Line of Duty Death Report Report Slides F2023-03: Career Firefighter Dies While Trapped During Overpressure Events in a Mixed-Use Structure - New York

Details

• Corporate Authors:
  Fire Fighter Fatality Investigation and Prevention Program (U.S.)
• Description:
  On March 1, 2023, a career firefighter (E-2B) died during overpressure events in a three-story mixed-use structure after becoming trapped by debris. At 09:56, the public safety answering point telecommunicator (PSAP-T) transmitted a full alarm assignment for a building fire. PSAP-T advised that the caller reported seeing flames coming from the building while working on masonry on the outside of the building. At 09:58 Engine 2 (E-2) and Ladder 2 (L-2), not on the original dispatch, arrived on scene after clearing another call nearby. E-2 pulled beyond the dispatched address after observing a civilian waving to them from a parking lot which contained a one-story building. L-2 was positioned behind E-2. The civilian was the reporting person. E-2 notified PSAP-T that there was nothing showing. A battalion chief (B-43) arrived on scene at 09:59 and reported a one-story ordinary construction building and then paused. The reporting person directed them to the fire building as battalion chief B-56 (IC) arrived on scene at 10:00, took command, and notified PSAP-T with a confirmed address. The IC described heavy smoke on the first floor of a three-story fire resistive construction building. The IC requested a second alarm, with staging south of the fire building, and police for traffic control. E-2 and L-2 self-deployed a 1¾-inch hoseline to Side Alpha and began to breach multiple doors to make entry. The IC was not notified of these actions. IC requested Rescue 1 (R-1) to 'recon' to see how far back the building went and if entry from Side Charlie was needed. R-1 acknowledged this request and reported that they were currently making entry on Side A. Feeling intense heat and rapidly changing conditions, the interior crews decided to evacuate the building just as the IC ordered an evacuation. As crews were exiting, fire conditions again rapidly changed, resulting in an overpressure event (OPE) that separated E-2 officer and E-2B. During this same time, IC reported to PSAP-T that the fire became heavy with turbulent smoke and was extending. IC notified PSAP-T that they were going to pull everyone out and go with defensive operations. PSAPT initiated evacuation tones and called for evacuation by radio. The OPE occurred while IC was ordering defensive operations for Side Alpha and Side C. IC notified PSAP-T of a "possible backdraft" and that there was heavy fire on all three floors. PSAP-T notified IC of mayday calls from E-2B, and then PSAP-T attempted to obtain a location from E-2B. IC attempted to obtain an accountability report from E-2 crew and coordinated for an additional Ladder to Side C. E-2 officer confirmed E-2B as missing. At this same time, R-1 attempted to make reentry for rescue, although this was not coordinated with IC. IC observed R-1 making entry and ordered B-43 to stop R-1 from entry because they did not have a handline. IC put B-43 in charge of the mayday. B-43, R-1 and firefighter assist and search team (FAST) coordinated rescue operations. R-1 made entry due to being familiar with E-2B's location. FAST remained outside for R-1. At this time, E-2B's personal alert safety system (PASS) device was heard by R-1and E-2B was located. E-2B was entangled in clothing racks and other contents. While R-1 attempted to extricate E-2B from the racks and debris another OPE occurred which forced R-1 to evacuate and abandon the rescue. Between 10:21 and 13:40 defensive operations continued. At 13:41 hours, recovery personnel made entry and recovery was completed at 13:44. E-2B was transported to a local hospital and pronounced deceased. Contributing Factors: Scene size-up and risk assessment; Fire behavior/dynamics and tactics; Professional development/fireground operations procedures; Communicating critical incident benchmarks; Mayday management; Incident management; Building condition and renovations. Key Recommendations - Fire departments should: 1) Ensure the first arriving resource completes an initial scene size-up and risk assessment to inform a risk-benefit analysis before committing firefighters to interior operations. 2) Train personnel on modern fire dynamics, including air flow path management, and develop fireground strategies based on a thorough risk/benefit analysis that accounts for building types, their characteristics, associated risks, and available on-scene resources. 3) Ensure fireground operations and safety procedures are developed, trained on, and followed by fire officers and firefighters. 4) Ensure critical incident benchmarks are communicated to the IC through the chain of command throughout the incident. 5) Ensure that fire officers and dispatchers are trained in managing a Mayday. 6) Ensure that the Incident Command System (ICS) is compliant with national incident management system (NIMS), fire department members and dispatchers are trained and can demonstrate ICS proficiency, and that the incident command group is properly resourced to address multiple duties. Governing municipalities (federal, state, regional/county, and local) should: Ensure the applicable fire and life safety codes are enforced for commercial occupancies and relevant information is shared with and made available to the fire department.
• Subjects:
  Accidents, Occupational Firefighters Fires Mortality Occupational Health Safety
• Keywords:
  Region 2; Fire fighters; Fire fighting; Fatalities; Emergency responders; Recommendations; Accident analysis; Fire safety; Training; Risk assessment
• FACE - Firefighter:
  Cause of Death Trauma (0004) ; Structure Fire (0011) ; Non-Residential (0013) ; Flashover (0015) ; Miscellaneous (structure fire) (0017) ; Explosion (0060)
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Subseries:
  Firefighter Fatality Investigation
• Publisher:
  National Institute for Occupational Safety and Health
• Document Type:
  Text
• Genre:
  Field Study ; Report
• Place as Subject:
  New York ; West Virginia ; Philadelphia Region [OSHA] ; New York City Region [OSHA]
• 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:
  16 pdf pages
• NIOSHTIC Number:
  nn:20071038
• 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 F2023-03, 2026 Jan; :1-16
• Federal Fiscal Year:
  2026
• NORA Priority Area:
  Public Safety
• Peer Reviewed:
  False
• NAICS and SIC Codes:
  92 - Public Administration - (NAICS)
• Start Date:
  20230301
• Source Full Name:
  National Institute for Occupational Safety and Health
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:38ad993f05b04dde076d3e3a524de365f13b0aaefe7882f5676c69ac28a531a34fdf4631aa2a8dcc06ad37c56e9e233608f1d8dd7fcf28d0ecf01b37f62c3242
• Download URL:
  https://stacks.cdc.gov/view/cdc/257814/cdc_257814_DS1.pdf
• File Type:
  [PDF - 1.26 MB ]