FACE 97-16: One
Fire Fighter Dies of Smoke Inhalation, One Overcome by Smoke
While Fighting an Attic Fire--New York
SUMMARY
On July 4, 1997, one fire fighter died and another was injured
while fighting a residential fire. As the two fire fighters
advanced into the attic of the residence, the heat and smoke
became so intense that fire fighter 1 (victim), on the attack
nozzle, stated "I've got to go." Fire fighter 2
(injured), the back-up fire fighter, asked, "Are you
OK?" Fire fighter 1 responded, "Yeah." Fire
fighter 2 moved forward to control the attack nozzle that had
been turned off. However, the heat and smoke were so intense that
he could not advance. As he retreated, he had trouble with his
air supply. After trying emergency procedures, he unsuccessfully
attempted to remove his facepiece, and let out an
undistinguishable sound. This is the last thing he remembered
until he regained consciousness on the second floor. He was
hospitalized and the fire fighter who remained in the attic died
of smoke inhalation. NIOSH investigators concluded that, to
prevent similar occurrences, employers should:
INTRODUCTION
On July 4, 1997, a 30-year-old male fire fighter died of smoke
inhalation and a 39-year-old male fire fighter was overcome by
smoke while fighting a residential attic fire. On July 9, 1997,
the International Association of Fire Fighters (IAFF) notified
the Division of Safety Research (DSR) of the fatality and injury,
and requested technical assistance in investigating the
circumstances surrounding the fatality and the serious injury. On
July 16, 1997, the Chief of Trauma Investigations Section
traveled to New York to investigate this incident. Meetings were
held with the chief assigned to conduct the internal
investigation; fire fighters involved in the incident, including
the injured fire fighter; and the local president of the IAFF. A
site visit was conducted and photographs of the incident site
were taken. Also, a copy of the dispatch log was obtained from
the fire department. The self-contained breathing apparatus
(SCBA) worn by fire fighter 1 and fire fighter 2 was sent to the
NIOSH Laboratory in Morgantown, West Virginia for evaluation and
testing.
The fire department involved in the incident serves a population
of 320,000 in a geographic area of 35 square miles. The fire
department is comprised of approximately 980 workers, of whom 800
are fire fighters. The fire department provides all new fire
fighters with the basic 10-week training at the fire academy, and
requires an additional 124 hours of on-the-job training per year.
The monthly training schedule is developed by the training
officer and is sent to all stations. The required training is
designed to cover fire department operation, such as ladder
training, aerial operations, hose training, and breathing
apparatus. The written standard operating procedures manual was
reviewed and appeared to be complete.
The site of the incident was an older, 2 ½ story wood frame
house measuring 47 feet deep by 22 feet 6 inches wide. The house
contained one apartment on each floor.
Although several fire companies were involved in this incident,
only those directly involved up to the time of the fatal incident
are discussed in this report.
INVESTIGATION
On July 4, 1997, at 2240 hours, a fire call came into the 911
dispatcher reporting a residence fire. The call was immediately
directed to fire dispatch. A first alarm was sounded and Engine
33, Engine 18, Engine 31, Ladder 6, Ladder 14, Rescue 1, and a
Battalion Chief were ordered to respond. Engine 33 was the first
on the scene at 2243 hours. Upon arrival at the residence, smoke
and fire were visible along the front leading edge roof (yankee)
gutter. Engine 33 was manned by four fire fighters: fire fighter
1 (victim), fire fighter 2 (injured), an acting lieutenant, and
the driver.
Fire fighters 1 and 2 pulled a 1 3/4-inch charged line to the
front of the residence where they were met by one of the
residents, who directed them through the front door and up the
stairs to the attic. The acting lieutenant was the third fire
fighter up the stairs. Fire fighters 1 and 2 donned their SCBA
and went up the steps from the second floor to the attic where
they encountered heavy black smoke and intense heat, but did not
see any flames. The acting lieutenant went back downstairs to
feed the charged line that had become hung up.
At 2251, the Division Chief arrived on the scene and assumed
command, and the Battalion Chief assumed command of interior
operations.
At 2255 hours, the lieutenant from Ladder 14 donned his SCBA and
went up to the attic to assist Fire Fighters 1 and 2, while two
other fire fighters on the outside were raising an aerial ladder
to vent the roof. The fire fighters trying to vent the roof
reported the roof was "spongy" so the attempt was
aborted. Fire fighter 1 was using the attack nozzle and fire
fighter 2 was directly behind him (advancing approximately 10
feet into the attic), both in a crawling position. The lieutenant
from Ladder 14 was a few feet back, but was unable to see either
fire fighter because of the thick, black smoke. Within a few
minutes, fire fighter 1 turned and yelled to fire fighter 2,
"I've got to go." Fire fighter 2 asked, "Are you
OK?" Fire fighter 1 responded, "Yeah." Fire
fighter 1 then moved to the right to exit, while fire fighter 2
moved up to take control of the attack nozzle which had been
turned off. Fire fighter 2 stated that the heat was so intense
that he could not advance very far before he had to get out. As
he turned to retreat from the attic, he had trouble with his air
supply. After trying emergency procedures, he unsuccessfully
attempted to remove his facepiece, and let out an
undistinguishable sound. This is the last thing he remembered
until he regained consciousness on the second floor. The
lieutenant from Rescue 1 radioed to command "May day, may
day, we have a man down," and went to the attic to assist
the lieutenant from Ladder 14 in rescuing the downed fire fighter
(fire fighter 2) from the attic (this radio transmission was not
heard by the alarm office and was not received by command due to
radio traffic. However, the transmission was heard in firehouses,
not on the fire ground). They dragged him down the stairs to the
outside, and he was taken to the hospital. Because of the thick,
black smoke in the attic, the rescuers did not see fire fighter
1, who was only a few feet from fire fighter 2. There are
conflicting reports on whether either fire fighter (1 or 2) had
activated his PASS (personal alert safety system) device.
At 2258 hours, the Division Chief ordered everyone out of the
attic.
At 2303 hours, the Division Chief also ordered the deck gun, in
use to fight the exterior fire, shut down and a search of the
attic by Rescue 1. The lieutenant from Rescue 1 and two fire
fighters went back into the attic, and at approximately 2306
hours, they found fire fighter 1 down, unresponsive, and with his
mask off. He was immediately removed to the outside and taken to
the hospital, where he did not respond to life-support measures.
CAUSE OF DEATH
According to the medical examiner, the cause of death was carbon
monoxide poisoning due to smoke inhalation.
RECOMMENDATIONS/DISCUSSION
Recommendation #1: Fire departments should ensure
that fire command always maintains close accountability for all
personnel at the fire scene. [1-3]
Discussion: Accountability for all fire fighters at a fire scene
is paramount, and one of the fire command's most important
duties. However, at the current time the fire department does not
have any formal written accountability procedures for the fire
scene. The fire department is currently reviewing different types
of accountability procedures to determine which would work best
in their department.
Recommendation #2: Fire departments should strictly
enforce the wearing and use of PASS devices when fire fighters
are involved in fire fighting, rescue, or other hazardous
duties.[2]
Discussion: The PASS device is a small electrical device worn by
the fire fighter and will emit a distinctive audible alarm if the
fire fighter is motionless for more than 30 seconds. Both fire
fighter victims were wearing the device; however, there are
conflicting reports as to whether the PASS devices were
activated.
Recommendation #3: Fire departments should develop
and implement written maintenance procedures for the
self-contained breathing apparatus (SCBA). [4,5]
Discussion: From the information gathered as a result of this
investigation, it appears that the fire department does not have
a preventive maintenance program for self-contained breathing
apparatus. The fire department should develop a comprehensive
record-keeping system that includes the following:
(1) It was apparent from the NIOSH investigation of a few of the
air hoses that they were not being replaced as needed. A written
procedure that establishes a policy for returning each SCBA to
the Air-Mask Maintenance Shop on a regular basis for preventive
maintenance should be implemented. This procedure should provide
for a tracking system that ensures the SCBA will be returned at
the proper intervals. 29 CFR 1910.134 states that respirators
shall be maintained as to retain its original effectiveness...
shall be approved for use in hazardous atmospheres where they are
maintained in an approved condition and are the same in all
respects as those devices for which a certificate of approval has
been issued. Fire Departments should also refer to the
manufacturers specific inspection and maintenance procedure.
(2) Establish a record-keeping system that will record the
results of:
(a) Regular calibration of the respirator test equipment as recommended by the manufacturer.
(b) Any repairs made during both routine preventative maintenance and necessary maintenance on SCBA taken out of service.
(c) Performance tests conducted on a regular basis as well as before and after repairs are performed.
These records should identify the SCBA and regulator
identification numbers, test equipment identification numbers,
date, a description of the service action including parts (and
part numbers) involved, and identification of the repair person.
(3) Establish a record-keeping system for tracking the SCBA
cylinders to ensure that the cylinders are hydro-statically
retested and recertified every 3 years as required by DOT in 49
CFR 179.34(e)(13) and NIOSH in 42 CFR 84.81(a).
REFERENCES
1. Morris, Gary P., Brunacini, Nich., Whaley, Wynn; Fireground
Accountability: The Phoenix System Fire Engineering, Vol.
147, No. 4, April, 1994.
2. National Fire Protection Association. NFPA 1500 Standard on
Fire Department Occupational Safety and Health Program, National
Fire Protection Association, Quincy, MA.
3. National Fire Protection Association. NFPA 1561, Standard on
Fire Department Incident Management System, National Fire
Protection Association, Quincy, MA.
4. 29 Code of Federal Regulations 1910.134 Respiratory
Protection.
5. National Fire Protection Association. NFPA 1404, Standard on
Fire Department SCBA Program, National Fire Protection
Association, Quincy, MA.
The National Institute for Occupational Safety and
Health (NIOSH), Division of Safety Research (DSR),
performs Fatality Assessment and Control Evaluation
(FACE) investigations when a participating State reports
an occupational fatality and requests technical
assistance. 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. States participating in this study: North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. |
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