2016

07

December 19, 2017

Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Executive Summary
On April 30, 2016, a 20-year-old male
volunteer fire fighter died after he ran out
of air and became disoriented while
fighting a fire in a commercial strip mall.
The fire fighter was a member of the
first-due engine company, Engine 3 from
Department 7. Once Engine 3 arrived on-
scene, a preconnected 1¾-inch crosslay
was stretched into the 7,000-square-foot
retail store to attack the fire. The Engine
3 hoseline crew consisted of a senior
captain, a lieutenant, and two fire
fighters. After the fire was located and
water was flowed on the fire, a fire
fighter working the nozzle ran low on air,
gave the nozzle to the second fire fighter
(victim), and proceeded to follow the
hoseline to exit the structure. While Retail golf store in middle of commercial strip mall
operating the nozzle near the where 20-year-old fire fighter was fatally injured.
Charlie/Delta corner of the retail store, (Photo NIOSH.)
the remaining fire fighter also ran low on air and told the lieutenant and captain that he had to go
outside. He immediately tried to exit but quickly became disoriented in the near-zero visibility
conditions within the retail store. The fire fighter returned to the hoseline near the nozzle and the
lieutenant and captain tried to calm him down. The lieutenant was low on air and told the captain that
he would take the fire fighter outside but the fire fighter broke away and disappeared into the thick
smoke toward Side C, the rear of the store. The lieutenant began to follow the hoseline out. He heard
the missing fire fighter yelling for help off to his right and tried to make his way toward the missing
fire fighter but became entangled in the display racks. After freeing himself, the lieutenant briefly
located the missing fire fighter who stated he was completely out of air and had to get out. The fire
fighter again disappeared, moving toward the rear of the store. The lieutenant also ran out of air and
had to remove his helmet and facepiece because his facepiece was fogging up. The lieutenant activated
his PASS device and was soon located by the Engine 16 crew and helped outside. The lieutenant told
rescuers that the fire fighter was missing inside the store. A Mayday was transmitted by the Engine 20
captain at the front door for a missing fire fighter. The Engine 3 fire fighter was located about 2

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

minutes later and transported to the hospital where he was pronounced dead. The lieutenant was
transported to the hospital for treatment of smoke inhalation and was released later that day.

Contributing Factors
• Lack of crew integrity
• Inadequate air management training
• Inexperienced fire fighter
• Ineffective fireground communications
• Failure to call a Mayday in a timely manner
• No sprinkler system in commercial structure
• Zero-visibility conditions in smoke-filled retail store
• Restricted mobility due to arrangement of floor displays.

Key Recommendations
• Fire departments should ensure that crew integrity is properly maintained by sight, voice, or
radio contact when operating in an immediately-dangerous-to-life-or-health (IDLH)
atmosphere.
• Fire departments should ensure all fire fighters are trained on and actively practice air
management principles.
• State, local and municipal governments, building owners, and authorities having jurisdiction
should consider requiring the use of sprinkler systems in commercial structures.
• Fire departments should train company officers and fire fighters to report interior conditions to
the incident commander as soon as possible and on a regular basis.
• Dispatch centers should provide timeframe bench marks to Incident Command on a regular
basis.
• Fire departments should ensure that fire fighters are trained and proficient on following
hoselines outside as a means for egress and self-rescue.

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and
Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of
work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the
NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire
fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire fighter deaths in the future. The
agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or
assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH
investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop
a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and
interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH
report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's
recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

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 2016
07

December 19, 2017

Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Introduction
On April 30, 2016, a 20-year-old male volunteer fire fighter died after he ran out of air and became
disoriented while fighting a fire in a commercial strip mall. The fire fighter was a member of the initial
engine company who advanced a preconnected 1¾-inch crosslay into the retail store to attack the seat
of the fire. On May 2, 2016, the U.S. Fire Administration notified the National Institute for
Occupational Safety and Health (NIOSH) of this incident. On May 15, 2016, a safety engineer, a
general engineer, and an investigator with the NIOSH Fire Fighter Fatality Investigation and
Prevention Program traveled to North Carolina. The NIOSH investigators met with representatives of
the fire department and the assistant fire marshal from the county where the incident occurred. The
NIOSH investigators visited the incident site and took photographs and measurements. The NIOSH
investigators interviewed members of the volunteer fire department who were involved in the incident.
The NIOSH investigators also interviewed members of both the career department and the volunteer
department who responded to the incident for mutual aid. The NIOSH investigators also met with
representatives of the North Carolina Department of Labor, the city police department, the county
medical examiner’s office who performed the autopsy, the county emergency medical services (EMS)
agency, and county fire dispatch center. The NIOSH investigators obtained copies of the fire fighter’s
training records, fire department standard operating procedures, building information, and the dispatch
audio records for the incident.

On June 20, 2016, NIOSH investigators returned to North Carolina and met with representatives of the
fire department and the city police department. The NIOSH investigators took possession of two self-
contained breathing apparatus (SCBA) that were used by the two fire fighters who ran out of air inside
the structure. These SCBA were transported to the SCBA manufacturer’s facility where the SCBA data
logger information was downloaded. This process was witnessed by representatives of the fire
department, the county fire marshal’s office, the North Carolina Department of Labor, and NIOSH.
Following this process, the SCBA were transported to the NIOSH National Personal Protective
Technology Laboratory (NPPTL) in Morgantown, West Virginia, for secure storage. See Appendix
One for further information on the NPPTL SCBA Evaluation Report.

On August 15, 2016, the two SCBA were tested by the NIOSH NPPTL staff. The testing was
witnessed by representatives of the fire department, the county fire marshal’s office, the North
Carolina Department of Labor, and the NIOSH Fire Fighter Fatality Investigation and Prevention
Program.

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Fire Department
This combination fire department was an incorporated entity that provided fire suppression and other
emergency services under contract within the city limits where this incident occurred. At the time of
the incident, the fire department had 50 members including 28 trained interior fire fighters who
operated out of one station that served a population of approximately 7,900 within an area of about 3.5
square miles.

The fire department had four paid fire fighters who were trained fire fighter/emergency medical
technicians (EMTs). These fire fighters provided coverage 5 days per week during 0700 hours through
1800 hours. One paid fire fighter worked from 0700 hours to 1600 hours. Two fire fighters worked
from 0800 hours to 1700 hours, and one fire fighter worked from 0900 hours to 1800 hours. There was
no paid coverage from 1800 hours to 2100 hours. Fire fighters could work overtime shifts from 2100
hours to 0600 hours.

The fire department had a fire chief, three assistant chiefs, one senior captain, four captains, and five
lieutenants. One lieutenant served as the department safety officer. The fire chief and assistant chiefs
were voted in by the membership. All lieutenants and captains were appointed by the fire chief. All fire
department members received an annual physical examination that complied with NFPA 1582
Standard on Comprehensive Occupational Medical Program for Fire Departments. All interior fire
fighters were respirator fit-tested on an annual basis.

The fire department operated three engines, one tower ladder truck (105-foot ladder), one brush truck,
one heavy rescue, and one light duty rescue (squad) vehicle. The fire department rotated the engines on
a regular basis to limit the hours of operation on each engine. Engine 2 was operated on even-
numbered days. Engine 3 was operated on odd-numbered days, and Engine 4 was operated every
Wednesday. The fire department responded to approximately 2600 emergency calls in 2015 and at the
time of this investigation was on a pace to respond to approximately 3000 emergency calls in 2016.
The fire department had automatic aid agreements with neighboring volunteer departments within the
county and also had a mutual aid agreement with the nearby metro-sized career fire department.

The fire department was classified by Insurance Services Office (ISO) as a Class 5 fire department. In
the ISO rating system, Class 1 represents exemplary fire protection, and Class 10 indicates that the
area's fire-suppression program does not meet ISO's minimum criteria.

Training and Experience

The state of North Carolina does not have minimum training requirements for a fire fighter to be an
interior fire fighter. In the state of North Carolina, fire fighters are required to receive 36 hours of
training each year, and each fire chief is responsible for setting departmental training requirements.
The fire department involved in this incident strives to have all interior fire fighters trained to both Fire
Fighter I and Fire Fighter II equivalent to the National Fire Protection Association (NFPA) 1001

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Standard for Fire Fighter Professional Qualifications and 1403 Standard on Live Fire Training
Evolutions [NFPA 2012, 2013a].

The fire department did not have an officer development training program for a member to become an
officer. At the time of this incident, the fire department required a fire fighter to be an active member
for 3 years as an active interior fire fighter before being able to serve as an officer. All lieutenants and
captains were appointed by the fire chief.

The Engine 3 fire fighter who was critically injured and died following this incident had been a
volunteer member of the fire department for less than 3 years. Fire department records indicated the
fire fighter had received 127 documented hours of training during 2014, 198 documented hours of
training during 2015, and 23.5 documented hours of training during 2016 at the fire department.
Subjects included appartus familiarization, truck tools, building construction, SCBA use, personal
protective equipment (PPE), Fire Fighter I, and Fire Fighter II. Records from the North Carolina
Department of Insurance, Fire & Rescue Commission identified International Fire Service
Accreditation Congress (IFSAC) certification in a number of subjects including:
• Emergency Vehicle Driver/Operator
• Hazardous Materials Level 1
• Firefighter Level I
• Firefighter Level II

The Engine 3 lieutenant had been a member of the fire department for 5 years and was working an
overtime shift (2100 hours – 0600 hours) at the time of this incident. He also worked as a career fire
fighter at the nearby metro-sized fire department. Fire department records indicated the lieutenant had
received 87.5 documented hours of training during 2014, 52 documented hours of training during
2015, and 10 documented hours of training during 2016 at the fire department. The lieutenant also
received significant training at the career fire department.

The Engine 3 senior captain had 29 years of experience at the combination fire department. Fire
department records indicated the senior captain had received 64.5 documented hours of training during
2014, 68.5 documented hours of training during 2015, and 8 documented hours of training during 2016
at the fire department. The senior captain had received certification through the North Carolina
Department of Insurance, Fire & Rescue Commission in Firefighter Level I, Firefighter Level II,
Hazardous Materials Responder with PPE Certification, Basic Rescue Technician, Emergency Rescue
Technician, and several others.

The fire chief of Department 7 (who was the incident commander) had 27 years experience at the
combination fire department and had been the fire chief for 2 years at the time of the incident. Fire
department records indicated the fire chief had received 63.5 documented hours of training during
2014, 110.5 documented hours of training during 2015, and 14 documented hours of training during
2016 at the fire department. The fire chief of Department 7 was also a captain at the nearby metro-
sized career fire department with 15 years total experience working for the career fire department. The

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

fire chief had received certifications on a number of subjects both through the North Carolina
Department of Insurance, Fire & Rescue Commission and the International Fire Service Accreditation
Congress (IFSAC). The fire chief also received significant training at the career fire department.

Equipment and Personnel

This incident involved the local combination fire department (Department 7) being dispatched for the
report of smoke in a commercial strip mall. Department 2 was dispatched for automatic mutual aid.
The following units from Department 7 responded on the initial dispatch on April 30, 2016:

• Engine 3 from Department 7: senior captain, driver (captain), two lieutenants, and two fire
fighters including the victim (Fire Fighter 2).
• Ladder 1 from Department 7: assistant chief and one fire fighter
• Squad 8 from Department 7: two fire fighters and two junior fire fighters
• Car 7 from Department 7: fire chief
• Five Department 7 fire fighters responded to the scene via privately-owned vehicle (POV).

The neighboring volunteer Department 2 was dispatched on automatic mutual aid. Their initial
response consisted on the following unit:

• Engine 3 from Department 2: captain and fire fighter. The fire fighter made entry with the
Department 7 second hoseline.

The Department 7 fire chief arrived on-scene and assumed incident command. A ladder company from
the nearby city fire department was in the area on a medical call. The incident commander radioed
dispatch and requested that the ladder company be added to the assignment. The following career fire
department company was added:

• Ladder 24: captain, driver, two fire fighters.

After confirming that a working fire was in progress, the Department 7 fire chief (incident commander)
radioed Dispatch and requested a first alarm assignment from the city fire department. The following
units and fire fighters were dispatched:

• Engine 39: captain, driver and two fire fighters

• Engine 26: captain, driver and two fire fighters
• Engine 20: captain, driver and one fire fighter
• Engine 16: relief captain, driver and two fire fighters
• Rescue 10
• Battalion Chief 5

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
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Structure
The building was part of a 70,000-square-foot commercial strip mall complex. The strip mall complex
was originally built in 1978 (see Photo 1).

The fire occurred in a 7,037-square-foot retail store that measured 50 feet wide and 140 feet 9 inches
deep and housed a retail golf store. The front (Side Alpha) was constructed entirely of plate-glass
windows with a center entrance doorway protected by a metal security gate (see Photo 2). Side Bravo
and Side Delta were constructed of concrete block fire walls approximately 12 feet high. A storage
room, offices, and rest rooms were located at the rear of the structure. A closed fire door was located
at the rear (Side Charlie) near the Charlie/Delta corner and was used for employee entrance only. The
front door at Side Alpha provided the only means of normal ingress and egress to the store. The flat
roof consisted of a metal roof deck covered by three layers of asphalt, foam, and waterproof membrane
covered by asphalt and gravel (see Photo 3 and Photo 4). The one-story building rested on a concrete
pad. The building did not contain a sprinkler system or automatic fire suppression system.

The store was serviced by both natural gas and electrical utilities. The electrical panel was located at
the Charlie/Delta corner of the store near the origin of the fire.

The county fire marshal’s office investigators determined that the fire was likely caused by a lightning
strike that hit the roof near the rear of the building [Weather Underground 2016]. Weather records and
police department interviews with witnesses in the area indicated that heavy thunderstorms, rain,
lightning, and loud thunder were observed in the immediate area around 2000 hours through 2100
hours.

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
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Photo 1. Overhead view of commercial strip mall where incident occurred. The fire building was
a retail golf store where the 20-year-old fire fighter was fatally injured (fire building is
highlighted in red).
(Photo adapted from Google Earth.)

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Photo 2. Photo shows sliding plate-glass entrance door and metal security gate.
(NIOSH photo.)

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Photo 3. Photo shows construction of flat metal roof covered with asphalt, foam insulation, and
gravel. Chain saws were initially used in an effort to open the roof for vertical ventilation but
would not cut through the metal deck. K12 saws with metal cutting blades had to be retrieved to
cut through the roof deck.
(NIOSH photo.)

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
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Photo 4. Photo shows close-up of asphalt and foam insulation covering metal roof deck. Note that
the section of roof has been flipped upside down as a result of roof ventilation work.
(NIOSH photo.)

Timeline
Note: This timeline is provided to set out, to the extent possible, the sequence of events as the fire
departments responded. The times are approximate and were obtained from review of the fire dispatch
records, police dispatch records, witness interviews, and other available information collected by
NIOSH. In some cases the times may be rounded to the nearest minute, and not all events have been
included. The timeline is not intended, nor should it be used, as a formal record of events.

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

• 2103 Hours
Local police respond for a security alarm activation and find smoke in a retail golf store in
commercial strip mall.

• 2106 Hours
Department 7 and Department 2 dispatched for a commercial structure fire. Department 7
Engine 3, Ladder 1, and Fire Chief (in fire department chief’s vehicle) responded along with
Department 2 Engine 3.

• 2108 Hours
Department 7 Fire Chief arrives on-scene. Drives around structure and reports nothing
showing.

• 2110 Hours
Department 7, Engine 3 arrives on-scene. Engine 3 fire fighters force front door and pull 1¾-
inch preconnect into the golf store.

• 2135 Hours
Mayday called by Engine 20 captain.

• 2143 Hours
Downed fire fighter removed from building.

• 2145 Hours
Downed fire fighter transported to hospital.

• 2200 Hours
Ambulance arrives at hospital.

• 2222 Hours
Fire fighter pronounced dead.

Personal Protective Equipment

At the time of this incident, the Engine 3 Fire Fighter 2 was wearing a full fire-fighting ensemble
consisting of a turnout coat and pants, helmet, hood, gloves, and leather fire boots. He was wearing a
station uniform consisting of a cotton T-shirt and station work pants. He carried a fire department-
issued portable radio and a flashlight was attached to the front of his turnout coat. He was wearing a
self-contained breathing apparatus (SCBA) with an integrated PASS device. His radio was found to be
turned on and set on the proper channel.

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Following the incident, the SCBA worn by Engine 3 Fire Fighter 2 along with the SCBA worn by the
Engine 3 lieutenant, were transported to the NIOSH National Personal Protective Technology
Laboratory in Morgantown, West Virginia, for evaluation and testing. A summary of the NIOSH
evaluation is included in Appendix One. The full evaluation report is available upon request from the
NIOSH National Personal Protective Technology Laboratory. The full evaluation report can also be
downloaded from the NIOSH NPPTL PPE website
https://www.cdc.gov/niosh/npptl/ppe-fireservice/pdfs/PinevilleFireDepartment20922.pdf.

Weather Conditions
The weather on April 30, 2016, at approximately 2100 hours was overcast with rain and thunderstorms
in the area. The temperature was approximately 64 degrees Fahrenheit with 93 percent relative
humidity and winds from the west/northwest at 6 miles per hour. Heavy thunderstorms had passed
through the area approximately 1 hour prior to the fire being discovered. Investigators from the county
fire marshal’s office determined that the fire was likely caused by a lightning strike that hit the roof on
Side Charlie near the Charlie/Delta corner of the building [Weather Underground 2016].

Investigation
On April 30, 2016, a 20-year-old male volunteer fire fighter died after he ran out of air and became
disoriented while fighting a fire in a commercial strip mall. At 2106 hours, Department 7 (the local
combination fire department) was dispatched for a fire in a commercial strip mall. A lightning storm
had recently passed through the area. A lieutenant was working the night shift (2100 hours to 600
hours) at the station. Several volunteer members were also present at the station at the time of the
dispatch. Department 2 was also dispatched for mutual aid.

Engine 3 responded from Department 7 with a total of six fire fighters on the apparatus. While en
route, the fire fighters heard over the radio a city police officer confirm smoke in the building. Note:
While en route, the lieutenant who was on duty and riding in the right rear jump seat dropped his
portable radio on the floor of Engine 3. He felt underneath the seat and in the immediate area but
could not locate the radio. When they arrived on-scene the crew immediately went to work. The
lieutenant did not take time to continue searching for his radio. He did not have a portable radio when
he entered the structure.

The Department 7 fire chief responded from his home in his fire department vehicle and drove past the
front of the strip mall building to get a visual size-up of the exterior. He did not see any smoke on this
initial drive around and radioed Dispatch that nothing was showing. He parked his fire department
vehicle in front of the strip mall (Side Alpha) in the parking lot (see Photo 5) and assumed incident
command. The city police department was already on-scene and established good traffic control. A police
officer radioed that smoke was visible through the plate-glass front windows. The fire chief radioed the
in-coming Engine 3 from Department 2 (automatic mutual aid) and directed them to reverse lay from
Department 7 Engine 3 which was located at Side Alpha near the front door (see Photo 5), to the

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Photo 5. Location of Engine 3 and Chief’s vehicle on Side A of fire building.

(Photo courtesy of County Fire Marshal’s Office.)

hydrant located east of the strip mall. When Engine 3 from Department 2 arrived with a captain and
one fire fighter onboard, the fire chief ran to the engine and verbally directed them where to lay out
their 5-inch supply line to supply water to Engine 3. The Department 2 engine supplied water to
Department 7 Engine 3, which never ran low on water.

The fire chief radioed Dispatch and requested a first-alarm assignment from the city department (four
engines, one ladder, one heavy rescue, one battalion chief). The Department 7 assistant chief radioed to
the fire chief and reported that he was bringing the Department 7 ladder truck (Ladder 1) to the scene
with one additional Department 7 fire fighter onboard. The city fire department Ladder 24 was in the
area on a medical call and cleared the call, so the incident commander radioed county fire dispatch and
requested that Ladder 24 be added to the assignment. Ladder 24 set up in the parking lot in front of the

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

strip mall at Side Alpha. Note: The county fire dispatch system is able to provide a radio “patch” so
that county fire departments can talk directly to city fire department units over the fireground channel.

The Engine 3 crew observed a light haze of smoke when they arrived in the strip mall parking lot. The
Engine 3 senior captain, lieutenant, and Fire Fighter 2 approached the golf store door. Another fire
department member arrived soon after in his privately owned vehicle (POV) and joined the Engine 3
crew. They quickly forced open the outer sliding plate-glass door and were confronted with an inner
security gate door (see Photo 2). When the plate-glass door was opened, thick gray smoke rolled out of
the store interior. The senior captain requested a power saw from Engine 3 to cut open the security
gate. The lieutenant and senior captain from Department 7 continued to work on the security gate and
were able to force open the security gate before the power saw was retrieved from Engine 3. The
captain directed the Engine 3 fire fighters to pull a 200-foot section of 1¾-inch preconnected hoseline
to the front door while the lieutenant entered the structure a short distance and used a thermal imager to
scan the interior. Additional units arrived on-scene. Department 7 Rescue Squad 8 arrived with two
fire fighters and two junior fire fighters onboard. A total of five members of Department 7 arrived at
the strip mall in their POVs. The lieutenant observed that the thermal imager was registering high heat
at the rear of the store showroom near the Charlie/Delta corner. While the Engine 3 fire fighters
stretched the hoseline to the front door, the lieutenant went back outside and reported to the captain
that the fire appeared to be burning above the drop ceiling. The fire had burned through the drop
ceiling but not through the roof. Two fire fighters and the senior captain advanced the hoseline inside
the structure with the lieutenant directing them down the center isle using the thermal imager. A third
fire fighter stayed at the front door and fed them the hoseline as they advanced. After they advanced
inside about 10 feet they encountered thick light brown smoke banked down to the floor creating
almost zero visibility. There was little to moderate heat inside the building.

The fire chief assigned the city Ladder 24 crew to perform roof ventilation work. The city battalion
chief (Battalion Chief 5) arrived on-scene and assisted the Department 7 fire chief at the command post
by setting up accountability. The Department 7 assistant chief arrived on-scene in Ladder 1. The
Department 7 assistant chief was assigned as the operations chief, and the Department 7 senior captain
was in charge of suppression. The city fire department Engine 39 arrived on-scene and was assigned
by Command (the Department 7 fire chief) to go to Side C and open the rear door. Note: The captain
on Engine 39 was also the Department 2 assistant chief. The city fire department Engine 26 arrived
on-scene and was directed by Command to assist Ladder 24 with roof ventilation. The city fire
department Rescue 10 arrived and was also directed by Command to go to the roof. Note: The roof
crews had difficulty cutting through the roof layers and the supporting metal roof deck (see Photo 3
and Photo 4).

The Department 7 assistant chief (operations chief) assembled a second hoseline crew of three
Department 7 fire fighters and directed them to pull a second 1¾-inch preconnected hoseline from
Engine 3 to the front door. Then he radioed Command and asked to get the back door opened to help
with ventilation. The assistant chief also told the Engine 3 driver to make sure nobody broke out the
storefront windows.

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The first hoseline crew advanced toward the Charlie/Delta corner and began to flow water toward the
fire. The Engine 3 lieutenant used the thermal imager to direct the fire fighter working the nozzle on
where to flow the water. The fire fighter on the nozzle ran low on air and became fatigued and passed
the nozzle to Fire Fighter 2. The first fire fighter began to follow the hoseline outside after informing
the lieutenant that he had to leave, but the senior captain was not advised that the fire fighter was
leaving. The senior captain walked back toward the Bravo / Charlie corner to check for fire extension
in that area. Fire Fighter 2 continued to work the nozzle with the lieutenant directing him with the
thermal imager. The Engine 3 crew became aware of the roof crew from the career fire department
working overhead to open the roof. Conditions continued to deteriorate inside the structure with
increasing smoke and heat. Visibility was near zero.

The city fire department Engine 16 arrived on-scene followed by Engine 20. Engine 20 was assigned
to assist Department 7 on the second 1 ¾-inch preconnected hoseline pulled off Engine 3. Engine 16
was assigned by the operations chief to pull a 2 ½-inch preconnected hoseline from Engine 3 to the
front door.

At the front door, the Department 7 assistant chief directed the second hoseline crew from Department
7 to advance their hoseline inside. The assistant chief followed the first hoseline inside and the second
hoseline crew followed the assistant chief. The assistant chief passed the fire fighter from the first hose
line crew just inside the front door as the fire fighter was coming out and the assistant chief was
following the first hoseline inside. The fire fighter told the assistant chief that he was low on air and
they briefly discussed the conditions inside the structure. The assistant chief (operations) again radioed
for the rear door to be opened to help with ventilation. The second 1¾-inch preconnected hoseline was
advanced about 40 feet into the center of the store when a coupling snagged on the doorframe at the
front of the store. The crew on the second hoseline was unable to advance the hose so one of the crew
members followed the hoseline back to the entrance to get more slack. Fire fighters at the door
working to free the second 1¾ inch hoseline delayed Engine 16 in advancing the 2½-inch hoseline
inside the structure. The Department 7 fire fighters working the second 1¾-inch hoseline ran low on air
and had to follow their hoseline outside. The Engine 16 crew came to the nozzle on the second 1¾-
inch hoseline and decided to advance the 1¾-hoseline because it had more slack and would be easier to
advance.

The Engine 3 Fire Fighter 2 ran low on air and his alarm began to go off. Fire Fighter 2 told the
lieutenant that he needed to get out. The lieutenant tried to calm Fire Fighter 2 and took the nozzle and
asked Fire Fighter 2 to hold the thermal imager up to the lieutenant’s mask so he could locate the fire.
While doing this, the hose stream hit the thermal imager and knocked it out of Fire Fighter 2’s hand.
Fire Fighter 2 again said he needed to get out. The senior captain and the lieutenant tried to calm him
down. Fire Fighter 2 began following the line out but soon became separated from the line where it
crossed over a display stand that held golf bags and ended up on the other side of a display case from
where the lieutenant was operating the nozzle. Fire Fighter 2 bumped into the senior captain who told
the fire fighter where to find the hoseline and directed the fire fighter to follow the hoseline out. The

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

Department 7 assistant chief arrived at the nozzle and talked with the senior captain. The lieutenant’s
low-air alarm began to go off so the lieutenant told the assistant chief that he was going to go outside
with Fire Fighter 2. The lieutenant directed Fire Fighter 2 to follow him on the hoseline.

Engine 39 forced open the rear door at Side C. Command directed Engine 39 to enter the structure
through the rear door and start a primary search. Two ambulances arrived on-scene with an EMS
supervisor.

The Engine 3 lieutenant followed the hoseline until he came to a coupling. He looked back for Fire
Fighter 2 and saw that he was standing up. The lieutenant turned around and grabbed hold of Fire
Fighter 2. They fell over a display of golf bags and became separated from the hoseline. The lieutenant
turned in the direction that he thought was Side Alpha and began pulling Fire Fighter 2 with him. They
were both walking in near-zero visibility when they ran into another display that consisted of racks of
golf clubs. Fire Fighter 2 stated that he was completely out of air and had to get out of the building.
The lieutenant was momentarily entangled in the golf clubs and became disoriented. Fire Fighter 2
disappeared into the thick smoke moving away from the lieutenant toward the rear of the store. The
lieutenant also ran out of air and his facepiece fogged up, so he removed his helmet and facepiece in an
effort to try to see so that he could orient himself. Note: The lieutenant’s facepiece and helmet were
found near the Side Charlie wall after the fire was extinguished (see Photo 6). The lieutenant activated
his PASS device as he continued to crawl through a series of golf club displays. The lieutenant did not
have a personal radio so he could not radio for assistance. He heard a voice in front of him (Engine 16
crew) and began to yell for help. The Department 7 assistant chief (Operations) radioed to Command
that he could hear a PASS alarm going off. The Engine 16 driver radioed that he thought it was a fire
alarm going off. The fire chief radioed for Engine 39 to investigate the PASS alarm.

The Engine 16 crew members saw the PASS device flashing lights and turnout reflective trim on the
Engine 3 lieutenant who was approximately halfway inside the structure and near Side C. The Engine
3 lieutenant did not have his helmet or facepiece on. They quickly assisted him to the hoseline. One of
the Engine 16 fire fighters stayed with the Engine 3 lieutenant all the way to the door.

The Engine 20 crew was assigned to assist with the second preconnected 1¾-inch hoseline off Engine
3. They arrived at the front door and observed that both hoselines were already deployed so they
retrieved a rope bag from Engine 3 and deployed a search rope at the front entrance and began
advancing inside the structure. They had advanced inside about 20 feet when they observed the Engine
3 lieutenant being assisted outside. One of the Engine 20 fire fighters helped assist the Engine 3
lieutenant to the front door.

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Photo 6. Photo shows U-shaped display racks built out from the Side Bravo wall that housed golf
clubs and other golfing articles. The Engine 3 lieutenant reported becoming entangled in golf
clubs in this area in near-zero visibility.
(Photo NIOSH.)

During this same time, the Engine 3 senior captain’s low-air alarm went off. The Department 7
assistant chief (Operations) told the senior captain to follow the hoseline out and to send the lieutenant
on the backup hoseline up to operate the nozzle. The senior captain began following the hoseline out.
He briefly became stuck under a clothes rack and had to extricate himself. He was completely out of
air when he made it outside.

When the Engine 3 lieutenant (out of air) arrived at the front entrance he was pulled outside by the
Engine 3 driver. The lieutenant tried to tell fire fighters on the outside that the missing Engine 3 Fire

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Fighter 2 was still somewhere inside. The Department 7 fire chief (Command) observed the Engine 3
lieutenant crawling out the front door on his hands and knees at approximately 2140 hours.

The Engine 3 senior captain who had self-extricated from the structure, quickly changed his air
cylinder and went back inside to assist with the search for the missing fire fighter.

The Engine 16 crew continued down the center of the store. They advanced in approximately 75 feet.
The Engine 16 captain observed the golf club racks along the Side C wall and then noticed a downed
fire fighter through one of the display racks. The Engine 20 crew also continued its search in the golf
store. One of the Engine 20 fire fighters heard a PASS device sounding and the Engine 20 crew
quickly assisted Engine 16 with the downed fire fighter. The Engine 3 Fire Fighter 2 was found with
his facepiece and helmet on. He was completely out of air. The Engine 20 captain radioed a Mayday
for a downed fire fighter. Dispatch directed the Mayday traffic to move to Fireground Tactical Channel
8 while the rest of the fireground communications remained on tactical channel 6. Note: When the
change of tactical channels was made, the county fire dispatch center didn’t establish the “patch” with
the city fire department that would have enabled the two fire departments to communicate directly on
the new channel. Approximately 2 minutes later, Engine 3 Fire Fighter 2 was pulled outside by the
Engine 16 and Engine 20 crews. The EMS supervisor told Command that two fire fighters were being
evaluated.

The fire was reported under control at 2157 hours.

Engine 3 Fire Fighter 2 exhibited weak agonal breathing and was cyanotic. Advanced life support
measures were immediately initiated. Engine 3 Fire Fighter 2 was transferred onto a stretcher and
loaded into an ambulance. Following locally established treatment protocols, he was transported
Priority 1 to a trauma hospital in the city approximately 15 minutes away, bypassing the closest
community hospital that was about 2 minutes from the strip mall. The Engine 3 Fire Fighter 2 went
into cardiac arrest while en route. Cardio-pulmonary resuscitation (CPR) was immediately initiated on
Engine 3 Fire Fighter 2 while en route to the hospital. After the Engine 3 Fire Fighter 2 was removed
from the structure, the Fire Chief (Command) started a personal accountability report (PAR) but a
phone call from one of the paramedics notifying the Fire Chief that the Engine 3 Fire Fighter 2 was in
critical condition interrupted the PAR and the PAR was never completed. The Engine 3 Fire Fighter 2
was pronounced dead at the hospital at 2222 hours. The Engine 3 lieutenant was transported to the
hospital and treated and released later in the day.
Note: This was the first working fire that the Engine 3 Fire Fighter 2 had made entry as part of a
hoseline crew and worked the nozzle.

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Fire Behavior
The county fire marshal’s office fire investigators determined that the fire was accidential in nature and
was likely caused by lightning striking the roof of the retail golf store near the Side Charlie/Delta
corner (at the rear) and igniting the asphalt-based roofing materials covering the metal roof deck.
Investigators from the county fire marshal’s office were able to eliminate all identifiable and potential
ignition sources during their fire scene examination.

Key factors related to fire behavior and development in this incident include the following:
• Severe thunder and lightning storms moved through the area at approximately 2000 hours.
• Police responded to the incident scene at approximatley 2103 hours for an alarm activation.
• Police officer observed light smoke around light fixtures outside the structure.
• Fire department dispatched at 2106 hours for report of a commercial structure fire.
• Fire department initially reported nothing showing then reported a working fire at 2111 hours.
• Fire department forced entry at front entrance.
• Thick, gray smoke rolled out of the store interior when the plate-glass door was opened.
• The lieutenant entered into the store a short distance, and using a thermal imager, was able to
observe high heat in the rear of the structure at the Charlie/Delta corner.
• The initial hoseline crew advanced inside about 10 feet and encountered thick, light brown
smoke banked down to the floor, creating almost zero visibility.
• Little to moderate heat was reported inside the building.
• The hoseline crew used a thermal imager to locate the fire overhead near the Charlie/Delta
corner.
• Operations chief requested rear door be opened to aid ventilation.
• Roof crews experienced difficulty in cutting through metal roof deck (see Photo 3 and Photo 4).
• Crews continued to work in near-zero visibility conditions.
• Fire burning in the void space above the drop-down ceiling.
• Fire brought under control at 2157 hours.
• Evidence shows a combustible metal deck roof fire (see Photo 7).

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Photo 7. Side C exterior wall above the rear entrance door. Note the melted asphalt that ran
down exterior wall from the roof. This is consistent with a combustible metal deck roof fire.
(NIOSH photo.)

Contributing Factors
Occupational injuries and fatalities are often the result of one or more contributing factors or key
events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH
investigators identified the following items as key contributing factors in this incident that ultimately
led to the fatality:

• Lack of crew integrity

• Inadequate air management training

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• Inexperienced fire fighter

• Ineffective fireground communications
• Failure to call a Mayday in a timely manner
• No sprinkler system in commercial structure.
• Zero-visibility conditions in smoke-filled retail store
• Restricted mobility due to arrangement of floor displays.

Cause of Death
According to the medical examiner’s report, the cause of death was inhalation of products of
combustion due to “fire fighter in structure fire.” The manner of death was listed as accidental.

Recommendations
Recommendation #1: Fire departments should ensure that crew integrity is properly maintained by
sight, voice, or radio contact when operating in an immediately-dangerous-to-life-or-health (IDLH)
atmosphere.

Discussion: Crews of fire fighters should operate as cohesive teams of at least two and remain in
contact by visual (eye-to-eye contact), verbal (by radio or by person-to-person), or direct (by touch)
contact when entering a structure or potentially hazardous area. NFPA 1500 Standard on Fire
Department Occupational Safety and Health Program states in Paragraph 8.5.5, “Crew members
operating in a hazardous area shall be in communication with each other through visual, audible, or
physical means or safety guide rope, in order to coordinate their activities” [NFPA 2013c].
Additionally, NFPA 1500 Paragraph 8.5.6 states, “Crew members shall be in proximity to each other
to provide assistance in case of an emergency” [NFPA 2013c]. The Occupational Safety and Health
Administration (OSHA), Title 29, Code of Federal Regulations (CFR), Part 1910.134(g)(4)(i) requires
that at least two fire fighters enter an IDLH environment together and remain in visual or voice contact
with each other at all times [OSHA 1998].

The International Association of Fire Chiefs, Safety, Health, and Survival Section has defined a set of
Rules of Engagement for Structural Fire-Fighting, based on nationally recognized best practices. One
of the objectives is to ensure that fire fighters always enter a burning building as a team of two or more
members and no fire fighter is allowed to be alone at any time while entering, operating in, or exiting a
building. A critical element for fire fighter survival is crew integrity. Crew integrity means fire fighters
stay together as a team of two or more. They must enter a structure together and remain together at all
times while in the interior, and all members come out together. Crew integrity starts with the company
officer ensuring that all members of the company understand their riding assignment, have the proper

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personal protective equipment, and have the proper tools to perform their job. Crew integrity continues
upon arrival at the incident, where the incident commander assigns tasks. The company officer
communicates to the members of the company what their assignment is and how they will accomplish
the assignment. Members of a company enter a hazardous environment together and should leave
together to ensure that crew integrity is maintained. If one member has to leave, the whole company
leaves together [IAFC 2012].

Every fire fighter is responsible for staying in communication with other crew members at all times.
All fire fighters must maintain the unity of command by operating under the direction of the incident
commander, division/group supervisor, or their company officer at all times. The ultimate
responsibility for crew integrity (functioning as a team, ensuring no members get separated or lost) at
the company level rests with the company officer. They must maintain constant contact with their
assigned members by visual observation, voice, or touch while operating in a hazard zone. They must
ensure they stay together as a company or crew. If any of these elements are not adhered to, crew
integrity is lost and fire fighters are placed at great risk. If a fire fighter becomes separated and cannot
re-connect with his/her crew immediately, the fire fighter must attempt to communicate via portable
radio with the company officer. If reconnection is not accomplished after three radio attempts or
reconnection does not take place within 1 minute, a Mayday should be declared. If conditions are
rapidly deteriorating, the Mayday must be declared immediately. As part of a Mayday declaration, the
fire fighter must next activate the radio’s emergency alert button (where provided), followed by
manually turning on the PASS alarm. Similarly, if the company officer or the fire fighter’s partner
recognizes they have a separated member, they must immediately attempt to locate the member by
using their radio or by voice. A Mayday must be declared immediately if contact is not established
after three attempts or within 1 minute [IAFC 2012]. Most importantly, a Mayday can be declared by
any member operating on the incident scene once they become aware that they, or any other member is
in danger and in need of assistance.

The fire department involved in this incident had standard operating procedures in place at the time of
this incident that stressed maintaining crew integrity. In this incident, Engine 3 Fire Fighter 2 ran low
on air and stated that he needed to get out of the building. His crew members attempted to calm him
down. He began to follow the hoseline out but soon became separated from the hoseline. When the
Engine 3 lieutenant also ran low on air, he told the assistant chief that he would lead the Engine 3 Fire
Fighter 2 outside. While following the hoseline, the Engine 3 lieutenant looked back to see where the
Engine 3 Fire Fighter 2 was and observed Engine 3 Fire Fighter 2 stand up and move away from the
hoseline. The lieutenant tried to catch the Fire Fighter 2 but they both ended up separated from the
hoseline. The lieutenant became disoriented and needed to be rescued by another crew. During this
incident, there were a number of other reported instances where crew integrity was not maintained.
Fire fighters were reported to be alone while searching for fire, operating hoselines and following
hoselines outside. Near-zero visibility within the structure also contributed to the fire fighters
becoming separated from crew members.

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Recommendation #2: Fire departments should ensure all fire fighters are trained on and actively
practice air management principles.

Discussion: Chief Bobby Halton, retired fire chief and current editor-in-chief of Fire Engineering
notes: “If you run out of air in a working fire today, you are in mortal danger. There is no good air at
the floor anymore, no effective filtering methods, no matter what others may say to the contrary.” The
only protection for fire fighters in the toxic smoke environments in today’s fires is the air that they
carry on their backs. Like SCUBA divers, fire fighters must manage their air effectively to leave
enough reserve air to escape in case of unforeseen occurrences while inside a structure fire. Fire
fighters must manage their air so that they leave the immediately-dangerous-to-life-or-health (IDLH)
atmosphere before the low-air alarm activates. This leaves an emergency air reserve and removes the
noise of the low-air alarm from the fireground [Gagliano et al. 2008]. Air management is a program
that the fire service can use to ensure that fire fighters have enough breathing air to complete their
primary mission and to escape an unforeseen emergency. Fire departments and fire fighters need to
recognize that the smoke in modern construction is an IDLH atmosphere and manage their air along
with their work periods so the fire fighters exit the IDLH atmosphere with their reserve air intact.
NFPA 1404 Standard for Fire Service Respiratory Protection Training states that fire fighters should
exit from an IDLH atmosphere before the consumption of reserve air supply begins; a low-air alarm is
notification that the individual is consuming the reserve air supply and activation of the reserve air
alarm requires immediate action of the individual and the fire-fighting team [NFPA 2013b].

A low-air alarm is a fireground emergency and should be treated accordingly. A crew of fire fighters
who enter an IDLH environment together can be expected to run low on air in rapid sequence as
experienced in this incident. At least three members of the initial attack crew ran completely out of air,
resulting in one death with two other fire fighters who needed assistance and could have easily been
fatalities. A low-air emergency for one crew member should be treated as an emergency for the entire
team, requiring the entire team to exit simultaneously, maintaining crew integrity.

The vast majority of the structure fires responded to are single- or multi-family residential
occupancies. For some fire departments, a typical strategy is an aggressive offensive fire fight to
achieve the tactical priorities. Generally, fire crews are able to search these structures quickly, put out
the fire, and exit the hazard zone without having to give much thought to air management. Multiple
points of egress are usually close by should a rapid retreat to the exterior become necessary. High-rise
apartment buildings, commercial structures, and large open floor plan mansions present additional
challenges that fire fighters must consider.

It's critical to ensure fire fighters exit the hazard zone with an emergency reserve of air. According to
NFPA 1404, “all members using an SCBA in the hazard zone of an incident shall monitor the amount
of air in their SCBA cylinder as well as their rate of air consumption in order to exit the hazard zone
prior to the low-air alarm activation of the SCBA” [NFPA 2013b]. Just as ocean divers are trained to
surface with an emergency reserve of air, fire fighters shall exit the hazard zone of an incident with an
emergency reserve of air. It is critical that fire fighters understand that the initial 67% of the air supply

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is the "working and exiting air" [NFPA 2013b]. This includes air used for gaining access, working
toward the tactical objectives, and exiting the hazard zone.

Company officers should frequently assess their crew's air consumption rates and decide the crew's
exit time based on the individual with the greatest assumed air consumption rate. It is the individual
fire fighter's responsibility to continually assess and report his/her air consumption to his/her company
officer.

In this incident, three members of the initial hoseline crew from Engine 3 ran completely out of air
before exiting the smoke-filled store interior. Engine 3 Fire Fighter 2, the lieutenant, and the senior
captain all ran low on air and started to exit the burning golf store after their low-air alarms went off.
The Engine 3 Fire Fighter 2 ran low on air while working the attack hoseline nozzle. The lieutenant
and senior captain tried to calm down the less-experienced fire fighter. As the lieutenant and fire
fighter attempted to follow the hoseline out, they became separated. The senior captain and lieutenant
reported that their SCBA air cylinders ran completely out of air before they exited the building. The
lieutenant had to be treated for smoke inhalation and was transported to the hospital for medical
attention. Engine 3 Fire Fighter 2 was not able to exit the building after he ran completely out of air.
All of this occurred after the Engine 3 Fire Fighter 1 ran low on air and successfully self-extricated
alone. In this case, the entire crew should have exited together when the first fire fighter ran low on air
which was a valid warning that all of the Engine 3 crew would run low on air in rapid succession.

Recommendation #3: State, local, and municipal governments, building owners, and authorities
having jurisdiction should consider requiring the use of sprinkler systems in commercial structures.

Discussion: This recommendation focuses on fire prevention and minimizing the impact of a fire if one
does occur. The National Fire Protection Association (NFPA) Fire Protection Handbook states:
“Throughout history there have been building regulations for preventing fire and restricting its spread.
Over the years these regulations have evolved into the codes and standards developed by committees
concerned with fire protection. The requirements contained in building codes are generally based upon
the known properties of materials, the hazards presented by various occupancies, and the lessons
learned from previous experiences, such as fire and natural disasters” [NFPA 2008]. Although
municipalities have adopted specific codes and standards for the design and construction of buildings,
structures erected prior to the enactment of these building codes may not be compliant. Such new and
improved codes can improve the safety of existing structures [NFPA 2008]. Sprinkler systems are one
example of a safety feature that can be retrofitted into older structures. Sprinkler systems can reduce
fire fighter and civilian fatalities since such systems can contain and may even extinguish fires prior to
the arrival of the fire department.

Fire development beyond the incipient stage is one of the greatest hazards that fire fighters face in
today’s combustible environment. This exposure and risk to fire fighters can be dramatically reduced
when fires are controlled or extinguished by automatic sprinkler systems. NFPA statistics show that
most fires in sprinklered buildings are controlled prior to fire department arrival by the activation of

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one or two sprinkler heads. The presence of automatic fire sprinklers also reduces the exposure risk to
fire fighters in rescue situations by allowing the safe egress of building occupants before the fire
department arrives on-scene. Finally, the exposure to hazards such as building collapse and overhaul
operations are greatly reduced, if not eliminated, when fire development is arrested and controlled.

The commercial strip mall involved in this incident was constructed in 1978. The fire and building
codes at that time did not require a sprinkler system. The fire started due to a lightning strike to the
roof. The fire burned in the void space between the metal roof deck and the drop ceiling for some time.
While a sprinkler system in the golf store protecting the store contents would not have initially
contained the fire, a quick-action sprinkler system in the void space above the drop ceiling would have
significantly reduced the risk to all by containing the fire to the area of origin, if not extinguished the
fire completely.

Recommendation #4: Fire departments should define fireground strategy and tactics for an
occupancy that are based upon the organization’s standard operating procedures. Incident
commanders should base the strategy and tactics on the community risk assessment, building
occupancy, pre-incident planning, critical building information system, staffing, and available
resources.

Discussion: Since no two fire departments are alike, there is no standard scale to measure and evaluate
frequency and severity of risk. Some fire departments will have a greater or lesser degree of tolerance
for risk than others. The intent of the risk management process is for a fire department to develop a
standard level of safety. This standard level of safety defines the parameters of the acceptable degree of
risk for which members perform their job functions.

By definition, frequency is how often something does, or might, happen. Severity (risk) is a measure of
the consequences if an undesirable event occurs (see Figure 1). Each risk will have its own set of
factors that will dictate how a fire department will try to determine how severe the consequences might
be. This scale is used to establish the degree of priority. Priority of the risk is in direct relation to
inherent risks that have had a harmful effect on a fire department and its members [NFA 2004].

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Figure 1.
Risk versus Frequency. Low frequency, high risk events can be especially hazardous to fire
fighters and emergency responders.

In this incident, the fire department responded to a working fire in a commercial strip mall. A working
fire in a commercial strip mall is a low frequency event with high risk to fire fighters due to
construction features that limit ingress and egress. The fire department did not have a pre-incident plan
for this structure.

Recommendation #5: Fire departments should conduct pre-incident planning inspections of

buildings within their jurisdictions to facilitate development of safe fireground strategies and
tactics.

Discussion: National Fire Protection Association (NFPA) 1620 Standard for Pre-Incident Planning,
2015 Edition, A.4.1.1 states, “a pre-incident plan is one of the most valuable tools available for aiding
responding personnel in effectively controlling an emergency.” The pre-incident plan is defined as “a
document developed by gathering general and detailed data that is used by responding personnel in

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effectively managing emergencies for the protection of occupants, responding personnel, property, and
the environment [NFPA 2015]. A pre-incident plan identifies deviations from normal operations and
can be complex and formal, or simply a notation about a particular problem, such as the presence of
flammable liquids, explosive hazards, modifications to structural building components, or structural
damage from a previous fire [Dunn 2007, NFPA 2015, NIOSH 1999].
In addition, NFPA 1620 outlines the steps involved in developing, maintaining, and using a pre-
incident plan by breaking the incident down into pre-, during- and post-incident phases. In the pre-
incident phase, for example, it covers factors such as physical elements and site considerations,
occupant considerations, protection systems and water supplies, hydrant locations, and special hazard
considerations. Building characteristics including type of construction, materials used, occupancy,
fuel load, roof and floor design, and unusual or distinguishing characteristics should be recorded,
shared with other departments who provide mutual aid, and if possible, entered into the dispatcher’s
computer so that the information is readily available if an incident is reported at the noted address.
Since many fire departments have tens and hundreds of thousands of structures within their
jurisdiction, making it impossible to pre-plan them all, priority should be given to those having
elevated or unusual fire hazards and life safety considerations. Additionally, it is important to note that
strategies and tactics employed at the emergency incident need to match the structure. The pre-plan
information can be used to help ensure that residential fire tactics are not applied at commercial
structures.

In this incident, the fire department had not conducted a formal pre-plan inspection at the structure.

Recommendation #6: Fire departments should train company officers and fire fighters to report
interior conditions to the incident commander as soon as possible and on a regular basis.

Discussion: Proper size-up and risk-versus-gain analysis requires that the incident commander (IC)
has a number of key pieces of information and be kept informed of the constantly changing conditions
on the fireground. The IC must develop and utilize a system that captures pertinent incident
information to allow continuous situational evaluation, effective decision making, and development of
an incident management structure. Decisions can be no better than the information on which they are
based. The IC must use an evaluation system that considers and accounts for changing fireground
conditions in order to stay ahead of the fire. If this is not done, the incident action plan (IAP) will be
out of sequence with the phase of the fire, and the IC will be constantly surprised by changing
conditions [Brunacini 1985; Dunn 1988; NIOSH 1999]. Interior size-up is just as important as exterior
size-up. Since the IC is staged at the command post (outside), the interior conditions should be
communicated to the IC by interior crews as soon as possible. Interior conditions could change the
IC’s strategy or tactics. Interior crews can aid the IC in this process by providing reports of the interior
conditions as soon as they enter the fire building and by providing regular updates. According to Chief
Dunn, construction features discovered in a commercial structure should be immediately
communicated to the IC. An example would be drop ceilings and other features that could hide void
spaces [Dunn 1988]. Also, NFPA 1500, Chapter 8.2, Communications, section 8.2.1, states that the fire

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department shall establish and ensure the maintenance of a fire dispatch and incident communications
system that meets the requirements of NFPA 1561 Standard on Emergency Services Incident
Management and Command Safety [NFPA 2014] and NFPA 1221 Standard for the Installation,
Maintenance, and Use of Emergency Services Communications Systems [NFPA 2013c].

Chief Brunacini states that critical fireground factors, including interior and exterior conditions, are
among the many items that the IC must consider when evaluating tactical situations. These items
provide a checklist of the major topics involved in size-up, decision making, initiating operations, and
review and revision. The IC deals with these critical factors through a systematic management process
that creates a rapid, overall evaluation; sorts out the critical factors in priority order; and then seeks out
more information about each factor. The IC must train and prepare (through practice) to engage in
conscious information management. Incident factors and their possible consequences offer the basis
for a standard incident-management approach. A standard information approach is the launching pad
for effective incident decision making and successful operational performance. The IC must develop
the habit of using the critical factors in their order of importance as the basis for assigning the specific
assignments that make up the IAP. The IC must create a standard information system and use effective
techniques to keep informed at the incident. The IC can never assume the action-oriented responder
engaged in operational activities will stop what they are doing so they can feed the IC with a
continuous supply of top-grade objective information. It is the IC’s responsibility to do whatever is
required to stay effectively informed [Brunacini 2011]. One effective strategy for obtaining important
incident-critical information is to utilize a “Conditions-Actions-Needs” or “CAN” report. This allows
the incident commander to call an interior officer and request a CAN report, prompting the officer to
respond in a standardized manner with crucial intelligence that contributes to the IC’s ability to make
informed decisions.

During this incident, roof crews reported conditions observed on the roof and this information was
considered by the IC and company officers at the scene. However, no interior condition reports were
broadcast over the radio (to the chief officers or other fire fighters) during this incident. Verbal
exchanges between the interior crews and company officers took place, but this information did not
reach the incident commander to help make tactical decisions in fighting the fire.

Recommendation #7: Fire departments should ensure that an initial risk assessment is performed
and continuous risk assessment is accomplished throughout the incident and the strategy and tactics
match the conditions encountered.

Discussion: A risk management plan ensures that the risks are evaluated and matched with the actions
and conditions. At any incident, life safety is always the first priority, followed by incident
stabilization (second priority) and then property conservation (third priority). The ability to ensure for
the safety of fire fighters is a continuous process throughout the incident. The following risk
management principles should be utilized by incident commanders:

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• Activities that present a significant risk to the safety of fire fighters should be limited to
situations that have the potential to save endangered lives.

• Activities that are routinely employed to protect property should be recognized as inherent risks
to the safety of fire fighters, and the actions should be taken to reduce or avoid these risks.

• No risk to the safety of fire fighters should be acceptable where there is no possibility to save
lives or property [Brunacini 2002].

The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and initial
report by the first arriving officer. As in this case, and at every structure fire, it is a priority that a 360-
degree size-up is included in the risk assessment. Life hazard, fire extent and location, and building
conditions are factors that need to be a part of the size-up and help to match the strategy and tactics
with the conditions encountered and this information must be continual. If a 360 degree walk around
cannot be completed, then a size-up of the areas can be accomplished through the assignment of
personnel and apparatus to divisions starting with a priority of Division C or the rear of the building.

The incident commander is responsible for evaluating conditions at a structure fire and determining the
strategy and tactics for fighting the fire. In many cases the first arriving officer is the initial incident
commander and sets in motion the strategy and tactics. Command is later passed to a higher-level
officer and a formal command is established. The incident commander needs to ensure that the strategy
and tactics are appropriate with all of the size-up factors. To accomplish this, the incident commander
should use a standardized strategic decision-making model.

First, the incident commander should size up the critical fireground factors [PFD 2009]. Before
ordering an offensive attack, the incident commander must make a determination that offensive
(interior) operations may be conducted without exceeding a reasonable degree of risk to fire fighters
and must be prepared to discontinue the offensive attack if the risk evaluation changes during the fire-
fighting operation. A full range of factors must be considered in making the risk evaluation, including
the following:
• Presence of occupants in the building
• A realistic evaluation of occupant survivability and rescue potential
• Size, construction, and use of the building
• Age and condition of the building
• Nature and value of building contents
• Location and extent of the fire within the building
• Adjacent exposures (structures)
• Fire involvement or compromise of the building’s structural components
• Residential or commercial structure
• Delayed discovery/reporting and its effect on burn time and structural stability
• Considerations of fire loading and fire behavior

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• A realistic evaluation of the ability to execute a successful offensive fire attack with the
resources that are available [PFD 2009; NIOSH 2010].

These fireground factors should be weighed against the risk management plan. Fire fighters are
routinely exposed to certain known and predictable risks while conducting operations that are directed
toward saving property. The incident commander is responsible for recognizing and evaluating those
risks and determining whether the level of risk is acceptable or unacceptable. However, risks taken to
save property should always be less than those to save lives [Grorud 2009; NIOSH 2010]. Risks to fire
fighters versus gains in saving lives and property should always be considered when deciding whether
to use an offensive or defensive attack.

The incident commander should continually match the actions against the conditions based upon
continuous reports from all operating companies. This gives the incident commander the ability to
control the situation by forecasting and staying ahead, rather than the fire dictating the actions taken.
The incident commander should routinely evaluate and re-evaluate conditions and radio progress
reports in reaching objectives to Dispatch and on-scene fire fighters. This process allows the incident
commander to determine whether to continue or revise the strategy and attack plans. Failure to revise
an inappropriate or outdated attack strategy is likely to result in an elevated risk of death or injury to
fire fighters [NFPA 2013c; PFD 2009].

The risk assessment of a building during fire-fighting operations should be continuous with building
intelligence and reconnaissance communicated on degrading conditions, fire extension and
compromise, building integrity considerations, the effects of fire spread and suppression on the interior
compartment(s), and the structural system and building envelope.

It is important that fire officers and fire fighters understand risk management principles and apply that
knowledge to modern fire conditions, especially in commercial structures.

In this incident, the fire department responded at 2106 hours on a Sunday evening to a fire in a
commercial strip mall. The front door and security gate were locked and had to be forced open to gain
access to the structure. The fire chief drove around the structure to get a full view of the building and
then established command in the parking lot at Side A. The crews entering the structure reported near-
zero visibility. The locked doors, time of day, the weekend, and few cars in the parking lot suggested
that the building was likely unoccupied. It is important to note that the building becomes an “occupied
structure” when the incident commander permits fire fighters to enter it for extinguishment purposes.
The decision to allow fire fighters to enter a burning building should be a calculated one based upon
available information, not an automatic response. The IC should have a plan (and resources) in place to
quickly and effectively remove fire fighters from the structure before allowing them to commit deeply
into a fire fight.

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Recommendation #8: Fire fighters and officers should ensure critical benchmarks, such as progress
or lack of progress, are communicated to the incident commander and that positive communication
disciplines are used.

Discussion: Fire officers and fire fighters need to understand that communicating benchmarks is
critical and radio communications are often difficult to hear and/or understand. Effective
communication involves a thorough understanding of the message. The sender transmits a clear
message and the receiver must acknowledge the transmission so the sender knows that the transmission
was understood.

Retired Fire Chief Alan Brunacini states that critical fireground factors, including interior and exterior
conditions, are among the many items that the incident commander must consider when evaluating
tactical situations. These items provide a checklist of the major issues involved in size-up, decision
making, initiating operations, and review and revision. The incident commander deals with these
critical factors through a systematic management process that creates a rapid, overall evaluation; sorts
out the critical factors in priority order; and then seeks out more information about each factor. The
incident commander should train and prepare (through practice) to engage in conscious information
management. Incident factors and their possible consequences offer the basis for a standard incident
management approach. A standard information approach is the launching pad for effective incident
decision making and successful operational performance. The incident commander should develop the
habit of using the critical factors in their order of importance as the basis for making the specific
assignments that make up the incident action plan. The incident commander should create a standard
information system and use effective techniques to keep informed at the incident. The incident
commander can never assume the action-oriented responder engaged in operational activities
will stop what they are doing so they can feed the incident commander with a continuous supply
of objective information. It is the incident commander’s responsibility to do whatever is required
to stay effectively informed [Brunacini 2002].

When using radio communication the sender and receiver are only using one of the human senses
(hearing) to communicate. Effective communication is always better when you can use more of the
human senses to communicate. This is not always practical or possible on the fire ground and it is why
positive communication discipline is required to close the communication loop. It is not a complicated
process, but frequently overlooked (positive feedback from the receiver). If the sender communicates a
message and the receiver doesn’t provide a disciplined feedback response, the sender may assume
his/her message was understood, when in fact it may never have been received or understood.

Another key point with benchmark communications is that the back and forth communications aids the
incident commander and any accountability officers on the fireground with important accountability
information such as the location and status of the crew providing the interior information. In this
incident, critical benchmark information was not communicated in a standardized manner. Critical
benchmarks that should be communicated over the fireground radio channel and communicated to
dispatch include but are not limited to:

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• On-scene arrival
• Scene size up (360 degree size up complete or communicate portion of size up
complete)
• Making entry
• Water supply established
• Hoseline charged
• Water on fire
• Fire knocked down
• Ventilation in process
• Ventilation complete (windows or doors opened, roof ventilation complete, etc.)
• Search complete
• Fire under control.

During this incident, many of these benchmarks were not communicated over the radio. Verbal
exchanges between the interior crews and company officers took place, but this information did not
reach the incident commander to help make tactical decisions in fighting the fire and to aid in
accountability.

Recommendation #9: Dispatch centers should provide timeframe benchmarks to Incident Command
on a regular basis.

Discussion: Dispatchers are a critical link in the chain of survival for fire fighters operating in
emergency situations, and an effective dispatch system is a key factor in fire department operations.
The central dispatch center is used for receiving notification of emergencies, alerting personnel and
dispatching equipment, coordinating the activities of the units engaged in emergency incidents, and
providing non-emergency communications for the coordinating fire departments [IFSTA 1998; NFPA
1997, 2013c]. The dispatch system must be able in advance to identify the type and number of units
due to respond to the type of incident based on risk criteria and unit capabilities [NFPA 2014].

Central Dispatch should be staffed with operators who are trained to understand fire department
operations, terminology, and the role the operator plays in fire fighter survival. Central Dispatch could
then also monitor fireground activity and inform Command of time intervals and of possible missed
transmissions, such as Maydays. Dispatchers are in a position to objectively monitor and report time
intervals (e.g., every 10 minutes). Such time intervals are critical as most Mayday events occur within
the first 10 – 15 minutes of fire fighting operations, coincident with the expected effective available air
in an SCBA cylinder used by a fire fighter doing moderate work. A central dispatch center equipped
with regional mutual aid channels could serve multiple jurisdictions. This type of system would
provide operational advantages in the communication system, reflect a more functional mutual aid
system, and reduce overall costs of operating centers in individual jurisdictions [Sealy 2003]. Dispatch
centers need to evaluate their role in fireground operations. In addition to providing timeframe
benchmark reports to the incident commander, Dispatch can play an important role in prompting

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Command to consider building evacuations, providing building evacuation tones, giving prompts on
whether or not to change radio channels during a Mayday, and many other important issues that
directly affect fire fighter safety and health.

In this incident, the fire department and the dispatch center did not have a procedure for broadcasting
automatic time interval updates over the fireground channel. Dispatch did not provide Command with
benchmark time references (i.e., 10 minutes on-scene, 20 minutes on-scene, etc.).

Recommendation #10: Fire departments should ensure that Mayday training programs are
developed and implemented so that fire fighters are adequately prepared to call a Mayday.
Discussion: The highest priority in fire fighter safety is avoiding situations that render responders
unable to perform their duties effectively. The fire fighter must maintain situational awareness at all
times while operating on the fireground. Fire fighters must understand that when they are faced with a
life-threatening emergency, there is a very narrow window of survivability, and any delay in egress
and/or transmission of a Mayday message reduces the chance for a successful rescue. Knowledge and
skill training on how to prevent a Mayday situation and how to call a Mayday should begin and be
mastered before a fire fighter engages in fireground activities or other immediately-dangerous-to-life-
or-health environments. Mayday training should include utilizing a standard pneumonic that is
practiced regularly. One example is L-U-N-A-R (Location, Unit, Name, Assignment and Air,
Resources). Calling a Mayday is not intuitive. Fire fighters must, from a very early point in their basic
training, understand the circumstances under which they should call a Mayday. This can and should be
accomplished through non-IDLH scenario-based training that mimics circumstances a fire fighter is
expected to encounter [Clark 2005, 2008].

Beginner fire fighter training programs should include training on such topics as air management;
familiarity with an SCBA, a radio, and personal protective equipment; crew integrity; reading smoke,
fire dynamics, and fire behavior; entanglement hazards; building construction; and signs of pending
structural collapse. Fire fighters must be able to recognize when they find themselves in a questionable
position (whether immediately dangerous or not) and be trained on procedures for when and how a
Mayday should be called. A fire fighter’s knowledge, skill, and ability to declare a Mayday must be at
the mastery level of performance. This performance level should be maintained throughout their career
through training offered more frequently than annually [IAFF 2012].

Fire departments must understand that each fire fighter may have a different interpretation of what is
life-threatening. The ability of a fire fighter to call a Mayday is a complicated behavior that includes
the affective, cognitive, and psychomotor domains of learning and performance [Clark 2005;
Grossman and Christensen 2008]. Any delay in calling a Mayday reduces the chance of survival and
increases the risk to other fire fighters trying to rescue the downed fire fighter. This incident illustrates
the need for fire fighters to be given specific training on determining when a Mayday must be called.

No rules are established for determining when a Mayday must be called, and Mayday training is not
included in the job performance requirements in NFPA Fire Fighter I or II standards. It is up to the

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authority having jurisdiction to train members for emergency operations [NFPA 2013a,c] and to
develop rules and performance standards for a fire fighter to call a Mayday. The National Fire
Academy (NFA) has an on-line course addressing the fire fighter Mayday doctrine: Q133 Firefighter
Safety, Calling the Mayday, a 2-hour program covering the cognitive and affective learning domain of
the fire fighter Mayday doctrine [Clark 2005]. The NFA course H0134 Calling the Mayday: Hands-on
Training, an 8-hour course covering the psychomotor learning domain of the fire fighter Mayday
doctrine, was handed off to state fire training academies and metro fire departments [Clark 2008].
These courses are based on the military methodology used to develop and teach ejection doctrine to
fighter pilots. The NFA Mayday courses present specific Mayday parameters or rules for determining
when a fire fighter must call a Mayday. The courses may help fire departments in developing and
teaching Mayday procedures for fire fighters. Also, NFPA 1001 Standard for Fire Fighter
Professional Qualifications includes job performance requirements related to the fire fighter calling for
assistance (such as a Mayday situation) [NFPA 2013a].

The International Association of Fire Fighters (IAFF) Fire Ground Survival program is another
resource for fire departments and was developed to ensure that training for Mayday prevention and
Mayday operations is consistent among all fire fighters, company officers, and chief officers [IAFF
2012].

Any Mayday communication must contain the location of the fire fighter in as much detail as possible
and, at a minimum, should include the division (floor) and quadrant. It is imperative that fire fighters
always know their location when in IDLH environments to effectively be able to give their location in
the event of a Mayday. Once in distress, fire fighters must immediately declare a Mayday. The
following example uses LUNAR (Location, Unit, Name, Assignment/Air, Resources needed) as a
prompt: "Mayday, Mayday, Mayday, Division 1 Quadrant C, Engine 71, Smith, search/out of
air/vomited, can't find exit." When in trouble, a fire fighter's first action must be to declare the Mayday
as accurately as possible. Once the incident commander and rapid intervention team (RIT) know the
fire fighter's location, the fire fighter can then try to fix the problem, such as clearing the nose cup,
while the RIT is en route for rescue [USFA 2006].

A fire fighter who is breathing carbon monoxide (CO) quickly loses cognitive ability to communicate
correctly and can unknowingly move away from an exit, other fire fighters, or safety before becoming
unconscious. Without the accurate location of a downed fire fighter, the speed at which the RIT can
find them is diminished, and the window of survivability closes quickly because of lack of oxygen and
high CO concentrations in an IDLH environment [Clark 2005, 2008; USFA 2006].

In this incident, the Engine 3 Fire Fighter 2 and the Engine 3 lieutenant became separated from the
hoseline while attempting to exit the fire building, became disoriented, and could not exit. The Engine
3 lieutenant did not have a radio so he could not call a Mayday. The Engine 3 Fire Fighter 2 had a
radio but did not use it. It was reported that during this incident, the Engine 3 Fire Fighter 2 was
operating on a hoseline in the interior of a burning structure fire for the first time.

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Recommendation #11: Fire departments should ensure that fire fighters are trained and proficient
on following hoselines outside as a means for egress and self-rescue.

Discussion: Fire fighters should always work and remain in teams whenever they are operating in a
hazardous environment. Team integrity depends on team members knowing who is on their team and
who is the team leader; staying within visual contact at all times (if visibility is low, teams must stay
within touch or voice distance of each other); communicating needs and observations to the team
leader; and rotating together for team rehab, team staging, and watching out for each other (e.g.,
practicing a strong buddy system). Following these basic rules helps prevent serious injury or even
death by providing personnel with the added safety net of fellow team members. Teams that enter a
hazardous environment together should leave together to ensure that team continuity is maintained.

Hoselines can be the last line of defense and the last chance for a lost fire fighter to find egress from a
burning building. According to the USFA Special Report, Rapid Intervention Teams and How to Avoid
Needing Them, the basic techniques taught during entry-level fire-fighting programs describe how to
escape a zero-visibility environment using only a hoseline [USFA 2003]. However, as years elapse
from the time of basic training, fire fighters may overlook this technique. Exiting a structure in zero
visibility should be simple, fast, and easy for a fire fighter with a hoseline based on training and
experience to build muscle-memory. A fire fighter operating on a hoseline should search along the
hose until a coupling is found. Once found, the fire fighter can "read" the coupling and determine the
male and female ends. The IFSTA manual Essentials of Fire Fighting teaches that the female coupling
is on the nozzle side of the set and the male is on the water side of the set. In most cases, the male
coupling has lugs on its shank while the female does not. Once oriented on the hose, fire fighters can
follow the hoseline in the direction away from the male coupling which will take them toward the exit
(see Diagram 1)[IFSTA 1998, NIOSH 2009]. A fire hose can also be marked in a number of ways that
will indicate the direction to the exit, including the use of raised arrows and chevrons that provide both
visual and tactile indicators. Fire departments may use a variety of techniques to train fire fighters on
how to identify hoseline couplings and the direction to the exit, based on the model of hose used by the
department. The key point is that this training needs to be conducted and repeated often so that fire
fighters are proficient in identifying the direction to the exit in zero-visibility conditions while wearing
gloves, when the hose is entangled, and with various obstructions present. This procedure should be
incorporated into standard operating procedures, trained upon, and enforced on the fireground.

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Diagram1. Hose couplings will indicate the direction toward the exit.
(Adapted from IFSTA Essentials of Fire Fighting, 4th Edition.)

In this incident, Engine 3 Fire Fighter 2 ran low on air and told his crew members that he needed to get
out. He began following the hoseline but soon lost contact with the hoseline due to the arrangement of
the display racks in the store. The other crew members attempted to calm him down. The Engine 3
lieutenant also ran low on air and stated that he would take the fire fighter outside. The Engine 3
lieutenant and fire fighter again began to follow the hoseline outside. The lieutenant turned around to
check on the fire fighter and noticed that he was standing up and soon disappeared into the near-zero
visibility conditions within the store. The lieutenant soon lost contact with the hoseline. Both Fire
Fighter 2 (the victim) and lieutenant ran completely out of air. The Engine 16 crew heard the lieutenant
yelling for help, was able to locate him, and assist him outside. The Engine 3 Fire Fighter 2 was
located about 2 minutes later. Fire Fighter 2 was immediately transported to a hospital but did not
survive his injuries. The lieutenant was treated and released.

Recommendation #12: Fire departments should ensure that fire fighters are trained in fireground
survival procedures.

Discussion: As part of emergency procedures training, fire fighters need to understand that their
personal protective equipment and SCBA (PPE) do not provide unlimited protection. PPE that is not
properly donned, worn, or activated may provide reduced protection or no protection at all. In such
cases, delay in egress to transmit a Mayday message may be fatal. However, the Mayday message
should be transmitted as soon as the crew is in a defensible position. The International Association of
Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) have developed the IAFF

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Fire Ground Survival program to ensure that training for Mayday prevention and Mayday operations
are consistent between all fire fighters, company officers, and chief officers [IAFF 2012]. Fire fighters
must act promptly when they become lost, disoriented, injured, low on air, or trapped [Angulo et al.
2004; Carter el al. 2000; DiBernardo 2003; Hoffman 2002; Miles and Tobin 2004; Sendelbach 2004].

After quickly assessing the tenability of their location, the fire fighter must transmit a Mayday while
they still have the capability and sufficient air, noting their location if possible. As noted above, fire
fighters may need to move away from untenable fire conditions before calling the Mayday. The next
step is to manually activate their personal alert safety system (PASS) device. To conserve air while
waiting to be rescued, fire fighters should try to stay calm, be focused on their situation and avoid
unnecessary physical activity. They should survey their surroundings to get their bearings and
determine potential escape routes such as windows, doors, hallways, and changes in flooring surfaces,
and stay in radio contact with the incident commander and other rescuers. Additionally, fire fighters
can attract attention by maximizing the sound of their PASS device (e.g., by pointing it in an open
direction), pointing their flashlight toward the ceiling or moving it around, and using a tool to make
tapping noises on the floor or wall.

A crew member who initiates a Mayday call for another person should quickly try to communicate
with the missing member via radio and, if unsuccessful, initiate another Mayday providing relevant
information on the missing fire fighter’s last known location. Training should include situations
dealing with “uncontrolled” SCBA emergencies, egress through small openings, emergency window
egress, building collapse, and other situations that could be encountered during a Mayday situation.

Additional emphasis must be placed on appropriate procedures for tactical withdrawal under
worsening fire conditions and/or pending building collapse [Dodson 2005]. The use of an operational
retreat is designed to quickly remove fire fighters from operations in an unsafe or potentially unsafe
environment. The incident commander shall initiate an operational retreat whenever the operational
area is deemed unsafe for emergency personnel. All personnel operating in the unsafe area shall
evacuate as the operational retreat procedures are initiated. Operational retreat shall begin with radio
traffic announcing “EMERGENCY TRAFFIC” with directions for all emergency personnel to
evacuate the operational area. An emergency egress signal shall be sounded. An example of an
emergency egress signal would be 10 seconds of short air horn blasts, followed by 10 seconds of
silence, with the sequence repeated three times.

Upon hearing the operational retreat signal, all fire fighters should immediately withdraw from any
operations they are performing and leave the operational area. All company officers should
immediately perform a personnel accountability report (PAR) of all personnel they are responsible for
and report the results to the incident commander.

In addition, fire fighters need to understand the psychological and physiological effects of the extreme
level of stress encountered when they become lost, disoriented, injured, run low on air, or trapped
during rapid fire progress. Most fire training curriculums do not include discussion of the

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psychological and physiological effects of extreme stress such as encountered in an imminently life
threatening situation, nor do they address key survival skills necessary for effective response.
Understanding the psychology and physiology involved is an essential step in developing appropriate
responses to life-threatening situations. Reaction to the extreme stress of a life-threatening situation
(such as being trapped by extreme fire behavior or building collapse) can result in sensory distortions
and decreased cognitive processing capability [Grossman and Christensen 2008].

As noted, training is frequently limited to breathing apparatus emergencies, egress through small
openings, emergency window egress, etc. Additional emphasis must be placed on appropriate
procedures for tactical withdrawal under worsening fire conditions and structural collapse situations.
Modern self-contained breathing apparatus (SCBA) contain a feature known as the “emergency escape
breathing support system” or EBSS. This system allows the “donor” fire fighter to transfer some of the
air in their SCBA cylinder to a “receiver” fire fighter who may be low on air, injured, trapped, or
otherwise in distress. The decision to use the EBSS is a conscious one made under extremely harsh and
hazardous conditions. If the fire department supports the use of EBSS, all fire fighters need to be
thoroughly trained in its effective use.

In this incident, the Engine 3 Fire Fighter 2 did not transmit a Mayday message. A Mayday was not
transmitted until after the Engine 3 lieutenant came outside and the missing Engine 3 Fire Fighter 2
was discovered by the Engine 16 and Engine 20 crews. The Engine 3 lieutenant did not have his radio
with him while he was inside the structure. The Mayday was transmitted by the Engine 20 captain
when the missing fire fighter was located.

Recommendation #13: Fire departments should ensure that appropriate staffing levels are available
on-scene to accomplish fireground tasks and be available for unexpected emergencies including the
establishment of a dedicated rapid intervention crew (RIC) or team (RIT).

Discussion: Adequate resources are needed at incident scenes to ensure rapid incident stabilization and
to promote fire fighter safety. A department should pre-plan the tasks that may be performed at any
structural fire prior to response and develop response packages to address the tasks. From determining
the required fire flow, to stretching hoselines, forcing entry, search, rescue, extinguishment and much
more, fire departments should consider what the staffing needs are in order to simultaneously perform
these tasks. The planning for the first-alarm assignment needs to include sufficient additional
unassigned fire fighters to be on-scene, staged and ready to assist with fireground operations in the
event of an emergency or to allow for on-scene fire fighter rehabilitation. Incident commanders should
recognize the limits of available resources to complete fireground tasks and adjust their desired action
plan to coincide with resources on hand.

In addition, a study released by the National Institute for Standards and Technology (NIST), Report on
Residential Fireground Field Experiments, concluded that a three-person crew started and completed a
primary search and rescue 25% faster than a two-person crew and that a four or five-person crew
started and completed a primary search and rescue 6% faster than a three-person crew [NIST 2010].

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In order to ensure compliance with 29 CFR 1910.134, Respiratory Protection, [OSHA 1998] fire
departments must maintain a rapid intervention crew or company when members are operating in an
immediately dangerous to life and health (IDLH) or potentially IDLH atmosphere.

The RIC function should be incorporated into the department’s incident management system and the
personnel accountability system [NFPA 2014]. Critical fireground operations and staffing needs should
be continuously evaluated in regards to fire fighter safety. Resource assignments should be made with
the goal of having the RIC function in place at all times. When the incident commander needs
additional resources, the consideration of deploying the rapid intervention team for an operational
assignment without additional resources on-scene to function as a RIC should be carefully assessed
[NFPA 2014].

The following restrictions regarding the use of a RIC should be considered by the incident commander
during fireground operations:
• The RIC should not be used for fire-fighting operations.
• The RIC is dedicated to assist, and if necessary, rescue members who become trapped,
distressed, or involved in other serious life-threatening situations.
• The RIC should not be used to provide relief for operating companies until the fire/incident has
been declared “Under Control” by Command.
• If assigned by a superior officer to other than RIC duties, the RIC unit officer should remind
such officer of RIC designation [Toledo Fire & Rescue Department 2012; TSFRS 2014].

When the incident commander orders the RIC to work, the incident commander should immediately
assign another on-scene company to stand by as the RIC. At a minimum, the incident commander
should request an additional alarm and designate a company or companies to function as RIC. The
remainder of the companies should report to staging. If no units are available, the incident commander
should assign at least two members to act as a rapid intervention team while awaiting a special-called
RIC to arrive. An engine company may be designated as the RIC pending arrival of an additional
ladder company or rescue company. This ensures compliance with OSHA’s “Two In/Two Out” rule
under 29 CFR 1910.134, Respiratory Protection [OSHA 1998].

Upon deploying a RIC, the incident commander must expand the Incident Action Plan or IAP to reflect
a high-priority rescue effort, focusing resources on the simultaneous tasks of controlling the fire and
rescuing the endangered fire fighter(s). Such changes in the IAP need to be announced over the radio
so that everyone on the incident scene and in the Dispatch Center, understands what is happening.
Consideration should be given to expanding the Incident Organizational Structure to include a Rescue
Branch (focused on RIC activities) and a Suppression Branch (focused on fire fighting). In this way,
Command assigns a Branch Director (a Chief Officer) to each branch and addresses both functions
requiring immediate attention. This action also reduces the likelihood of overwhelming the incident
commander with “task saturation,” a condition in which auditory and sensory inputs overload an
individual’s ability to maintain situational awareness, leading to a failure at the command level.

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Many fire departments have a defined response plan for the dispatch of an additional company (engine,
truck, squad, or rescue) to respond to an incident and stand by as the rapid intervention team. Based
upon the complexity, magnitude, configuration of the structure, or geographical layout of the incident,
the incident commander may deploy additional RIC by location or function [NFPA 2014].

Upon arrival or upon appointment, the RIC officer should confer with the incident commander. The
RIC officer should establish an area to stage the RIC and the necessary RIC equipment. The RIC
equipment should include:
• A tool staging tarp
• Rescue SCBA (RIC Pack)
• Forcible entry tools such as a Halligan bar or other pry tool
• Stokes basket
• 150-foot rope for search and rescue
• Wire cutters
• Rebar cutter
• Saws
• Thermal imager
• Emergency strobe lights
• Life-saving rope/life belt
• Elevator keys for buildings with elevators [FDNY 2011; LAFD 2001; TSFRS 2014].

It is important to stage all necessary RIC equipment in an expedient manner (see Photo 8). The RIC
officer (equipped with a thermal imager), accompanied by one member of the RIC, should perform an
incident scene survey while the remaining RIC members assemble the RIC equipment. If the size of
the structure negates a 360-degree survey of the building, this fact should be relayed to the incident
commander as soon as possible. This should be a benchmark for Command to designate another RIC
in order to effectively cover all sides of the building.

During this survey, the RIC officer and members should look for ways in and out of the structure,
including window configuration, fire escapes, and construction features. The RIC officer should note
the feasibility for placement of ground ladders for rescue or escape purposes. The RIC officer should
be responsible for setting up and securing a suitable secondary egress for interior crews. This may
include laddering multiple sides of the structure. Once the RIC has determined the need for an egress
ladder, the window glass should be removed. This should only be done after conferring with Command
that the removal of the window will not affect fire fighting operations. Once approved by Command,
the egress ladder should be placed at the window. The location of the egress ladder(s) shall be
announced over the radio by the RIC officer [Toledo Fire & Rescue Department 2012].

After the above tasks are completed, the RIC officer should inform Command that a 360-degree survey
is complete and the RIC is ready to intervene, if necessary. Once the incident scene survey has been

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completed and the RIC equipment is in place, the entire RIC should be located in an area immediately
accessible to the building in order for rapid deployment plus maintaining radio contact with Command.
The RIC officer should brief all members of the RIC as to the results of his/her incident scene survey.
The RIC should operate as one unit. Additional crews may be added to or in support of the team as
necessary. When more than one company is added as part of the rapid intervention team, a rescue
group should be formed with a rescue group supervisor [Toledo Fire & Rescue Department 2012].

Photo 8. This is an example of the equipment needed for rapid intervention crew (RIC)
operations. One of the most important pieces of equipment is the strobe light, which can be
used to identify/mark an exit in a building in the event a rapid egress is needed by a fire
fighter or fire fighters.
(Photo courtesy of the Google Bing.com Free Photo Search.)

The RIC officer and RIC members will coordinate with Command to formulate rescue plan
contingencies and continue to monitor the radio and fireground conditions. RIC protection is not a
passive assignment. This is a process of ongoing information gathering and diligent scene monitoring
until the unit is released by the incident commander. The RIC function is a critical component for fire
fighter safety.

In this incident, a dedicated rapid interview crew was never established.

Recommendation #14: Fire departments should provide all fire fighters with radios and train them
on their proper use.

Discussion: In September 2003, NIOSH released the document, Current Status, Knowledge Gaps, and
Research Needs Pertaining to Firefighter Radio Communication Systems [TriData 2003]. Page 13
states: “It is critical for firefighters to communicate with one another within a structure and with units

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operating outside the structure, regardless of the building construction.” The best way this can be done
when crews are separated or in trouble is through the use of a personal portable radio.

National Fire Protection Association (NFPA) 1561, Standard on Emergency Services Incident
Management System and Command Safety, Section 6.3 Emergency Traffic, states in section 6.3.1: “To
enable responders to be notified of an emergency condition or situation when they are assigned to an
area designated as immediately dangerous to life or health (IDLH), at least one responder on each crew
or company shall be equipped with a portable radio and each responder on the crew or company shall
be equipped with either a portable radio or another means of electronic communication” [NFPA 2014].
The joint U.S. Fire administration (USFA) and International Association of Fire Fighters (IAFF)
report, Voice Radio Communications Guide for the Fire Service [USFA/IAFF 2008, 2016], provides an
overview of radio communication issues involving the fire service. Effective fireground radio
communication is an important tool to ensure fireground command and control as well as helping to
enhance fire fighter safety and health. Every fire fighter on the fireground should be provided with
their own radio in case they become lost or separated from their crew. It is every fire fighter’s and
company officer’s responsibility to ensure radios are properly used. Ensuring appropriate radio use
involves both taking personal responsibility (to have your radio, having it on, and on the correct
channel) and a crew-based responsibility to ensure that the other members of your crew are doing so as
well. Radios should be designed and positioned to allow the fire fighter to monitor and transmit a clear
message. These radios should be well maintained and inspected by qualified personnel on a regular
basis.

The fire department involved in this incident typically issues a radio to every fire fighter. In this
incident, the Engine 3 lieutenant dropped his radio while donning his personal protective clothing and
equipment inside Engine 3 while en route to the fire. The lieutenant was not able to locate his radio in
a timely manner and entered the structure without his radio. During interviews, other fire fighters
reported to NIOSH investigators that they were working inside the structure and did not have a
portable radio.

Both the International Association of Fire Chiefs (IAFC) [IAFC 2009] and the International
Association of Fire Fighters (IAFF) [USFA/IAFF 2008] recommend that all fire fighters be assigned a
radio. In 1999, the U.S. Fire Administration technical report Improving Firefighter Communications
identified a number of radio communication issues, including the need for all fire fighters to have
portable radios. The report stated “Ideally, every firefighter working in a hostile environment should
have a portable radio with emergency distress feature [USFA 1999].” The IAFF Fireground Survival
Program contains training on radio communication procedures in emergency operations including how
to call a Mayday [IAFF 2012].

Issuing a radio to every fire fighter is not enough. Training must accompany any effort to improve
fireground communication. First and foremost, the fireground radio frequency can become congested,
especially during the early stages when the incident is not yet under control. As such, radio discipline
is important and messages should be limited to those of an important tactical nature (Conditions-

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Actions-Needs or CAN report), accountability (PAR) report, and fireground emergencies (Mayday).
Second, training must also encompass circumstances when an incident commander opts to change
radio frequencies. This is a potentially dangerous action and should only be undertaken in the most
extreme circumstances given the possibility of “losing” personnel in the movement from one channel
to another. After switching frequencies, command should conduct a PAR to confirm that the
appropriate units are operating on the correct channel.

Recommendation #15: Standard setting organizations, enforcement agencies, and authorities

having jurisdiction should consider developing, implementing, and enforcing national fire fighter
and fire officer training standards and requirements.

Discussion: Most large and metropolitan fire departments have dedicated resources that establish
training requirements and curriculum meeting the needs of the location and population served. Smaller
departments (paid, combination, or volunteer) may have limited resources to devote to training
purposes. Most states delegate the actual training requirements to the fire chief or the authority having
jurisdiction over the fire department. The result is that training requirements, and thus the training
itself, varies widely from location to location across the United States.

Standard setting organizations, states, and authorities having jurisdiction should consider developing
national standards so that fire fighters across the United States are trained to the same minimum levels.
Additionally, combination and volunteer fire departments should ensure that all members, regardless of
pay status, are trained to identical standards. Departments should not rely on other agencies to ensure
training is provided. Although company-level (hands-on) training is critical, it should not replace
formal training and certification. The fire does not differentiate between well-trained, experienced fire
fighters and those less experienced and trained. There is a dramatic difference between a 20-year
veteran fire fighter in an urban setting and a recently graduated rookie fire fighter from any
department, regardless of size. At its core, probationary fire fighter training programs are designed to
produce fire fighters who are prepared to function as a member of a team, not independently. Such fire
fighters rely on their company officers to ensure their safety while operating in an IDLH environment.

In this incident, the volunteer fire department involved had numerous members who also worked full-
time for the adjoining career metropolitan department where training standards were extensive. This
created a circumstance under which some members of the department received formal training from
the career department that was significantly different from that received by volunteer members. The
unintended result may have led to unrealistic (and even unconscious) expectations being placed on
newer, less experienced members. The Engine 3 Fire Fighter 2 encountered conditions that he may not
have been sufficiently trained and experienced to deal with. It was reported that this was the first
working fire that the Engine 3, Fire Fighter 2 had made entry as part of a hoseline crew and worked the
nozzle.

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Recommendation #16: Fire departments should utilize a functional personnel accountability system,
requiring a check-in and check-out procedure with the designated accountability officer or incident
commander.

Discussion: Although there is no clear evidence that fireground accountability was a contributing
factor in this incident, this recommendation is provided as a reminder of recommended best practices
for the fire service. Fire departments should review existing personnel accountability procedures to
ensure that they are functional and effective. If no personnel accountability procedures exist, the fire
department should develop, implement, and enforce standard operating procedures that ensure a
personnel accountability system is utilized at all emergency operations. The National Fire Protection
Association (NFPA) 1561 Standard on Emergency Services Incident Management System (2014
edition), Section 4.5.1 states that the emergency services organization shall develop and routinely use a
system to maintain accountability for all resources assigned to the incident with special emphasis on
the accountability of personnel. Section 4.5.3 states that the system shall include a specific means to
identify and keep track of responders entering and leaving hazardous areas, especially where special
protective equipment is required. Section 4.5.10 states that responders who arrive at an incident in or
on marked apparatus shall be identified by a system that provides an accurate accounting of the
responders on each apparatus [NFPA 2014]. NFPA 1500, Standard on Fire Department Occupational
Safety and Health Program, Section 8.4 identifies requirements for personnel accountability during
emergency operations. Section 8.4.1 states that the fire department shall establish written standard
operating procedures for a personnel accountability system that is in accordance with NFPA 1561,
[NFPA 2013c, 2014]. Section 8.4.4 of NFPA 1500 states that the incident commander shall maintain
an awareness of the location and function of all companies or crews at the scene of the incident.

Personnel accountability systems can range in complexity from simple identification tags to complex
electronic tracking systems. A variety of different personnel accountability systems have been used at
emergency operations across the country. At emergency response incidents involving volunteer and
combination fire departments, all emergency responders who respond in their privately-owned-
vehicles should be required to immediately report to the incident command post and check in face-to-
face with Command or the designated accountability officer prior to engaging in incident activities.

The fire department involved in this incident had written standard operating procedures defining a
personnel accountability system intended to meet the requirements of NFPA 1500 and NFPA 1561.
The written procedures specified that the incident commander shall be responsible for overall
personnel accountability for the incident and that the incident commander shall maintain an awareness
of the location and function of all companies or units at the scene of the incident. The procedures also
stated that the incident commander shall provide the use of additional accountability officers based on
the size, complexity, or needs of the incident.

During this incident, the first-due fire department was dispatched and upon arrival, confirmed a
working fire. The Department 7 fire chief (incident commander) requested a full alarm assignment
from the mutual aid career department. A battalion chief from the mutual aid department arrived on

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scene and assisted Command with accountability. A number of volunteer fire fighters responded to the
incident via their privately-owned-vehicles and became integrated into the emergency response.

References
Angulo RA, Clark BA, Auch S [2004]. You called Mayday! Now what? Fire Engineering 157(9):93–
95.
Brunacini AV [1985]. Fire command. Quincy, MA: National Fire Protection Association.
Brunacini AV [2002]. Fire command. Quincy, MA: National Fire Protection Association.
Brunacini AV [2011]. Critical fireground factors. Fire Engineering, June: 42–43.
Carter W, Childress D, Coleman R, et al. [2000]. Firefighter’s Handbook: Essentials of firefighting and
emergency response. Albany, NY: Delmar Thompson Learning.
Clark BA [2005]. 500 Maydays called in rookie school. Firehouse.com.
Clark BA [2008]. Leadership on the line: Firefighter Mayday doctrine where are we now? Firehouse.com.
DiBernardo JP [2003]. A missing firefighter: Give the Mayday. Firehouse, Nov: 68–70.
Dodson D [2005]. The art of first-due. Fire Engineering, March: 135–141.
Dunn V [1988]. Collapse of burning buildings: A guide to fireground safety. Saddle Brook, NJ: Fire
Engineering Books and Videos.
Dunn V [2007]. Strategy of firefighting. Saddlebrook NJ: Penn Well Publishing Co.
FDNY [2011]. Fire fighter assist and search team. In: Managing members in distress. New York: Fire
Department of New York.
Gagliano M, Phillips C, Jose P, Bernocco S [2008]. Air management for the fire service. Tulsa, OK:
Penn Well Corporation, Fire Engineering.
Grorud LJ [2009]. Written comment to NIOSH Docket #141, March 3.
Grossman D, Christensen L [2008]. On combat: The psychology and physiology of deadly conflict in
war and peace. 3rd ed. Millstadt, IL: Warrior Science Publications.
Hoffman JJ [2002]. MAYDAY-MAYDAY-MAYDAY. Fire Department Safety Officers Association
health and safety for fire and emergency service personnel, 13(4):8.
IAFC [2009]. Position statement: Assignment of portable radios/two-way communications devices to
every firefighter on the fireground. Fairfax, VA: International Association of Fire Chiefs.
IAFC [2012]. Rules of engagement for structural firefighting. Fairfax VA: International Association of
Fire Chiefs, Safety, Health and Survival Section.
IAFF [2012]. IAFF Fire Ground Survival Program. Washington, DC: International Association of Fire
Fighters.

Page 44
 Report # F2016-07
Volunteer Fire Fighter Dies After Running Out of Air and Becoming
Disoriented in Retail Store in Strip Mall Fire—North Carolina

IFSTA [1998]. Essentials of fire fighting. 4th ed. Stillwater, OK: Oklahoma State University,
International Fire Service Training Association.
LAFD [2001]. Rapid intervention company, fireground safety and incident accountability. Los
Angeles, CA: Los Angeles Fire Department.
Miles J, Tobin J [2004]. Training notebook: Mayday and urgent messages. Fire Engineering 157(4):22.
NFA [2004]. Incident safety officer (ISO). Emmitsburg, MD: Federal Emergency Management
Agency, United States Fire Administration, National Fire Academy.
NFPA [1997]. Fire protection handbook. 18th ed. Quincy, MA: National Fire Protection Association.
NFPA [2008]. Fire Protection Handbook. 20th ed. Quincy, MA: National Fire Protection Association.
NFPA [2012]. NFPA 1403 Standard on live fire training evolutions. Quincy, MA: National Fire
Protection Association.
NFPA [2013a]. NFPA 1001 Standard for fire fighter professional qualifications. Quincy, MA: National
Fire Protection Association.
NFPA [2013b]. NFPA 1404 Standard for fire service respiratory protection training. Quincy, MA:
National Fire Protection Association.
NFPA [2013c]. NFPA 1500 Standard on fire department occupational safety and health program.
Quincy, MA: National Fire Protection Association.
NFPA [2014]. NFPA 1561: Standard on emergency services incident management system and
command safety. Quincy, MA: National Fire Protection Association.
NFPA [2015]. NFPA 1620 Standard for pre-incident planning. Quincy, MA: National Fire Protection
Association.
NIOSH [1999]. NIOSH Alert: Request for assistance in preventing injuries and deaths of fire fighters
due to structural collapse. Cincinnati, OH: U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS
(NIOSH) Publication No. 99-146.
NIOSH [2009]. A career captain and a part-time fire fighter die in a residential floor collapse—Ohio.
Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Institute for Occupational Safety and Health, FACE Report F2008-09,
NIOSH [2010]. Preventing deaths and injuries of fire fighters using risk management principles at
structure fires. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH)
Publication No.2010-153.
NIST [2010]. Report on residential fireground field experiments. Gaithersburg, MD: National Institute
of Standards and Technology, NIST Technical Note 1661.

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Volunteer Fire Fighter Dies After Running Out of Air and Becoming
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OSHA [1998]. 29 CFR Parts 1910 and 1926 Respiratory Protection; Final Rule. Federal Register
Notice 1218-AA05. Vol. 63, No. 5. January 8, 1998. U.S. Department of Labor, Occupational Safety
and Health Administration. Washington DC.
PFD [2009]. Written comment to NIOSH Docket #141. Phoenix Fire Department, Phoenix, AZ, March
9.
Sealy CL [2003]. Multi-company training: Part 1. Firehouse, February.
Sendelbach TE [2003]. Managing the fireground Mayday: The critical link to firefighter survival.
Firehouse.com, May 8. http://www.firehouse.com/article/10541890/managing-the-fireground-mayday.
Date accessed: October 2017.
Toledo Fire & Rescue Department [2012]. Rapid intervention team (RIT) standard operating procedure
C82. Toledo, OH: Toledo Fire & Rescue Department.
TriData Corporation [2003]. Current status, knowledge gaps, and research needs pertaining to fire
fighter radio communication systems. Report prepared for NIOSH. Arlington, VA: TriData
Corporation.
TSFRS [2014]. Rapid intervention team, interim procedure 2014-003. West Lawn, PA: Township of
Spring Fire & Rescue.
USFA [1999]. Special report: improving firefighter communications. Emmitsburg, MD: U.S.
Department of Homeland Security, U.S. Fire Administration, Technical Report Series: USFA-TR-099,
January.
USFA [2003]. Rapid intervention teams and how to avoid needing them. Emmitsburg, MD: U.S.
Department of Homeland Security, U.S. Fire Administration, USFA–TR-123, March.
USFA [2006]. Mayday CD Q133 firefighter safety: calling the Mayday and H134 calling the Mayday:
hands on training. Emmitsburg, MD: U.S. Department of Homeland Security, U.S. Fire Administration,
National Fire Academy.
USFA/IAFF [2008]. Voice radio communications guide for the fire service. Emmitsburg, MD: U.S
Department of Homeland Security, U.S. Fire Administration. Washington, DC: International
Association of Fire Fighters.
USFA/IAFF [2016]. Voice radio communications guide for the fire service. Emmitsburg, MD: U.S.
Department of Homeland Security, U.S. Fire Administration. Washington, DC: International
Association of Fire Fighters.
Weather Underground [2016]. Historical weather data for April 30, North Carolina. Atlanta, GA: The
Weather Chanel Interactive, Inc.

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Investigator Information
This incident was investigated by Timothy R. Merinar, Safety Engineer, Matt E. Bowyer, General
Engineer, and Murrey Loflin, Investigator, with the Fire Fighter Fatality Investigation and Prevention
Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located
in Morgantown, West Virginia. An expert technical review was provided by Assistant Chief Matthew
Tobia, Loudoun County Virginia Combined Fire Rescue System. A technical review was also provided
by the National Fire Protection Association, Public Fire Protection Division.

Additional Information
IAFC Rules of Engagement for Firefighter Survival
The international Association of Fire Chiefs (IAFC) is committed to reducing fire fighter fatalities and
injuries. As part of that effort, the nearly 1,000-member IAFC Safety, Health and Survival Section has
developed the DRAFT Rules of Engagement for Structural Firefighting to provide guidance to
individual fire fighters and incident commanders regarding risk and safety issues when operating on
the fireground. The intent is to provide a set of “modern procedures” for structural firefighting to be
made available by the IAFC to fire departments as a guide for their own standard operating procedure
development process

IAFF Fire Ground Survival Program

The purpose of the International Association of Fire Fighters (IAFF) Fire Ground Survival Program is
to ensure that training for Mayday prevention and Mayday operations are consistent between all fire
fighters, company officers, and chief officers. Fire fighters must be trained to perform potentially life-
saving actions if they become lost, disoriented, injured, low on air, or trapped. Funded by the IAFF and
assisted by a grant from the U.S. Department of Homeland Security through the Assistance to
Firefighters (FIRE Act) grant program, this comprehensive fire ground survival training program
applies the lessons learned from fire fighter fatality investigations conducted by the National Institute
for Occupational Safety and Health (NIOSH) and has been developed by a committee of subject matter
experts from the IAFF, the International Association of Fire Chiefs (IAFC), and NIOSH.

National Institute for Standards and Technology (NIST) – Fire on the Web
Fire on the Web is a collection of resources from the Building and Fire Research Laboratory's Fire
Research Division at NIST. These web pages provide links to fire-related software, experimental fire
data, and mpeg/quick time movies of fire tests, which can be downloaded and/or viewed with a web
browser.

Underwriters Laboratories (UL) Firefighter Safety Research Institute

An online course offered by the UL Firefighter Safety Research Institute (FSRI) highlights the tactical
application of nearly two decades of research at the National Institute of Standards and Technology
(NIST) and UL on how best to fight modern fires. In 2012, the New York City Fire Department
(FDNY), NIST, and UL FSRI set fire to abandoned townhouses on Governors Island, New York, in a

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series of experiments to examine tactics for controlling fires and rescuing occupants inside burning
homes.

Modern Fire Behavior

This website is meant to serve as a clearinghouse of news and training information related to Modern
Fire Behavior and Modern Building Construction Research, Tactics, and Practices along with actual
street experiences. ModernFireBehavior.com is a joint effort between www.FirefighterCloseCalls.com
and the Underwriters Laboratories Fire Safety Research Institute.

National Volunteer Fire Council

The National Volunteer Fire Council (NVFC) is the leading nonprofit membership association
representing the interests of the volunteer fire, emergency medical, and rescue services. The NVFC
serves as the voice of the volunteer in the national arena and provides invaluable tools, resources,
programs, and advocacy for first responders across the nation.

In 2008, the National Volunteer Fire Council (NVFC) adopted a policy position that all volunteer fire
departments should establish a goal to train all personnel to a level consistent with the mission of the
fire department, based on the job performance requirements outlined in NFPA 1001 Standard for Fire
Fighter Professional Qualifications. The NVFC is committed to ensuring that volunteer fire fighters
have an appropriate level of training to safely and effectively carry out the functions of the
department(s) to which they belong. This issue actually encompasses the entire fire service and not just
the volunteer ranks, as expressed the NVFC White Paper on Volunteer Fire Firefighter Training
released in 2010:

“The roles and responsibilities of the fire service have evolved over the years. As the
breadth and scope of what it means to be a firefighter has expanded, to varying degrees
depending on the jurisdiction, the necessity for training within the fire service has grown.
Unfortunately, a large number of volunteer fire departments are still operating with
personnel who are not trained to a level consistent with national consensus standards for
basic firefighter preparedness. This can lead to ineffective and unsafe responses that put
lives and property at risk. As the need for proper training has become more urgent, many
volunteer fire departments are finding it increasingly difficult to attract new members.
The average age of volunteer firefighters has risen steadily over the past two decades, as
many young people move out of rural areas and the ones who stay find themselves with
less free time to devote to training.”

Voice Radio Communications Guide for the Fire Service

The U.S. Fire Administration (USFA) and the International Association of Fire Fighters (IAFF)
worked under a cooperative agreement to develop the Voice Radio Communications Guide for the Fire
Service as a document to help identify the unique communication needs required by the fire service.
This document covers basic radio communication technology, radios and radio systems, portable radio

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selection and use, trunked radio systems, system design and implementation, interoperability, and other
fire service radio communication issues.

Current Status, Knowledge Gaps, and Research Needs Pertaining to Firefighter Radio
Communication Systems
The National Institute for Occupational Safety and Health (NIOSH) commissioned a study to identify
and address specific deficiencies in fire fighter radio communications and to identify technologies that
may address these deficiencies. Specifically to be addressed were current and emerging technologies
that improve, or hold promise to improve, fire fighter radio communications and provide fire fighter
location in structures. This report was prepared under contract with NIOSH. It should not be
considered a statement of NIOSH policy or of any agency or individual who was involved.

Improving Radio Communications

Several recent incidents involving fire fighter fatalities where inadequate fireground communications
were identified as contributing factors to the injuries and deaths prompted the U.S. Fire Administration
(USFA) to study the potential causes of communication breakdown and to provide recommendations
that would help departments improve operational communications.

Disclaimer
Mention of any company or product does not constitute endorsement by the National Institute for
Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not
constitute NIOSH endorsement of the sponsoring organizations or their programs or products.
Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced
in this document were accessible as of the publication date.

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Appendix One
Self-Contained Breathing Apparatus Evaluation Report

Evaluation of Two Self-Contained Breathing Apparatuses for Potential

Contribution to a Fatal Event in the Fire Service.

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As part of the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter
Fatality Investigation and Prevention Program (FFFIPP), investigation F2016-07 NC, the
National Personal Protective Technology Laboratory (NPPTL) agreed to examine and evaluate two
SCBA units identified as Scott® Safety model Air-Pak® 4.5, 4500 psi, 30 minute, self-contained
breathing apparatus (SCBA). This SCBA status investigation was assigned NIOSH Task Number
20922.

The SCBA units were hand delivered to the NIOSH facility in Morgantown, West Virginia on June 28,
2016. The units were taken to the lower floor of the lab, room 1513, for secured storage. The SCBA
units were then removed from storage for inspection on August 12, 2016 and placed back into secured
storage until the testing on August 15, 2016.

The purpose of Respirator Status Investigations is to determine the conformance of each respirator to
the NIOSH approval requirements found in Title 42, Code of Federal Regulations, Part 84. A number
of performance tests are selected from the complete list of Part 84 requirements and each respirator is
tested in its “as received” condition to determine its conformance to those performance requirements.
Each respirator is also inspected to determine its conformance to the quality assurance documentation
on file at NIOSH.

The two SCBA units were submitted to NIOSH/DSR by the fire department for evaluation. The SCBA
units were delivered to NIOSH on June 28, 2016 and extensively inspected on August 12, 2016. The
units were identified as Scott® Safety model Air-Pak® 4.5, 4500 psi, 30-minute, SCBA (NIOSH
approval numbers, TC-13F-76CBRN). Corresponding facepieces were provided with the units. The
units did not show any signs of heat damage, but exhibited signs of normal wear and tear for the unit.
Only one unit arrived with a corresponding cylinder, identified as “Unit 1” for the remainder of this
report. The cylinder gauge showed that the tank was empty. The mask mounted regulator (MMR) and
sealing areas in both units were mostly clean. The locking assemblies did function, and the inside
flanges had minimal to no scratching. The NFPA approval label was present and readable on both
units. The personal alert safety systems (PASS) functioned and overall condition was good.

Both SCBA units passed the applicable performance tests conducted by NIOSH, meeting or exceeding
the applicable certification requirements of Title 42, Code of Federal Regulations, Part 84. The full
SCBA evaluation report is available upon request from the NIOSH National Personal Protective
Technology Laboratory. The full evaluation report can also be downloaded from the NIOSH NPPTL
PPE webpage at https://www.cdc.gov/niosh/npptl/ppe-
fireservice/pdfs/PinevilleFireDepartment20922.pdf

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