FACE 97-09: Restaurant/Tavern
Fire Results in The Death of One Fire Fighter and Serious
Injuries to Three Other Fire Fighters - Indiana
SUMMARY
On August 19, 1997, three male fire fighters (the victim and two
injured fire fighters), ages 21-, 27- and 35-years-old, entered a
restaurant/tavern structure that had smoke and flames emitting
through the roof above the kitchen area. The fire fighters
entered the structure by crouching/crawling through the front
door and advancing about 15 feet into the interior of the
structure. About 10 minutes later, intense heat filled the area.
The heat apparently startled or panicked the victim, who tried to
run for the doorway entrance. The victim subsequently died from
asphyxiation, while the other two fire fighters received serious
burns. Also, a fourth fire fighter, age 48 years, received
serious burns during a rescue attempt. NIOSH investigators
concluded that, to prevent similar incidents, employers should:
INTRODUCTION
On August 19, 1997, four male fire fighters (the victim and three
injured fire fighters) were part of a volunteer fire company that
responded to a restaurant/tavern structure fire. The victim
eventually died as a result of trying to exit the burning
structure, and the other fire fighters received serious burns. On
September 17, 1997, the Indiana State Fire Marshall requested
that NIOSH provide technical assistance in reviewing the
circumstances surrounding the fatality and serious injuries. On
September 24-25, 1997, the Chief of the Trauma Investigations
Section and a Safety Specialist traveled to Indiana to conduct an
investigation of this incident. Meetings were conducted with
officers from the two volunteer fire departments and two fire
fighters directly involved in the incident. Copies of photographs
and measurements of the incident site were obtained along with
the Fire Marshall's report, and a site visit was conducted.
The volunteer fire department involved in the incident serves a
population of 2700 in a geographic area of 45-square miles, and
is comprised of approximately 22 employees. The fire department
provides all new fire fighters with 24 hours of mandatory
training. The training is designed to cover personal safety,
forcible entry, ventilation, fire apparatus, ladders,
self-contained breathing apparatus, hose loads, streams, and
special hazards. The victim had 1 month of fire fighting
experience, and this was the victim's first structure fire.
Although 11 volunteer fire departments were involved in this
incident, only those directly involved up to the time of the
fatal incident are mentioned in this report.
INVESTIGATION
On August 19, 1997, at 0043 hours, a fire call came into the 911
dispatcher from the occupant of a private residence adjacent to
the incident site. The call was immediately directed to the
volunteer fire department serving the area where the fire was
located. The volunteer fire department arrived at 0050 and the
chief immediately called for assistance. The second volunteer
fire department, whose fire fighters were to suffer the fatality
and injuries, arrived at 0105. The second fire department
dispatched five vehicles and 18 fire fighters. The vehicles were
Lead Pumper-601, Town Pumper-602, Tanker-604, Grass Unit-606, and
Rescue Unit-608. The victim and two of the injured were assigned
to Lead Pumper-601, while the injured rescuer was assigned to
Town Pumper-602.
The site of the incident, a two-story restaurant/tavern structure
with a one-story addition measuring 62 feet by 62 feet total, was
located in a rural community. The structure was an old barn
(about 100-years old), which had been converted into a
restaurant/tavern. The structure had been remodeled several times
and at least three partial roofs remained intact in the structure
at the time of the fire. The exterior of the structure had been
constructed of wood siding and the roof was covered with asphalt
shingles. The structure had been built on a concrete slab and
access to the interior was provided by three doorways.
When the first fire department arrived on the scene, the chief
reported smoke and flames coming through the roof at an area in
the back of the structure which would later be identified as the
kitchen. He directed fire fighters to attack the fire from the
exterior of the structure, through a doorway (which had to be
forcibly knocked down) leading into the kitchen area. Upon the
arrival of the second fire department, including the victim and
injured fire fighters, they donned their turnout gear and
self-contained breathing apparatus to enter the structure. It was
determined that the victim, who did not have any structural fire-
fighting experience, would be the middle person on the hose line
as the three entered the structure, and one other fire fighter
would be a standby at the front doorway. The three fire fighters
pulled a 1 1/2" charged hose line and moved to the front
doorway entrance at about 0110 hours. They crouched/crawled about
15 feet (see Figure) into the
structure, with the charged line between their legs. They were
spraying water near the kitchen area when the standby approached
them and asked for further instructions. He was told to pull
another line into the structure to "blow the fire out the
back." The standby then noticed fire emanating from the
ceiling about 15 feet away and perpendicular to the fire
fighters. He brought this to the attention of the other fire
fighters and then left the area. After extinguishing the flames
on the ceiling, the fire fighter in charge ordered everyone out
of the structure. As the fire fighters were still crouching and
now turning to exit, following the hose line out through the
dense black smoke, intense heat from the kitchen area inundated
the area above and around the fire fighters. The intense heat
apparently startled/panicked the victim, who crawled/jumped over
the top of the fire fighter directly in front of him in an effort
to vacate the structure. The victim, disoriented and unable to
see because of the dense black smoke, stumbled to his right
toward the dining area of the restaurant away from the entrance.
Unable to find the doorway entrance, he collapsed from smoke
inhalation and died. The two remaining fire fighters tried to
locate the doorway entrance but were also disoriented and unable
to see. After about 3 to 4 minutes, one of the fire fighters
found a wall and was able to exit the structure. The other fire
fighter "disoriented" wandered around until he located
the rest room area, where he collapsed and became unresponsive.
In the interim, the standby had notified the chief as to the
situation. The chief directed search and rescue efforts for the
two fire fighters who remained in the structure. On one rescue
attempt another fire fighter followed the line into the structure
but could not locate anyone. In his attempt, he turned on the
hose and scalding steam rolled over him. He lost his helmet and
before he could exit the structure he received second and third
degree burns of the face and head. Another rescue attempt located
the third fire fighter near the rest room and he was removed from
the structure. On the final rescue attempt, the victim was found
and brought outside. The victim was unconscious and not
breathing. The emergency medical service initiated and continued
cardiopulmonary resuscitation for about ½ hour. The coroner
arrived at that time and pronounced the victim dead at the scene.
It was also reported that the victim had manually activated his personal alert safety system (PASS) device. However, due to the noise of the engines, pumps, positive pressure ventilation fans, etc., the rescuers could not hear the alarm.
CAUSE OF DEATH
The cause of death was listed by the medical examiner as
asphyxiation.
RECOMMENDATIONS/DISCUSSION
Recommendation #1: Fire departments should ensure
that defensive (exterior operation) fire fighting tactics are
suspended prior to switching the strategic mode of operation to
an offensive strategy (interior fire attack with hand lines), and
notify all affected personnel of the change in strategic modes.
Discussion: When the second volunteer fire company arrived on the
fire scene and prepared to enter the structure, orders should
have been given to suspend the exterior fire attack. In such an
instance, it is essential to notify all affected personnel of the
change in strategic modes. In this case two volunteer fire
companies were directing their streams of water at the origin of
the fire, from opposing angles. The heat/smoke may have been
pushed from the kitchen area into the dining room area where the
three fire fighters were located. The inexperienced victim
apparently was startled and panicked, and tried to run for the
doorway entrance. After becoming disoriented and running into the
dining area, he collapsed on the floor and died from
asphyxiation. If the exterior fire attack had been suspended, the
flames/heat/smoke may have naturally vented through the roof and
the fire may have been controlled by the interior attack.
Recommendation #2: Fire departments should ensure that fire fighters who enter hazardous areas, e.g., burning or suspected unsafe structures, be equipped with two-way communications with incident command.
Discussion: When the fire fighters entered the burning
structure none were equipped with two-way communications. If the
fire fighters had been equipped with a portable radio, then
incident command may have been able to determine that the fire
fighters had experienced a problem and needed immediate
assistance.
Recommendation #3: Fire departments should establish
and implement an incident-management system with written standard
operating procedures for all fire fighters.
Discussion: The NFPA recommended standard states the purpose of
an incident-management system is to provide structure and
coordination to the management of emergency incident operations
to provide for the safety and health of fire fighters. An
incident-command system may be more difficult when several
volunteer fire departments respond to the same incident;
therefore, a type of unified command system may have to be
established. The unified command system can be used to coordinate
command of the incident when several departments arrive on the
scene.
References:
1. NFPA 1500, 1992 Edition, Standard on Fire
Department Occupational Safety and Health Program, National Fire
Protection Association, Quincy, MA.
2. NFPA 1561, 1995 Edition, Standard on Fire
Department Incident Management System National
Fire Protection Association, Quincy, MA.
3. 29 CFR Part 1910.120, Code of Federal Regulations,
Washington, D.C.: U.S. Government Printing Office, Office of the
Federal Register.
Fire Fighter Fatality Project - Using the
Fatality Assessment and Control Evaluation (FACE) Model The National Institute for Occupational Safety and
Health (NIOSH), Division of Safety Research (DSR),
performs Fatality Assessment and Control Evaluation
(FACE) investigations when a line-of-duty Fire Fighter
Fatality is reported. The goal of these evaluations is to
prevent fatal work injuries in the future by studying the
working environment, the worker, the task the worker was
performing, the tools the worker was using, the energy
exchange resulting in fatal injury, and the role of
management in controlling how these factors interact. |
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