Death in the Line of Duty…a Summary of a NIOSH Fire Fighter Fatality Investigation

On August 18, 2007, a 53-year-old male career fire fighter (Victim #1) and a 33-year-old male career fire fighter (Victim #2) became trapped in the maze-like conditions of a high-rise building undergoing deconstruction. The building's standpipe system had been disconnected during the deconstruction and the partitions constructed for asbestos abatement prohibited fire fighters from getting water to the seat of the fire. An hour into the incident, the fire department was able to supply water by running an external hoseline up the side of the structure. Soon after the victims began to operate their hoseline, they ran out of air. The victims suffered severe smoke inhalation and were transported to a metropolitan hospital in cardiac arrest where they succumbed to their injuries. By the time the fire was extinguished, 115 fire fighters had suffered a variety of injuries. Key contributing factors to this incident include: delayed notification of the fire by building construction personnel, inoperable standpipe and sprinkler system, delay in establishing water supply, inaccurate information about standpipe, unique building conditions with both asbestos abatement and deconstruction occurring simultaneously, extreme fire behavior, uncontrolled fire rapidly progressing and extending below the fire floor, blocked stairwells preventing fire fighter access and egress, maze-like interior conditions from partitions and construction debris, heavy smoke conditions causing numerous fire fighters to become lost or disoriented, failure of fire fighters to always don SCBAs inside structure and to replenish air cylinders, communications overwhelmed with numerous Mayday and urgent radio transmissions, and lack of crew integrity. NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should: 1. review and follow existing standard operating procedures on high-rise fire fighting to ensure that fire fighters are not operating in hazardous areas without the protection of a charged hoseline. 2. be prepared to use alternative water supplies when a building's standpipe system is compromised or inoperable. 3. develop and enforce risk management plans, policies, and standard operating guidelines for risk management during complex high-rise operations. 4. ensure that crew integrity is maintained during high-rise fire suppression operations. 5. train fire fighters on actions to take if they become trapped or disoriented inside a burning high-rise structure. 6. ensure that fire fighters diligently wear their self-contained breathing apparatus (SCBA) when working in environments that are immediately dangerous to life and health (IDLH). 7. train fire fighters in air management techniques to ensure they receive the maximum benefit from their self-contained breathing apparatus (SCBA). 8. use exit locators (both visual and audible) or safety ropes to guide lost or disoriented fire fighters to the exit. 9. conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics. 10. encourage building owners and occupants to report emergency situations as soon as possible and provide accurate information to the fire department. 11. consider additional fire fighter training using a high-rise fire simulator. Manufacturers, equipment designers, and researchers should: 1. conduct research into refining existing and developing new technology to track the movement of fire fighters in high-rise structures. 2. continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communications in conjunction with properly worn self-contained breathing apparatus (SCBA). Municipalities should: 1. ensure that construction and/or demolition is done in accordance with NFPA 241: Standard for Safeguarding Construction, Alteration, and Demolition Operations. 2. develop a reporting system to inform the fire department of any ongoing, unique building construction activities (such as deconstruction or asbestos abatement) that would adversely affect a fire response. 3. establish a system for property owners to notify the fire department when fire protection/suppression systems are taken out of service.