FACE 97-04: Floor Collapse in a Single Family Dwelling Fire Claims the Life of One Fire Fighter and Injures Another - Kentucky
SUMMARY
On February 17, 1997, two male fire fighters (the victim and
injured) were part of a fire company that responded to a single
family dwelling fire. When the fire company arrived at the fire
scene, the District Major reported heavy smoke emitting from the
roof area of the dwelling. The victim and injured pulled two
water hoses from the engine they were assigned to and proceeded
toward the dwelling. After knocking down a ceiling fire, they
entered the dwelling through the front door and both immediately
fell through the floor into the basement area. One fire fighter
was seriously injured while the victim died from asphyxiation.
NIOSH investigators concluded that, to prevent similar
occurrences, employers should:
ensure that fire command always maintains close
accountability for all personnel at the fire scene
ensure at least four fire fighters be on the scene before
initiating interior fire fighting operations at a working
structural fire
ensure that fire fighters who enter hazardous areas, e.g.,
burning or suspected unsafe structures, be equipped with two-way
communications with incident command.
INTRODUCTION
On February 17, 1997, two male fire fighters (the victim and
injured), ages 29- and 31-years-old, respectively, entered a
single family dwelling that had heavy smoke emitting from the
roof area and from around the door and window openings. The two
fire fighters entered the house through the front door and both
immediately fell through the floor into the basement area. One
fire fighter was seriously injured while the victim died from
asphyxiation. On March 10, 1997, the International Association of
Fire Fighters (IAFF) requested that NIOSH provide technical
assistance in reviewing the circumstances surrounding the
fatality and serious injury. On April 15, 1997, the Chief of
Trauma Investigations Section and a Safety Specialist traveled to
Kentucky to conduct an investigation of this incident. Meetings
were conducted with Kentucky OSHA personnel, including the OSHA
compliance officer assigned to the case, fire department
officers, the IAFF union representative, and the State Fire
Marshall. Copies of photographs of the incident site and the
transcription of dispatch tapes were obtained, and a site visit
was conducted.
The fire department involved in the incident serves a population
of 240,000 in a geographic area of 280 square miles. The fire
department is comprised of approximately 430 employees, of whom
360 are fire fighters. The fire department provides all new fire
fighters with the basic 16-week recruit training at the fire
department training center. The department also requires 100
hours of additional on-the-job training for each fire fighter
each year. The required training is designed to cover fire
department operation, e.g., ladder training, aerial operations,
hose training, breathing apparatus, etc. Recertification training
is conducted at the training center on an annual basis. The fire
department's written standard operating procedures manual was
reviewed and appears to be complete. The victim and injured had 7
and 4 years fire fighting experience respectively.
The site of the incident, a one-story single family residence
measuring 28 feet by 28 feet, was located in a residential
neighborhood. Most of the homes in the area were one-story frame
and vinyl/aluminum sided structures and mobile homes, with the
exception of the residence involved in the incident. The roof had
been constructed of wood framing and sheeting, and shingles,
while the exterior walls of the residence had been constructed of
concrete block. The residence had a full basement about 8 ½-feet
high; access to the basement was gained through either an
interior stairway or an exterior doorway which was located on the
back side of the residence.
Although two fire companies were involved in this incident,
only those directly involved up to the time of the fatal incident
are mentioned in this report. The figure shows all companies
responding to this incident.
INVESTIGATION
On February 17, 1997, at 0009 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
fire station serving the district of the city where the fire was
located. The District Major-204, Engine-11, Engine-6, Emergency
Medical Service-EC6, and Aerial-4 were ordered to respond.
Altogether, 5 pieces of equipment and 16 personnel arrived at the
fire scene between 0013 and 0014 hours. The District Major was
first on the scene at 0013 hours and assumed command. All the
remaining vehicles and crews arrived seconds behind the District
Major.
When the District Major pulled up near the front of the residence
where the incident occurred, he reported heavy smoke coming from
the structure. He then asked a small group of spectators standing
on the street, whether anyone might be in the house. A spectator
responded that they didn't think anyone lived there. He then
ordered fire fighters from Engine ll to pull two 1 3/4-inch water
lines and approach the front door area. After the lines had been
pulled and moved to the door area, it was discovered that the
pressure relief valve on the Engine 11 water pump was sticking
and could not sustain adequate water pressure. In the interim, a
fire fighter attempted to open the front door, but found it was
locked. He kicked open the door which allowed considerable
amounts of heavy black smoke and heat to emit from the door
opening. He was ordered to close the door and pull two lines from
Engine 6. Also, fire fighters from Aerial 4 had started a
generator and illuminated the area, then carried two positive
pressure ventilation (PPV) fans to the front of the residence.
The PPV fans were started, but use of the fans was restricted
until charged lines were brought to the front door area. Other
fire fighters had pulled exposure lines and were fighting fires
on the opposite side of the structure and protecting an adjacent
residence.
While the District Major was working with the engineer from
Engine 11, trying to get the pump on Engine 11 functioning, he
called for Engine 6 to pull two water lines. Two fire fighters
(the victim and injured) pulled two lines from Engine 6 and
proceeded to the front door of the residence. The air-flow volume
of the PPV fans was increased and aimed toward the door opening.
The two fire fighters from Engine 6 donned their self-contained
breathing apparatus (SCBAs) and knocked down some fire in the
ceiling area of the structure before making entry (unknown to the
fire fighters, that three separate fires were burning in the
basement--one fire was directly below the entry of the front
door). Shortly thereafter (about 2/3 minutes after donning their
SCBAs) the two fire fighters entered the house through the front
door to attack the interior fire, and immediately fell through
the floor into the basement area. Approximately 8 minutes had
elapsed and the District Major said "let's ease off this
thing for a minute," (pull back and regroup), and then
realized two fire fighters were missing. A lieutenant, after
being advised of the problem, crawled along the ground and
discovered hose lines going into the front doorway and down into
a hole. A light from a flashlight was seen in the smoke/darkness
of the hole and the lieutenant stuck his right hand into the
floor opening and was grabbed by the one of the fire fighters
(injured). At about the same time, fire fighters on the outside
of the house lowered a 14 foot ladder through the front doorway
into the basement; the ladder brushed up against the injured fire
fighter and he grabbed it. The injured was pulled/lifted from the
basement area with the aid of the ladder. The injured fire
fighter, after being extracted from the basement, advised others
that the other fire fighter was still in the basement. Numerous
search and rescue efforts were made through the hole in the floor
and from the back door to the basement. The victim was eventually
located and removed from the basement area, and vital signs were
checked at 0118 hours, approximately 53 minutes after the victim
and injured were discovered missing. The injured fire fighter
reported that both he and the victim sprayed water on one another
trying to stay cool. It was also reported that the injured fire
fighter had manually activated his personal alert safety system
(PASS) device. However, due to the noise of the engines, pumps,
PPV fans, etc., no one heard the alarm. Approximately 8 to 10
minutes after entering the structure, both fire fighter's SCBAs
ran out of air and they tried to breath entrained air from the
water spray from their lines.
The following time line has been developed from fire and EMS
dispatch sheets, and personal and taped interviews of fire
personnel:
February 17, 1997 (minutes have been rounded off to the full
minute)
0009 | Call received at fire station |
0013 | District Major-204 arrives at fire scene |
0014 | Engine-11, Engine-6, EMS-EC-6, and Aerial-4 arrive at the fire scene |
0015-0017 | Victim and injured pull two lines from Engine-6, move to front door area and put on SCBAs, and fight ceiling fire |
0017 | Victim and injured fall into basement area |
0025 | Victim and injured discovered missing |
0040 | EC-6 departs fire scene with injured |
0118 | EC-5 departs fire scene with victim |
CAUSE OF DEATH
Preliminary cause of death was listed by the medical examiner as
asphyxiation 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.
Discussion: Accountability for all fire fighters at a fire scene
is paramount, and one of the fire command's most important
duties. The District Major was directing his attention towards
the various aspects of the total operation and had ordered the
two fire fighters to enter the structure, but not advance too
far; however, he was not aware of exactly when the fire fighters
entered the structure.
Recommendation #2: Fire departments should ensure at
least four fire fighters be on the scene before initiating
interior fire fighting operations at a working structural fire.
Discussion: When the District Major arrived at the scene he took
command and directed the operations. Personnel from the Engines
and Aerial Truck were performing duties as directed, or as
standard operating procedures directed. Although there were
approximately 16 fire fighters on the scene, no one actually
witnessed the two fire fighters (victim and injured) enter the
burning structure or fall through the floor, and about 8 minutes
elapsed before they were discovered missing. The National Fire
Protection Association (NFPA) and the Occupational Safety and
Health Administration (OSHA) recommends that four persons (two in
and two out), each with protective clothing and respiratory
protection, are the minimum number essential for the safety of
those performing work inside a structure. The team members should
be in communication with each other through visual, audible, or
electronic means to coordinate all activities, and determine if
emergency rescue is needed.
Recommendation #3: 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 two fire fighters entered the burning
residence and fell through the floor, the noise from the fire
fighting operations (pumps, engines, PPV fans, etc) obscured the
calls for help and the audible signal from the PASS device. If
the fire fighters had a portable radio, then incident command may
have been able to determine that the two fire fighters were
trapped in the basement of the burning structure.
References:
1. Morris, Gary P., Brunacini, Nick., 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, Qunicy,
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 1910.120, Hazardous Waste
Operations and Emergency Response.
5. U.S. Department of Labor, Occupational Safety and Health
Administration Compliance Memorandum to Regional
Administrators and State Designees, May 1, 1995.
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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