Line of Duty Death Report

On July 23, 2018, a 34-year-old male career firefighter died due to prolonged exposure to high temperatures and thermal injuries after falling into the crawlspace at a large residential structure fire. The residential structure was a custom designed 8,400 square feet single-family home. At approximately 0120 hours a lightning strike ignited a fire in the home. At 0151 hours, the homeowner called 9-1-1 to report a lightning strike, the odor of smoke in the home, but no visible fire in the home. The county's communication center dispatched a local box alarm (Box 5-62) for a single-family structure at 0152 hours for a lightning strike and smoke in the building. Engine 51 (E51), Engine 101 (E101), Tower 10 (TWR10), Battalion Chief 1 (BC1), and Paramedic 56 (P56) were dispatched. At 0157 hours, the homeowner called back and stated, "We have fire in our house due to lightning." He then repeated his address, and said, "I don't see a flame but our whole house is filled with smoke." E51 arrived on-scene at 0200 hours. The officer of E51 (E51A) reported they had a two-story, single-family dwelling with smoke showing. E51A requested a full first alarm box assignment for Box 5-62. After initially positioning on Side Alpha, E51 re-positioned to Side Charlie to access the swimming pool as a water source. Tower 10 arrived at 0202 hours and positioned on Side Alpha. BC1 arrived on-scene at 0204 hours and confirmed the initial report. BC1 assumed Command and declared an offensive strategy. At 0208 hours, E51 entered the structure through the laundry room door near the garage on Side Charlie. Command did not receive a complete report of conditions and operations on Side Charlie. Due to lack of smoke in the laundry room, E51 repositioned their hoseline to the lower basement entrance (Side Charlie/Side Delta) based on the size-up by the BC1 aide, stating there was floor to ceiling smoke in the basement. When E51 entered the basement on lower Side Charlie, they did not advise Command of the change in grade. At 0213 hours, after being informed by the BC1 aide, Command advised all units "We do have an all clear from the occupants, occupied times three, all clear of the house. We do have an all clear." At 0216 hours, E101 officer (E101A) advised Command, "We have heavy fire on floor number one, Side Charlie" but did not have an exact location of the fire. Command was not advised that the crew from E101 pulled a pre-connected hose line from E51 and went back to the 1st floor laundry room. Tower 10A transmitted, "Tower 10 to Command, "It's gonna be Quadrant Two, 101 and Engine 51 are making entry right now. We have made access to the basement, still smoke from floor to ceiling. We've closed the door back up. Only crews you should have in are on the first level entering side Charlie." E101B (deceased firefighter) entered the laundry room door advancing a 1¾-inch hoseline through the laundry room and into the kitchen/breakfast area with E101A trailing a significant distance behind. At approximately 0220 hours, E101B fell through the 1st floor into a basement level crawlspace with heavy fire conditions. Two Mayday emergency transmissions were made. The first Mayday was by E101A on Bravo 1 (the tactical channel used for this incident). The second by E101B on Bravo 2 (an unmonitored radio channel). Command deployed a rapid intervention crew (RIC) which had been staged on Side Alpha at 0218 hours, to enter the basement at approximately 0227 hours. The rescue group located E101B, who was removed from the structure at 0244 hours. Once outside the structure, E101B received advance life support care and was moved to Medic 105 (M105) to be transported to a local trauma hospital. E101B was pronounced deceased at 0312 hours. Contributing Factors - Lack of crew integrity

Lack of complete scene size-up

Below-grade fire

Large area residential structure

Lack of a defined incident action plan

Inadequate fireground communications

Missed critical incident benchmarks

Member operating on the wrong radio channel

Task saturation of the incident commander

Lack of personnel accountability

Wind/weather. Key Recommendations - 1) Fire departments should ensure that crew integrity is properly maintained by visual (eye-to-eye), direct (touch), or verbal (voice or radio) contact at all times when operating in an immediately dangerous to life and health (IDLH) atmosphere. The intent is to prevent firefighters from becoming lost or missing. 2) Fire departments should ensure incident commanders conduct a detailed scene size-up and risk assessment during initial fireground operations and throughout the incident including Side Charlie. 3) Fire departments should develop and implement a standard operating procedure/guideline (SOP/SOG) to identify below-grade fires and ensure that appropriate tactical operations are implemented. 4) Fire departments should ensure that a deployment strategy for low frequency/high risk incidents is developed and implemented for large area residential structures with unique architectural features. 5) Fire departments should ensure that incident commanders develop an incident action plan (IAP) that matches conditions encountered during initial operations and throughout the incident. 6) Fire departments should ensure that critical incident benchmarks and fire conditions are communicated to incident commanders throughout the incident. This is accomplished with effective fireground communications. 7) Fire departments should have a procedure to ensure all members operating in the hazard zone have their radios on the designated radio channel. 8) Fire departments should ensure all members and dispatchers are trained on the safety features of their portable radio, particularly the features useful during a Mayday. 9) Fire departments should develop a process to prevent task saturation of incident commanders during multi-alarm incidents. 10) Fire departments should ensure that the member assigned to the resource status and situation status function is not given other duties during an incident. 11) Fire departments should develop a formal training program that defines the job duties and functions for staff aides, incident command technicians, or staff assistants. 12) Fire departments should ensure incident commanders maintain control of situation status, resources status, and communications to ensure the completion of tactical objectives. 13) Fire departments should incorporate the principles of Command Safety into the incident management system during the initial assumption of command. This ensures that strategic-level safety responsibilities are being incorporated into the command functions throughout the incident. 14) Fire departments should review and/or develop SOG/SOPs to ensure that water supply is established during initial fireground operations, particularly in areas with limited or no hydrants. 15) Fire departments should ensure adequate staffing and deployment of resources based on the community's risk assessment. 16) Fire department should periodically review and, if necessary, revise their SOP/SOG on the deployment of rapid intervention crews (RICs). 17) Fire departments should use resources from the National Institute of Standards and Technology (NIST), Underwriter's Laboratories (UL) Fire Fighter Safety Research Institute (FSRI), and the International Society of Fire Service Instructors (ISFSI) to develop and revise operational procedures on fireground tactics and provide training in fire dynamics in structures for all firefighting staff. 18) Fire departments should consider having all members carry a wire cutting tool. 19) Fire departments should ensure that all members engaged in emergency operations receive annual proficiency training and evaluation on fireground operations, including live fire training. This training should be conducted with automatic aid and mutual aid fire departments. 20) Fire departments should ensure adequate incident scene rehabilitation is established in accordance with NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises. 21) Fire departments should consider a radio protocol that identifies the unit they are calling first (receiver), then identifies themselves (sender).