engine 21, Engine 26, Ladder 26, Engine 25-1, and Ladder 28 were dispatched. Ladder 21 arrived at 22:40 hours and advised Dispatch they had a single family dwelling, 2-story, Type V construction, with heavy black smoke from the roof. Small flames were also visible in the soffit of the Side Charlie/Side Delta corner. Deputy 21 was the officer in charge of Ladder 21 and established himself as the incident commander (IC). Ladder 21 deployed a 1¾-inch hoseline to the interior (PAR 3), making their way to the attic to locate the fire. Engine 21 responded with Chief 21 (chauffeur), lieutenant, and firefighter (Engine 21-2). Engine 21 arrived on-scene at 22:44 hours and laid a 5-inch supply line from a hydrant to Ladder 21. Engine 21-2 made the hydrant connection and charged the supply line. Chief 21 assumed IC at approximately 22:46 hours. Deputy 21 was assigned as Operations and remained outside. Ladder 21-1 radioed to Operations that they had heavy heat and smoke conditions in the attic but could not locate the fire. They could not find the fire because it was in the knee walls and voids. Engine 25-1 (PAR 6) arrived on-scene at 22:44 hours with two of their firefighters assigned to vent the roof via Ladder 21's aerial. Engine 21-2 and two firefighters from Ladder 26 entered the structure at approximately 22:55 hours. They were assigned to relieve Ladder 21's crew in the attic, who were exiting the building due to being low on air. Rescue 22's crew was tasked with checking for extension. They split their crew to go to the 2nd and 3rd floors. Engine 26's crew stretched the line to the rear. They also stretched a second 1¾-inch hoseline to Side Charlie for exterior fire attack. At 22:45 hours, Ladder 28 arrived on-scene and laddered Side Delta to gain access to the roof and cut two ventilation holes in the roof. The roof became spongy, conditions were deteriorating, and Ladder 28 was removed from the roof. At approximately 23:00 hours, Engine 21-2 transmitted a Mayday. At this time, a Rescue 22 crew was almost to the top of the attic steps. There was high heat and zero visibility but no fire in the finished section of the attic. There was fire showing in the unfinished section of the attic, where Rescue 22 found Engine 21-2. Engine 21-2's end of service time indicator (EOSTI) sound facilitated Engine 21-2 to be located and out of the attic at 23:06 hours. Engine 21-2, who was conscious at the time, was transported to the local trauma center where he later died. The fire was extinguished at 00:05 hours. At 01:49 hours, all fire companies were clear of the scene. Contributing Factors - Scene size-up and risk assessment; Personnel accountability system; Crew integrity; Attic fire into knee walls and void spaces; Mayday operations; Rapid intervention crew/team; Communicating critical incident benchmarks; Incident command; Communications. Key Recommendations - Fire departments should ensure: 1) Initial and ongoing size-ups and risk assessments are conducted throughout the incident. 2) Use of a functional personnel accountability system to identify the location and function of all personnel operating at an incident. Company officers and firefighters maintain crew integrity when operating in the hazard zone. 3) A rapid intervention team/crew is dedicated, assigned, and in place before interior firefighting operations begin and throughout an incident. 4) Fire department operations include Standard Operating Procedures (SOPs)/Standard Operating Guidelines (SOGs) for attic fires, including those that involve knee walls and void spaces. 5) Firefighters and fire officers are trained in Mayday operations. 6) Critical incident benchmarks are communicated to the IC throughout the incident. 7) ICs immediately establish divisions/groups with a supervisor to communicate conditions and provide accountability. Public Safety Answering Points (PSAPs)/9-1-1 Communications Centers (federal, state, regional/county, and local) should ensure: Communication SOPs and equipment are in place for dispatchers to support fireground operations and the IC, including the ability to monitor and record all radio traffic during fireground operations. AN - cdc:257797 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 3; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Safety practices; Accident analysis; Communications equipment; Hazard recognition KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania UR - https://stacks.cdc.gov/view/cdc/257797 ER -
Line of Duty Death Report 2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia

Loflin, Murrey E. ;

Attwood, Wesley R.

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On December 27, 2020, a 30-year-old military firefighter was struck on the head and killed by a falling structural support beam while fighting a barn fire. The heavy timber beam fell on the firefighter during the collapse of the barn. At 01:59 hours, stations 60 and 80 along with county emergency medical services (EMS), were dispatched for a barn f ...

Public Domain

Title : Line of Duty Death Report 2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia Personal Author(s) : Loflin, Murrey E.;Attwood, Wesley R.;Ringer, Stephen J.; Published Date : 2025/05/01 Pages in Document : 13 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257796
Loflin, M. E., Attwood, W. R., & Ringer, S. J. (2025). Line of Duty Death Report 2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257796

Loflin, Murrey E., Wesley R. Attwood, and Stephen J. Ringer. Line of Duty Death Report 2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257796.

Loflin, Murrey E., et al. Line of Duty Death Report 2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257796.
Export RIS Citation Information. TY - Array AU - Loflin, Murrey E. AU - Attwood, Wesley R. AU - Ringer, Stephen J. AB - On December 27, 2020, a 30-year-old military firefighter was struck on the head and killed by a falling structural support beam while fighting a barn fire. The heavy timber beam fell on the firefighter during the collapse of the barn. At 01:59 hours, stations 60 and 80 along with county emergency medical services (EMS), were dispatched for a barn fire. Captain 60 and assistant chief 60 responded in their privately owned vehicles. While enroute, assistant chief 60 requested stations 1 and 16 be added to the barn fire call as stations 60 and 80 were already operating on-scene at a nearby residential structure fire. At 02:05 hours, station 16 was dispatched with Rescue Engine 16 (RE16) going enroute. At 02:13 hours, captain 60 arrived on-scene and reported a fully involved barn fire. Captain 60 established himself as the incident commander (IC) and reported to the emergency communications center (ECC) that a partial roof collapse occurred on Side Delta of the barn. He also reported a powerline down on the Side Alpha/Side Bravo corner and requested the local electric company respond. Engine 61 responded and laid a 5" supply line from the hydrant located on the road in front of the property to the end of the driveway near the entrance of the barn on the Side Alpha/Side Delta corner. Engine 3 arrived on-scene at approximately 02:15 hours. The driver/operator spotted the hydrant and the supply line laid by Engine 61. He connected to the hydrant through the front intake, connected the 5" to the discharge, and then sent water to Engine 61. Suppression efforts began with the use of the front bumper turret of Engine 61. The driver/operator of Tanker 61 deployed a 1¾" hoseline with a combination nozzle from the front bumper of Engine 61 while proceeding to Side Alpha. Engine 3's crew deployed a 1¾" hoseline to Side Delta. RE16 and Rescue Engine 31 (RE31) arrived on-scene at 02:18 hours. RE31's crew deployed 100ft of 2½" hoseline to Side Delta. RE16's crew were assigned to Side Alpha of the barn where they met the Engine 4 crew operating the 1¾" hoseline from Engine 61. The nozzle on this hoseline became clogged resulting in reduced flow, forcing the hoseline crew to move closer to the barn for their stream to reach the fire. RE16's officer asked if RE16 firefighter 4 (deceased firefighter) could take over the hoseline to get some experience. RE16 firefighter 4 was backed up on the hoseline by another RE16 firefighter. Tanker 61's driver/operator then noticed the Side Alpha wall was now unsupported. He notified Engine 4's officer and requested that the firefighters on Side Alpha be told to back away from the barn. Engine 4's officer acknowledged but stated he would keep an eye on the barn and let the firefighters know when to back away. At 02:33 hours, the Side Alpha wall of the barn began to collapse. Multiple firefighters yelled that the wall was collapsing, and crews attempted to retreat while an EMS officer called a Mayday. The wall fell, striking three firefighters (RE16, Engine 4, and Engine 61) and knocking down seven others. One firefighter was struck in the shoulder, and another sustained a leg injury. RE16 firefighter 4 was trapped under a large timber frame. He was unconscious and not breathing with apparent blunt force trauma to his head sustained from a fallen beam. RE16 firefighter 4 was pulled towards the road. Firefighters performed a primary assessment and began CPR. Fire suppression efforts were halted. RE16 firefighter 4 was transported to a local medical center where he was pronounced deceased. Contributing Factors Scene size-up and risk assessment; Collapse zone; Hoseline selection and deployment; Equipment malfunction; Mutual aid training. Key Recommendations - Fire departments should ensure: 1) Initial and ongoing size-ups and risk assessments are conducted throughout the incident. 2) Fire officers and firefighters are trained to understand building performance under fire conditions and the potential for structural collapse. 3) Safety officers with training on structural collapse are utilized for fireground incident management. 4) Selection and use of appropriate hoseline based on conditions. 5) Fire officers and firefighters are trained to react appropriately to equipment malfunction. 6) Firefighters properly flush hydrants before establishing a water supply. 7) Periodic mutual aid training is conducted. AN - cdc:257796 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 3; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Structural failure; Safety practices; Falling objects KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report 2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia UR - https://stacks.cdc.gov/view/cdc/257796 ER -
Line of Duty Death Report Report Slides F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania

Fire Fighter Fatality Investigation and Prevention Program (U.S.)

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On Sunday, July 4, 2021, a 35-year-old volunteer firefighter (Engine 21-2) died after becoming lost and transmitting a Mayday in the attic of a single-family dwelling. Box 34162 was transmitted at 22:33 hours with a report of a roof on fire. Ladder 21, Engine 21, Engine 26, Ladder 26, Engine 25-1, and Ladder 28 were dispatched. Ladder 21 arrived at ...

Public Domain

Title : Line of Duty Death Report Report Slides F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania Corporate Authors(s) : Fire Fighter Fatality Investigation and Prevention Program (U.S.) Published Date : 2025/05/01 Pages in Document : 12 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257798
Fire Fighter Fatality Investigation and Prevention Program (U.S.) (2025). Line of Duty Death Report Report Slides F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257798

Fire Fighter Fatality Investigation and Prevention Program (U.S.). Line of Duty Death Report Report Slides F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257798.

Fire Fighter Fatality Investigation and Prevention Program (U.S.) Line of Duty Death Report Report Slides F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257798.
Export RIS Citation Information. TY - Array A2 - Fire Fighter Fatality Investigation and Prevention Program (U.S.) AB - On Sunday, July 4, 2021, a 35-year-old volunteer firefighter (Engine 21-2) died after becoming lost and transmitting a Mayday in the attic of a single-family dwelling. Box 34162 was transmitted at 22:33 hours with a report of a roof on fire. Ladder 21, Engine 21, Engine 26, Ladder 26, Engine 25-1, and Ladder 28 were dispatched. Ladder 21 arrived at 22:40 hours and advised Dispatch they had a single family dwelling, 2-story, Type V construction, with heavy black smoke from the roof. Small flames were also visible in the soffit of the Side Charlie/Side Delta corner. Deputy 21 was the officer in charge of Ladder 21 and established himself as the incident commander (IC). Ladder 21 deployed a 1¾-inch hoseline to the interior (PAR 3), making their way to the attic to locate the fire. Engine 21 responded with Chief 21 (chauffeur), lieutenant, and firefighter (Engine 21-2). Engine 21 arrived on-scene at 22:44 hours and laid a 5-inch supply line from a hydrant to Ladder 21. Engine 21-2 made the hydrant connection and charged the supply line. Chief 21 assumed IC at approximately 22:46 hours. Deputy 21 was assigned as Operations and remained outside. Ladder 21-1 radioed to Operations that they had heavy heat and smoke conditions in the attic but could not locate the fire. They could not find the fire because it was in the knee walls and voids. Engine 25-1 (PAR 6) arrived on-scene at 22:44 hours with two of their firefighters assigned to vent the roof via Ladder 21's aerial. Engine 21-2 and two firefighters from Ladder 26 entered the structure at approximately 22:55 hours. They were assigned to relieve Ladder 21's crew in the attic, who were exiting the building due to being low on air. Rescue 22's crew was tasked with checking for extension. They split their crew to go to the 2nd and 3rd floors. Engine 26's crew stretched the line to the rear. They also stretched a second 1¾-inch hoseline to Side Charlie for exterior fire attack. At 22:45 hours, Ladder 28 arrived on-scene and laddered Side Delta to gain access to the roof and cut two ventilation holes in the roof. The roof became spongy, conditions were deteriorating, and Ladder 28 was removed from the roof. At approximately 23:00 hours, Engine 21-2 transmitted a Mayday. At this time, a Rescue 22 crew was almost to the top of the attic steps. There was high heat and zero visibility but no fire in the finished section of the attic. There was fire showing in the unfinished section of the attic, where Rescue 22 found Engine 21-2. Engine 21-2's end of service time indicator (EOSTI) sound facilitated Engine 21-2 to be located and out of the attic at 23:06 hours. Engine 21-2, who was conscious at the time, was transported to the local trauma center where he later died. The fire was extinguished at 00:05 hours. At 01:49 hours, all fire companies were clear of the scene. Contributing Factors - Scene size-up and risk assessment; Personnel accountability system; Crew integrity; Attic fire into knee walls and void spaces; Mayday operations; Rapid intervention crew/team; Communicating critical incident benchmarks; Incident command; Communications. Key Recommendations - Fire departments should ensure: 1) Initial and ongoing size-ups and risk assessments are conducted throughout the incident. 2) Use of a functional personnel accountability system to identify the location and function of all personnel operating at an incident. Company officers and firefighters maintain crew integrity when operating in the hazard zone. 3) A rapid intervention team/crew is dedicated, assigned, and in place before interior firefighting operations begin and throughout an incident. 4) Fire department operations include Standard Operating Procedures (SOPs)/Standard Operating Guidelines (SOGs) for attic fires, including those that involve knee walls and void spaces. 5) Firefighters and fire officers are trained in Mayday operations. 6) Critical incident benchmarks are communicated to the IC throughout the incident. 7) ICs immediately establish divisions/groups with a supervisor to communicate conditions and provide accountability. Public Safety Answering Points (PSAPs)/9-1-1 Communications Centers (federal, state, regional/county, and local) should ensure: Communication SOPs and equipment are in place for dispatchers to support fireground operations and the IC, including the ability to monitor and record all radio traffic during fireground operations. AN - cdc:257798 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 3; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Safety practices; Accident analysis; Communications equipment; Hazard recognition KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report Report Slides F2021-12: Volunteer Firefighter Dies after Becoming Lost During a Residential Structure Fire - Pennsylvania UR - https://stacks.cdc.gov/view/cdc/257798 ER -
Line of Duty Death Report Report Slides F2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia

Fire Fighter Fatality Investigation and Prevention Program (U.S.)

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On December 27, 2020, a 30-year-old military firefighter was struck on the head and killed by a falling structural support beam while fighting a barn fire. The heavy timber beam fell on the firefighter during the collapse of the barn. At 01:59 hours, stations 60 and 80 along with county emergency medical services (EMS), were dispatched for a barn f ...

Public Domain

Title : Line of Duty Death Report Report Slides F2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia Corporate Authors(s) : Fire Fighter Fatality Investigation and Prevention Program (U.S.) Published Date : 2025/05/01 Pages in Document : 13 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257801
Fire Fighter Fatality Investigation and Prevention Program (U.S.) (2025). Line of Duty Death Report Report Slides F2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257801

Fire Fighter Fatality Investigation and Prevention Program (U.S.). Line of Duty Death Report Report Slides F2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257801.

Fire Fighter Fatality Investigation and Prevention Program (U.S.) Line of Duty Death Report Report Slides F2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257801.
Export RIS Citation Information. TY - Array A2 - Fire Fighter Fatality Investigation and Prevention Program (U.S.) AB - On December 27, 2020, a 30-year-old military firefighter was struck on the head and killed by a falling structural support beam while fighting a barn fire. The heavy timber beam fell on the firefighter during the collapse of the barn. At 01:59 hours, stations 60 and 80 along with county emergency medical services (EMS), were dispatched for a barn fire. Captain 60 and assistant chief 60 responded in their privately owned vehicles. While enroute, assistant chief 60 requested stations 1 and 16 be added to the barn fire call as stations 60 and 80 were already operating on-scene at a nearby residential structure fire. At 02:05 hours, station 16 was dispatched with Rescue Engine 16 (RE16) going enroute. At 02:13 hours, captain 60 arrived on-scene and reported a fully involved barn fire. Captain 60 established himself as the incident commander (IC) and reported to the emergency communications center (ECC) that a partial roof collapse occurred on Side Delta of the barn. He also reported a powerline down on the Side Alpha/Side Bravo corner and requested the local electric company respond. Engine 61 responded and laid a 5" supply line from the hydrant located on the road in front of the property to the end of the driveway near the entrance of the barn on the Side Alpha/Side Delta corner. Engine 3 arrived on-scene at approximately 02:15 hours. The driver/operator spotted the hydrant and the supply line laid by Engine 61. He connected to the hydrant through the front intake, connected the 5" to the discharge, and then sent water to Engine 61. Suppression efforts began with the use of the front bumper turret of Engine 61. The driver/operator of Tanker 61 deployed a 1¾" hoseline with a combination nozzle from the front bumper of Engine 61 while proceeding to Side Alpha. Engine 3's crew deployed a 1¾" hoseline to Side Delta. RE16 and Rescue Engine 31 (RE31) arrived on-scene at 02:18 hours. RE31's crew deployed 100ft of 2½" hoseline to Side Delta. RE16's crew were assigned to Side Alpha of the barn where they met the Engine 4 crew operating the 1¾" hoseline from Engine 61. The nozzle on this hoseline became clogged resulting in reduced flow, forcing the hoseline crew to move closer to the barn for their stream to reach the fire. RE16's officer asked if RE16 firefighter 4 (deceased firefighter) could take over the hoseline to get some experience. RE16 firefighter 4 was backed up on the hoseline by another RE16 firefighter. Tanker 61's driver/operator then noticed the Side Alpha wall was now unsupported. He notified Engine 4's officer and requested that the firefighters on Side Alpha be told to back away from the barn. Engine 4's officer acknowledged but stated he would keep an eye on the barn and let the firefighters know when to back away. At 02:33 hours, the Side Alpha wall of the barn began to collapse. Multiple firefighters yelled that the wall was collapsing, and crews attempted to retreat while an EMS officer called a Mayday. The wall fell, striking three firefighters (RE16, Engine 4, and Engine 61) and knocking down seven others. One firefighter was struck in the shoulder, and another sustained a leg injury. RE16 firefighter 4 was trapped under a large timber frame. He was unconscious and not breathing with apparent blunt force trauma to his head sustained from a fallen beam. RE16 firefighter 4 was pulled towards the road. Firefighters performed a primary assessment and began CPR. Fire suppression efforts were halted. RE16 firefighter 4 was transported to a local medical center where he was pronounced deceased. Contributing Factors Scene size-up and risk assessment; Collapse zone; Hoseline selection and deployment; Equipment malfunction; Mutual aid training. Key Recommendations - Fire departments should ensure: 1) Initial and ongoing size-ups and risk assessments are conducted throughout the incident. 2) Fire officers and firefighters are trained to understand building performance under fire conditions and the potential for structural collapse. 3) Safety officers with training on structural collapse are utilized for fireground incident management. 4) Selection and use of appropriate hoseline based on conditions. 5) Fire officers and firefighters are trained to react appropriately to equipment malfunction. 6) Firefighters properly flush hydrants before establishing a water supply. 7) Periodic mutual aid training is conducted. AN - cdc:257801 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 3; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Structural failure; Safety practices; Falling objects KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report Report Slides F2021-09: A Military Firefighter Killed and Two Firefighters Injured by a Wall Collapse at a Barn Fire - West Virginia UR - https://stacks.cdc.gov/view/cdc/257801 ER -
Line of Duty Death Report F2023-04: 46-Year-Old Motor Pump Operator Collapses During Residential Fire Response and Dies - Connecticut

Eisenberg, Judith S. ;

Saunders, Robert

2025/05/01 | Fatality Assessment and Control Evaluation Reports (FACE)

On December 26, 2022, at about 0100 hours, a 46-year-old motor pump operator/engine driver (MPO) was dispatched with his crew to a residential fire with occupants trapped inside. On arrival at the location, the MPO was assigned to provide support from the building exterior, operating the truck in the extreme cold (below freezing) conditions. When h ...

Public Domain

Title : Line of Duty Death Report F2023-04: 46-Year-Old Motor Pump Operator Collapses During Residential Fire Response and Dies - Connecticut Personal Author(s) : Eisenberg, Judith S.;Saunders, Robert;Wilkinson, Andrea; Published Date : 2025/05/01 Pages in Document : 19 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/257808
Eisenberg, J. S., Saunders, R., & Wilkinson, A. (2025). Line of Duty Death Report F2023-04: 46-Year-Old Motor Pump Operator Collapses During Residential Fire Response and Dies - Connecticut. National Institute for Occupational Safety and Health. https://stacks.cdc.gov/view/cdc/257808

Eisenberg, Judith S., Robert Saunders, and Andrea Wilkinson. Line of Duty Death Report F2023-04: 46-Year-Old Motor Pump Operator Collapses During Residential Fire Response and Dies - Connecticut. National Institute for Occupational Safety and Health, 2025. https://stacks.cdc.gov/view/cdc/257808.

Eisenberg, Judith S., et al. Line of Duty Death Report F2023-04: 46-Year-Old Motor Pump Operator Collapses During Residential Fire Response and Dies - Connecticut. National Institute for Occupational Safety and Health, 2025, Stacks. https://stacks.cdc.gov/view/cdc/257808.
Export RIS Citation Information. TY - Array AU - Eisenberg, Judith S. AU - Saunders, Robert AU - Wilkinson, Andrea AB - On December 26, 2022, at about 0100 hours, a 46-year-old motor pump operator/engine driver (MPO) was dispatched with his crew to a residential fire with occupants trapped inside. On arrival at the location, the MPO was assigned to provide support from the building exterior, operating the truck in the extreme cold (below freezing) conditions. When he noticed interior crews having difficulty advancing a hoseline inside, he took the initiative and left the pump panel to assist by pushing the hoseline from the outside and assisted with hose advancement up to the second-floor landing because the firefighter at the nozzle was advancing the line solo up to the third floor. The second-floor landing was not considered to be an IDLH atmosphere (immediately dangerous to life or health). One of his crew members asked the MPO to assist with changing out his self-contained breathing apparatus (SCBA) bottle. They walked back to the engine to do so. The MPO was standing at the engine's pump panel when he collapsed. The crew member he was assisting, who was also a paramedic, witnessed the MPO collapse to the ground. His initial assessment found the MPO to be unresponsive and pulseless. This crew member called a Mayday, and he and a firefighter from a rescue unit immediately initiated cardiopulmonary resuscitation (CPR). An advanced life support transport unit that was on the scene transported the MPO to the nearest emergency department. Resuscitation was unsuccessful. The MPO was declared dead at 0227 hours. The medical examiner found the death due to hypertensive and cardiovascular disease, with obesity and a bicuspid aortic valve as contributing factors. Connecticut Occupational Safety and Health (CT OSHA) conducted an investigation and in a letter dated April 13, 2023, determined there were no violations of OSHA standards involved in this incident, and no citations were issued. Key Recommendations - NIOSH offers the following recommendations to reduce the risk of adverse cardiac events among firefighters at this and other fire rescue agencies across the country. Key Recommendation #1: Consider requiring annual medical evaluations. Although annual medical evaluations are not required by department policy, NFPA 1582 recommends annual medical evaluations of members [NFPA 2022]. Key Recommendation #2: Consider providing NFPA educational material to the healthcare providers performing Respiratory Questionnaire Health Surveillance Records (also known as Respiratory Clearance Medical Evaluations). Include information on essential job tasks requiring respiratory protection as well as NFPA clearance guidelines for specific medical conditions [NFPA 2022]. Key Recommendation #3: Reinforce education among firefighters, including fire academy trainees, that developing new medical conditions after beginning a career in the fire service can happen and is accounted for in NFPA 1582. This standard is focused on ensuring that firefighters with various medical conditions can safely perform their essential job tasks while receiving the appropriate medical care for those conditions [NFPA 2024]. Key Recommendation #4: Encourage all Fire Department (FD) members to seek prompt medical care for new symptoms and medical concerns. Recommend that all members obtain a primary care provider regardless of any required FD annual medical evaluation. Having an existing relationship with a healthcare provider can enable discussion and management of new health issues as they arise. Key Recommendation #5: As required by OSHA's Respirator Standard, a Respiratory Clearance Medical Examination should precede each annual Respirator Certification (fit test). Consider creating a consolidated file management system to ensure this is occurring and provide easy access to past records. Key Recommendation #6: Assess emergency incident documentation procedures and consider consolidating emergency medical services and FD call records. Key Recommendation #7: Review FD Mayday call protocol with the dispatch office to ensure understanding and compliance to FD standard operating procedures. Dispatchers often operate from a controlled environment, such as an office or control center. They need to be familiar with fire rescue terminology to know how to best support the agencies they serve. This may include creating timers, assisting with notifications, and capturing any difficult to hear radio transmissions using a playback feature. Ensuring radio discipline is essential during these high stress incidents. AN - cdc:257808 KW - Fires KW - Firefighters KW - Safety KW - Accidents, Occupational KW - Occupational Health KW - Mortality KW - Region 1; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Medical fitness evaluation; Hypertension; Cardiovascular disease KW - Accidents, Occupational KW - Firefighters KW - Fires KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - National Institute for Occupational Safety and Health PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Line of Duty Death Report F2023-04: 46-Year-Old Motor Pump Operator Collapses During Residential Fire Response and Dies - Connecticut UR - https://stacks.cdc.gov/view/cdc/257808 ER -
A Warehouse Worker Dies After Falling from an Order Picker Forklift - California

Zubieta, Ingrid

2025/04/22 | Fatality Assessment and Control Evaluation Reports (FACE)

On Sep 15, 2023, a 45-year-old male warehouse worker (the victim) at a warehouse and distribution center was fatally injured after falling from the platform of an order picker forklift. The victim was operating the order picker to check an item from a shelving rack three levels up. The victim was working by himself and was not wearing fall protecti ...

Title : A Warehouse Worker Dies After Falling from an Order Picker Forklift - California Personal Author(s) : Zubieta, Ingrid Corporate Authors(s) : California Department of Public Health Published Date : 2025/04/22 Pages in Document : 9 pdf pages Series : Fatality Assessment and Control Evaluation Reports (FACE) Source : Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 23CA006, 2025 Apr; :1-9 DOI : 10.26616/NIOSHSFACE23CA006 Journal Title : National Institute for Occupational Safety and Health
Zubieta, I. (2025). A Warehouse Worker Dies After Falling from an Order Picker Forklift - California. National Institute for Occupational Safety and Health. https://doi.org/10.26616/NIOSHSFACE23CA006

Zubieta, Ingrid. "A Warehouse Worker Dies After Falling from an Order Picker Forklift - California." National Institute for Occupational Safety and Health (2025). https://doi.org/10.26616/NIOSHSFACE23CA006.

Zubieta, Ingrid "A Warehouse Worker Dies After Falling from an Order Picker Forklift - California." National Institute for Occupational Safety and Health, 2025. Stacks. https://doi.org/10.26616/NIOSHSFACE23CA006.
Export RIS Citation Information. TY - Field Study AU - Zubieta, Ingrid A2 - California Department of Public Health AB - On Sep 15, 2023, a 45-year-old male warehouse worker (the victim) at a warehouse and distribution center was fatally injured after falling from the platform of an order picker forklift. The victim was operating the order picker to check an item from a shelving rack three levels up. The victim was working by himself and was not wearing fall protection. A co-worker in a nearby aisle heard a sound and ran to the area where they found the victim lying on the concrete floor. The victim was transported to the hospital where he died from his injuries 17 days later. Contributing factors: Failure to ensure proper use of fall protection, inspect equipment, and correct unsafe work practices; Lack of written policies and procedures on how to safely operate forklifts and use fall protection; No forklift training or certification program; Lack of audible or visual alarms on forklifts to indicate when an employee is not tied-off. Recommendations - California FACE (CA/FACE) investigators determined that, in order to prevent similar incidents, warehouses & distribution centers and forklift manufacturers should: 1) Ensure that all order picker forklift operators receive training and adequate supervision to always use fall protection when working at heights. 2) Integrate fall protection warning devices that will activate audible and visual alarms if the operator is not tied-off while working at heights. AN - cdc:258866 DO - 10.26616/NIOSHSFACE23CA006 J2 - National Institute for Occupational Safety and Health KW - Falls KW - Safety KW - Occupational Health KW - Mortality KW - Region 9; Fatalities; Injury prevention; Traumatic injuries; Safety practices; Warehousing; Falls; Fall protection; Safety equipment; Forklifts; Warning devices KW - Falls KW - Mortality KW - Occupational Health KW - Safety PB - National Institute for Occupational Safety and Health PY - 2025 T2 - National Institute for Occupational Safety and Health T2 - Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 23CA006, 2025 Apr; :1-9 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - A Warehouse Worker Dies After Falling from an Order Picker Forklift - California UR - https://stacks.cdc.gov/view/cdc/258866 ER -
Construcción Narración de Muertes: Jornalero Sufre Quemaduras en Explosión de Adhesivo

Washington (State). Department of Labor and Industries

2025/04/18 | Fatality Assessment and Control Evaluation Reports (FACE)

Un jornalero de 53 años de edad falleció cuando el adhesivo para pisos de vinilo que estaba aplicando se incendió y los vapores explotaron. Trabajó durante cuatro años para su empleador, un contratista general, haciendo trabajos diversos de manera informal, cuando era necesario. Él y un asistente estaban instalando pisos de vinilo en un edificio co ...

Title : Construcción Narración de Muertes: Jornalero Sufre Quemaduras en Explosión de Adhesivo Corporate Authors(s) : Washington (State). Department of Labor and Industries Published Date : 2025/04/18 Pages in Document : 1 Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/229239
Washington (State). Department of Labor and Industries (2025). Construcción Narración de Muertes: Jornalero Sufre Quemaduras en Explosión de Adhesivo. Washington State Department of Labor and Industries. https://stacks.cdc.gov/view/cdc/229239

Washington (State). Department of Labor and Industries. Construcción Narración de Muertes: Jornalero Sufre Quemaduras en Explosión de Adhesivo. Washington State Department of Labor and Industries, 2025. https://stacks.cdc.gov/view/cdc/229239.

Washington (State). Department of Labor and Industries Construcción Narración de Muertes: Jornalero Sufre Quemaduras en Explosión de Adhesivo. Washington State Department of Labor and Industries, 2025, Stacks. https://stacks.cdc.gov/view/cdc/229239.
Export RIS Citation Information. TY - Report A2 - Washington (State). Department of Labor and Industries AB - Un jornalero de 53 años de edad falleció cuando el adhesivo para pisos de vinilo que estaba aplicando se incendió y los vapores explotaron. Trabajó durante cuatro años para su empleador, un contratista general, haciendo trabajos diversos de manera informal, cuando era necesario. Él y un asistente estaban instalando pisos de vinilo en un edificio comercial en renovación. Trabajaban solos y sin supervisión, pero recibían instrucciones del empleador por teléfono. Esperaban terminar con rapidez, pero el adhesivo líquido para pisos no estaba pegando bien. El jornalero dijo que la habitación estaba demasiado fría y decidió usar un soplete de propano con llama descubierta para calentar el adhesivo y el piso. Cuarenta minutos después, el soplete encendió los vapores del adhesivo o el líquido en el piso. Los trabajadores trataron de apagar el fuego con los pies, pero no pudieron hacerlo. El asistente le gritó al jornalero que huyera y corrió hacia una salida. Después sintió una explosión, volteó hacia atrás y vio que el jornalero trataba de apagar el soplete mientras la habitación se llenaba de humo. Mareado y con náuseas, le volvió a gritar al jornalero, pero lo perdió de vista al seguir avanzando hacia la puerta. Cuando llegó a la puerta, una segunda explosión lo lanzó al exterior. Después pudo alejarse más del edificio. El jornalero salió poco después, en llamas y gritando Cayó cerca de la puerta, poco antes de que una tercera explosión la hiciera salir volando. El área que lo rodeaba estaba demasiado caliente como para que el asistente se aproximara. Los vecinos llamaron al 911. El personal de respuesta a emergencias rescató al asistente y apagó el incendio. El jornalero murió en el lugar debido a las quemaduras y la inhalación de humo. Después del accidente, los investigadores determinaron que: El empleador no tenía un programa de prevención de accidentes (APP, por sus siglas en inglés), y no proporcionó hojas de datos de seguridad (SDS), capacitación sobre peligros químicos ni extintores de incendios antes de iniciar el trabajo. La SDS del adhesivo líquido inflamable indicaba que representaba un riesgo elevado de explosión con una baja concentración de vapor en el aire. El adhesivo, esparcido sobre un área superficial grande del edificio sin ventilación, emitió suficiente vapor para alcanzar el límite inferior de explosividad e incendiarse cuando se encendió el soplete. Se dejaron cuatro cubos de 5 galones de adhesivo abiertos en el edificio, lo que aumentó la concentración de vapor. [Description provided by NIOSH] AN - cdc:229239 KW - Safety KW - Occupational Health KW - Mining KW - Muertes KW - Educación en seguridad KW - Construcción KW - Riesgos de explosión KW - Adhesivos KW - Riesgos químicos KW - Mining KW - Occupational Health KW - Safety LA - spa PB - Washington State Department of Labor and Industries PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Construcción Narración de Muertes: Jornalero Sufre Quemaduras en Explosión de Adhesivo UR - https://stacks.cdc.gov/view/cdc/229239 ER -
Construction Fatality Narrative: Day Laborer Burned in Adhesive Explosion

Washington (State). Department of Labor and Industries

2025/04/18 | Fatality Assessment and Control Evaluation Reports (FACE)

A 53-year-old day laborer died when the vinyl flooring adhesive he was applying ignited and the vapor exploded. He worked for his employer, a general contractor, for four years doing random odd jobs on an informal, as-needed basis. He and an assistant were installing vinyl flooring in a commercial building under renovation. They were working alone ...

Title : Construction Fatality Narrative: Day Laborer Burned in Adhesive Explosion Corporate Authors(s) : Washington (State). Department of Labor and Industries Published Date : 2025/04/18 Pages in Document : 1 Series : Fatality Assessment and Control Evaluation Reports (FACE) URL : https://stacks.cdc.gov/view/cdc/229238
Washington (State). Department of Labor and Industries (2025). Construction Fatality Narrative: Day Laborer Burned in Adhesive Explosion. Washington State Department of Labor and Industries. https://stacks.cdc.gov/view/cdc/229238

Washington (State). Department of Labor and Industries. Construction Fatality Narrative: Day Laborer Burned in Adhesive Explosion. Washington State Department of Labor and Industries, 2025. https://stacks.cdc.gov/view/cdc/229238.

Washington (State). Department of Labor and Industries Construction Fatality Narrative: Day Laborer Burned in Adhesive Explosion. Washington State Department of Labor and Industries, 2025, Stacks. https://stacks.cdc.gov/view/cdc/229238.
Export RIS Citation Information. TY - Report A2 - Washington (State). Department of Labor and Industries AB - A 53-year-old day laborer died when the vinyl flooring adhesive he was applying ignited and the vapor exploded. He worked for his employer, a general contractor, for four years doing random odd jobs on an informal, as-needed basis. He and an assistant were installing vinyl flooring in a commercial building under renovation. They were working alone and unsupervised but received instruction from the employer over the phone. They hoped to finish quickly, but the liquid flooring adhesive was not bonding well. The laborer said the room was too cold and decided to use an open-flame propane torch to heat up the adhesive and flooring. Forty minutes later, the torch ignited either the adhesive vapor or liquid on the floor. The workers tried to stamp out the fire with their feet but were unable to. The assistant yelled at the laborer to flee and ran for an exit door. He then felt an explosion, looked back, and saw the laborer trying to shut off the torch as smoke filled the room. Dizzy and nauseous, he yelled again to the laborer but lost sight of him as he continued toward the door. When he reached the door, a second explosion threw him outside. He was then able to move further from the building. The laborer came out shortly after, in flames and screaming. He fell near the door just before a third explosion blew it off. The area around him was too hot for the assistant to approach. Neighbors called 911. First responders rescued the assistant and extinguished the blaze. The laborer died at the scene from burns and smoke inhalation. Following the incident, investigators found: The employer did not have an accident prevention program (APP) nor provide the workers Safety Data Sheets (SDS), chemical hazard training, and fire extinguishers before the job began. The SDS for the flammable liquid adhesive indicated it had a high risk of explosion at a low vapor concentration in the air. The adhesive spread over the large surface area in the unventilated building emitted enough vapor to reach the lower explosive limit and ignite while the torch was lit. Four 5-gallon buckets of adhesive were left open in the building, increasing the vapor concentration. [Description provided by NIOSH] AN - cdc:229238 KW - Construction Industry KW - Safety KW - Adhesives KW - Occupational Health KW - Mortality KW - Hazardous Substances KW - Fatalities KW - Safety education KW - Construction KW - Explosive hazards KW - Adhesives KW - Chemical hazards KW - Adhesives KW - Construction Industry KW - Hazardous Substances KW - Mortality KW - Occupational Health KW - Safety LA - eng PB - Washington State Department of Labor and Industries PY - 2025 T3 - Fatality Assessment and Control Evaluation Reports (FACE) TI - Construction Fatality Narrative: Day Laborer Burned in Adhesive Explosion UR - https://stacks.cdc.gov/view/cdc/229238 ER -