Volunteer Firefighter Killed After Becoming Trapped at an Assisted Living Facility Fire and Two Firefighters Injured – New York

Details

• Personal Author:
  Attwood WR ; Loflin, Murrey E.
• Corporate Authors:
  National Institute for Occupational Safety and Health ; Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) (U.S.)
• Description:
  On March 23, 2021, a 35-year-old volunteer firefighter died after becoming trapped while rescuing occupants at a fire in an assisted living facility. Two other firefighters were injured during fireground operations. Fire Department 17 was dispatched to the assisted living facility at 00:53 hours with visible smoke showing. Chief 17-1 arrived on-scene at 01:00 hours and assumed Command. Chief 17-1 requested Fire Department 6 respond with Tower 6-75. At approximately 01:01 hours, an occupant of Room 306 called 9-1-1 stating he was trapped in his room and needed to be rescued. Tanker 17 arrived on-scene at 01:12 hours and parked in the driveway on Side Alpha near the front awning. Tanker 17's officer (Tanker 17A) split his crew between rescue and firefighting. The crew entered through the lobby. The crew went into the hallway that led to the kitchen area, which was the older or original section of the facility. They noticed the carpet was wet as they entered the kitchen area. They found no victims and then went back down the hallway. The 1st floor was clear of occupants. Tanker 17D (deceased firefighter) and Tanker 17E were ordered to the 2nd floor and made several rescues, requiring at least two air cylinder changes. The firefighters were "on-air" going to the 2nd floor as occupants were being brought down to the lobby and then outside. Tanker 17E went to the 2nd floor and found a victim, which he got down to the lobby and outside with another firefighter. Tanker 17E went back to the 2nd floor and brought another victim down to the lobby and outside to emergency medical services (EMS). Tanker 17D was also removing victims from the 2nd floor at this time with Captain 12. Both firefighters then responded to the 3rd floor using the exterior fire escape following a report of another victim in Room 306. Tanker 17E changed cylinders at Tanker 17 and then went to the 3rd floor with Assistant Chief 24-2 via the internal stairwell. As they entered the lobby, the smoke was completely banked down to the floor with minimal visibility. The smoke was also banked down on the 3rd floor. Tanker 17D, Captain 12, Tanker 17E, and Assistant Chief 24-2 were assigned to locate and rescue the occupant of Room 306. The time was approximately 01:24 hours. Tanker 17D and Captain 12 got the male occupant to the doorway. The firefighters went into the hallway and moved towards the fire escape on Side Bravo. Between 01:27 and 01:45 hours, their End-of-Service Time Indicator (EOSTI) alarms began to sound starting with Assistant Chief 24-2 who left via the internal stairwell to get a new cylinder. Captain 12 moved towards the exterior fire escape to gauge their distance from the exit while Tanker 17E moved the male occupant down the hallway until he ran completely out of air. He was approximately 30 feet from the exit on Side Bravo. At the same time, Tanker 17D called a Mayday from Room 306 indicating he was out of air. The time was approximately 01:46 hours. The evacuation tones were sounded. Tanker 17E did not call a Mayday due to Tanker 17D's Mayday. A Firefighter Assist and Search Team (FAST) got Tanker 17E outside at approximately 01:53 hours with Command receiving notification minutes later that Tanker 17E was not the Mayday. The civilian victim was taken outside at 01:59 hours. Another FAST tried to reenter the 3rd floor to find Tanker 17D. Due to fire conditions, they were unable to enter the structure, which collapsed minutes later. At 02:17 hours, Command changed the strategy to defensive operations. The incident action plan was to knock down the fire from exterior locations. Defensive operations were continued until Command declared the fire under control at 10:00 hours. At 23:50 hours, Tanker 17D was located and pronounced deceased at 00:20 hours on March 24. He was removed from the structure and transported to the county medical examiner's office at 01:40 hours. All fire departments cleared the scene at 16:07 hours on March 24. Contributing Factors: Cultural cleansing ceremony conducted in the dairy kitchen; Building fire alarm system was off-line to the county dispatch center; Lack of a fire sprinkler system throughout the facility; Lack of enforcement of fire and building safety codes; Lack of available water supply for the sprinkler system and fire suppression; Lack of pre-incident planning; Lack of crew integrity; Inadequate personnel accountability system; Inadequate tactical and task level management; Lack of a Command Safety and Mayday management; Inadequate FAST operations. Key Recommendations - Fire departments should: 1) Develop a pre-incident plan for high-risk occupancies, including low frequency/high risk scenarios such as assisted living facilities, that is supported by national standards; 2) Ensure that company officers and firefighters maintain crew integrity when operating in the hazard zone; 3) Use a functional personnel accountability system, requiring a designated accountability officer or resource status officer; 4) Ensure that the Incident Command System (ICS) general staff functions are expanded during Type IV incidents when they extend to multiple operational periods; 5) Establish divisions/groups to provide an effective incident management organizational framework for the expansion of the incident action plan (IAP); 6) Incorporate the principles of command safety into the incident management system during the initial assumption of command; 7) Ensure that a rapid intervention crew (RIC) or firefighter assist and search team (FAST) is dedicated, assigned, and in place before interior firefighting operations begin and throughout an incident; 8) Ensure that all firefighters and fire officers are trained in fireground survival procedures and Mayday operations; 9) Provide a Mayday tactical worksheet for incident commanders (ICs) in the event of a Mayday; 10) Ensure that all members engaged in emergency operations receive annual proficiency training and evaluation on fireground operations, including live fire training; 11) 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; 12) Have Standard Operating Procedure (SOP)/Standard Operating Guidelines (SOG) to ensure that water supply is established during initial fireground operations, particularly in areas with limited water pressure, limited hydrants, or no hydrants; 13) Consider maintaining resources and protocols to address occupational exposure to potentially traumatic events for their members. Additionally, governing municipalities (federal, state, regional/county, and local) should: 1) Ensure that when the applicable fire code is not enforced by the fire department, the delegated authority shares information with the fire department which may affect fire department operations. 2) Ensure the water agency/authority responsible for municipal water supply shares information on hydrant testing and flow capabilities with the local fire departments. 3) Have an operational procedure when cultural cleansing ceremonies with live fire are performed inside a structure or facility. 4) Ensure that facilities have operational procedures when the facility's fire alarm system cannot transmit an alarm to a designated fire alarm monitoring service. [Description provided by NIOSH]
• Subjects:
  Emergency Responders Firefighters Fires Mortality Occupational Health Safety
• Keywords:
  Emergency Responders Fatalities Fire Fighters Fire Fighting Fire Safety Recommendations Region 1 Safety Practices
• FACE - Firefighter:
  Cause of Death: Trauma ; Structure Fire ; Structure Fire: Non-Residential ; Structure Fire: Collapse
• Series:
  Fire Fighter Fatality Investigation and Prevention Program (FFFIPP)
• DOI:
  https://doi.org/10.26616/NIOSHFFACEF202110Revised12172024
• Publisher:
  National Institute for Occupational Safety and Health
• Document Type:
  Text
• Genre:
  Field Study ; Case Report
• Place as Subject:
  New York ; New York City Region [OSHA] ; Philadelphia Region [OSHA] ; West Virginia
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Division:
  DSR - Division of Safety Research
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-67
• NIOSHTIC Number:
  nn:20070408
• Citation:
  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 F2021-10 (revised 12/2024), 2024 Dec; :1-67
• Federal Fiscal Year:
  2025
• Peer Reviewed:
  False
• NAICS and SIC Codes:
  92 - Public Administration - (NAICS)
• Start Date:
  20210323
• Source Full Name:
  National Institute for Occupational Safety and Health
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:375dec1f6722bc4a204d74e4d483a7488af0c3c1baae88e292042267b80e94c30d0693fc4671bfd872c1aeab6966b0a8a77328168bcbf51b2c3fa5e75b461187
• Download URL:
  https://stacks.cdc.gov/view/cdc/228495/cdc_228495_DS1.pdf
• File Type:
  [PDF - 2.64 MB ]