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Proper Staffing

Makes

Proper Tactics

Makes

Firefighters Survive

By:

Jeffrey S. Parker

Independent Fire Research

Professor William Kramer, PhD October 25th, 2008

Staffing � Tactics � Firefighter Survival 2

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ABSTRACT

The subject of this research is to specifically look at selected incidents that resulted in

firefighter fatalities, and to retrospectively consider how staffing deficits may have affected

these incidents. It is proposed that applying proper staffing to incidents will allow for proper

tactics to be applied to accomplish a strategy that fits the scenario presented. These proper

tactics will lead to increased firefighter survival.

The world today sees a much more sophisticated, intelligent, and protected fire service.

Working fire incidents are fewer than in the past, however firefighter fatalities remain

unchanged.

Firefighter deaths associated with the tragedy at the World Trade Center in 2001 were

excluded from the study.

The fire service is expected to be an “all-hazard” service, yet with less personnel. This

retrospective review of structure fires will focus on how proven tactics and safe practices have

been sacrificed due to improper staffing, and this has caused numerous firefighters to

unnecessarily lose their lives.

This selected review will show that where sacrifices in tactics were made, many times what

contributed to this in some degree was inadequate personnel at critical times during the

incident. What this report will also show is how inadequate staffing for pre-incident functions

such as fire code compliance enforcement, training, pre-incident planning, and unappreciated

administrative functions also indirectly negatively impacts firefighter survivability.


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The fire service in general has a severe shortage of both line and administrative staffing. When

line staffing is short, administrative staffing is sacrificed to compensate. There is an overall

under appreciation of the importance of the administrative function and the contribution that

the right kind formal education can contribute towards a safer world, for both firefighters and

civilians.

The National Fire Protection Association Standard 1710 for career depts. statesi, “It is

recommended that a minimum acceptable fire company staffing level should be 4 members

responding on or arriving with each engine and each ladder company responding to any type

of fire. The minimum acceptable staffing level for companies responding in high-risk areas

should be 5 members responding or arriving with each engine company and 6 members

responding or arriving with each ladder company." The industry standards body also states,

“When structural fire fighting takes place, it is recommended that backup personnel, a RIT

team, and other fire fighters be in place to perform any operations needed (i.e., stretch lines to

protect exposures, vertical ventilation, horizontal ventilation, forcible entry to secondary exits,

etc.). If the personnel are not available, the operations and tactics can be hindered or delayed.”

NFPA 1720 applies to volunteer fire depts. This standard also statesii that minimum

numbers of personnel should be assembled prior to interior structure fire attack. It states that

sufficient personnel shall be available to provide a sustained attack and mentions many typical

functions that must be undertaken such as, ventilation, rapid intervention, forcible entry, etc.

The fundamental requirement for both standards is that sufficient personnel must be at the

scene in the early, initial, critical high risk, high benefit potential period of time at a structure

fire to perform using proper strategy and tactics.

We should consider prevention as the most effective and preferred way to keep the

public and our firefighters safe. When prevention fails, rescue suppression must be relied

upon. The fire service and the public have suffered from emphasis on suppression, while


5

sacrificing the prevention function. Similarly, when a structure fire has occurred, and we must

engage in rescue and suppression, prevention of firefighter harm should also be considered as

the most effective and preferred way to keep firefighters safe. By prevention, we mean proper

tactics that prevent adverse situations. The fire service has also focused on handling an

adverse outcome. This has been in the form of firefighter survival and rescue training, the rise

of RIT, RAT, and FAST teams. These developments have all been lifesaving and obviously

very beneficial. At the same time, we need to insure that improper tactics do not cause these

situations, such as flashover, backdraft, smoke explosions, disorientation, and structural

collapse, that make these types of firefighter rescues unfortunately necessarily, and more

frequent.

The fire service is again attempting to compensate for inadequate staffing, by taking

forced shortcuts in proper information gathering, decision making, and tactics. Invariably,

when this diminished use of, or complete abandonment of proven practices gets us into life-

threatening trouble, we are again adapting by adding additional risk to more firefighters to

attempt to mitigate the original dire situation. The risk analysis for these situations are usually

high benefit, high risk, and ones that we always want to avoid, but are duty bound to

aggressively and offensively handle. This is where fire prevention, and proper strategies &

tactics have a direct affect on firefighters. These situations many times are beyond the margins

of an offensive mode, and forcing a defensive posture with only a recovery mode when made

safe.

The focus of this report will be confined to fireground cases not directly primarily

caused by a previously medical condition. Although, realistically all the cases may have some

degree of previous medical condition as some factor in the ultimate survivability. The report

will attempt to isolate actions on the fireground that contribute to bad outcomes. An NFPA


6

report found thatiii, “While the rate of non-heart attack deaths outside structure fires has been

dropping, the rate for deaths inside has been rising.”

This report includes statistics from as early as 1977 until 2007. Firefighter fatalities

have been as high as 173 in 1978 to a low of 75 in 1992. In 2007, there were 102 firefighter

fatalities, with a median number of 108 per year


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The main source of detail concerning structure fire where fatalities occurred is the

National Institute for Occupational Safety and Health. There are investigations of firefighter

fatalities by NIOSH as early as 1984. However, the number of studies were sporadic and at 1

or 2 per year. This number was greatly increased in 1998, when the Fire Fighter Fatality

Investigation and Prevention Program experienced a dramatic increase in funding after a

strong push from the International Association of Fire Fighters, and the International

Association of Fire Chiefs. Starting in 1999, the average number of reports published was

about 39 per year. An incident that occurred on November 29th, 2006, is the earliest pending

investigation. This example shows a lead time of nearly 2 years. There is 1 pending

investigation from 2006, 28 from 2007, and as of October 7, 2008, 22 thus far for 2008.

Firefighter Deaths Per Year

102

8987

105106

97103

112

91

999698

105

79

103

75

108108

118

136132

119

128

119

113

128

138

173

125

136

157

0

20

40

60

80

100

120

140

160

180

200

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Year


8

Looking at firefighter fatalities, all fires, and civilian deaths by year from 1977 thru

2007, the trends show that the numbers of fires are decreasing, and the number of civilian

deaths from fire are also, but the civilian deaths are not decreasing at the same rate as the fire

numbers. This long trend shows the decrease of fires compared to firefighter death trend

lines. They appear to be both decreasing in parallel fashion, however, the trend line for

firefighter deaths is widening slightly. It appears that firefighter deaths are not decreasing as

they should along with the trend for fire numbers. The lines should converge with all the

emphasis on firefighter safety in the past 35 yearsiv.


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1977 Thru 2007 Fire Problem

All Fires 10,000s

All Firefighter

Deaths, 102

173, All Firefighter DeathsAll Fires 10,000s

R2 = 0.9453

R2 = 0.92310

50

100

150

200

250

300

350

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Year

All Firefighter Deaths

Structure Fires10,000s

Structure Fire CivilianDeaths 100s

All Fires 10,000s

FF Deaths atStructure Fires

Residential StructureFires 10,000s

Residential FireCivilian Deaths 100s

All Civilian FireDeaths 100s

Poly. (Structure Fires10,000s)

Poly. (Structure FireCivilian Deaths 100s)

Poly. (All Fires10,000s)

Poly. (All FirefighterDeaths)

Poly. (FF Deaths atStructure Fires)

Poly. (ResidentialStructure Fires10,000s)

Poly. (All Civilian FireDeaths 100s)


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1977 Thru 2007 "STRUCTURE" Fire Problem

All Firefighter

Deaths, 102

173, All Firefighter Deaths

0

50

100

150

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Year

All Firefighter Deaths

Structure Fires10,000s

Structure Fire CivilianDeaths 100s

FF Deaths atStructure Fires

Poly. (Structure Fires10,000s)

Poly. (Structure FireCivilian Deaths 100s)

Log. (FF Deaths atStructure Fires)

Structure

Fires

Structure Fire

Civilian Deaths

Structure Fire

Firefighter Deaths

All

Firefighter

Deaths


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There are 377 Firefighter Fatality Reports listed by the National Institute of

Occupational Safety and Heath Administration. All firefighter deaths however are not

investigated. NIOSH has guidelines that it follows to determine whether an investigation is

warranted based on a decision tree shown below.

10

20 1

00

0

0

0

10

0

0

0

0

0

0

0

0

10

10

10

42

46

39

41

4344

3635

27

1

7

28

1

22

0

5

10

15

20

25

30

35

40

45

50

1984

1985

1986

1987

1988

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Number of Studies Published

Firefighter Fatality Reports Per Year

Pending

Completed


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Source: www.cdc.gov/niosh/fire/future.html#research

Of these 377, many pertain to motor vehicle accidents, accidents not on the

fireground, such as during training, in the station, or at some other activity. A large percentage

are due to heart disease. The number of investigations planned for each year has decreased

somewhat since 2003, from a high of 44 for that year, 35 for 2007, to 23 in 2008 with almost 3

months to go in the year (this would trend to about 31 for 2008. Looking at the prioritization

guidelines, this may be because similar issues are still emerging and are not re-studied.


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Of the 377 reports, 63v or about 17% involved structure fires. These were filtered out

for study to see patterns in tactics and staffing shortages that lead to comprised practices and

lead to these tragic outcomes. Staffing deficits cause a lack of information flow, or indirectly

impact proper command decisions, with pre-incident planning deficits, training available, and

inconsistency in personnel groups in both rank and numbers from one incident to the next.

The focus will retrospectively look at tactics that were involved and how staffing inadequacies

affected these outcomes. The real goal of this report is to add to the body of research that not

only the fire service, but society in general can point to in gaining understanding and eventual

acceptance of a cultural change that includes adequate fire personnel in initial structure fire

response.


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12

1 1 1

10

42

46

39

4143

44

3635

28

35

23

4

10

3

96 5 6 5

7 7

30

5

10

15

20

25

30

35

40

45

50

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Years

NIOSH Firefighters Fatality Reports

Structure Fires All Other Causes

There are many fire departments in our country that operate in a climate of over-

dependence on mutual aid. There are limitations on mutual efficiency and safety. A large,

geographically expansive department is not the same as many smaller departments using

frequent mutual aid operation serving the same jurisdiction. Increasingly, understaffed

departments, rely on other surrounding understaffed departments to ramp-up adequate

staffing for relative routine bread and butter structure fires. These departments are not

organized consistently, do not train together sufficiently, have awareness of each other’s

jurisdiction, have preplanned, or have real administrative control prior to incidents of all

resources that will interact at a scene. Small issues lead to inefficiencies such as inconsistent


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apparatus numbering systems, firefighter PPE coloring and helmet identification colors, SOPs,

and operational philosophies. Confidence in decision making and skill abilities in each other

has not been developed.

The organizational level in a particular incident’s command system that a separate

mutual aid department now commonly operates is not at a branch level but more commonly

much nearer a task level. Department members are commonly intermixed into sectors, groups

and divisions. Most the time this works well, but is not ideal. This condition will never be

eliminated, however the condition occurs much more frequently now than in previous eras.

There were multiple examples where this contributed to unsafe conditions.

Government leaders have seen this type of environment as the alternative answer to a

properly staffed, cohesive department that can handle properly a residential or moderately

sized structure fire incident within the confines of its department. The more we progress in

the direction of encouraging separate departments to train together, operate as one, etc, the

more we need to be in fact be a single, organized department with a single organizational

structure. This will only occur if it is accomplished by full consensus of all stake holders

including the represented citizens, through their elected and appointed government leaders,

and most importantly, employee groups, who are the risk takers.

The overall added risk of fires in large buildings became quickly evident in this review.

Tactics that are daily used and reinforced by positive results can not be used on these fires. A

quote from one particular multiple firefighter report statedvi, “A study by the NFPA from

1989 to 1993 revealed that 3.1 firefighters died for every 100,000 residence occupancy fires,

and that 11.6 firefighters died for every 100,000 non residential occupancy fires, such as

stores, offices and warehouses.” This is nearly a 3 fold increase in risk of death for firefighters

(274%). A later report stated that for the 5 year period of 2002 thru 2006, 3.1 firefighters died

for every 100,000 residence occupancy fires. This compares to 13.9 for stores and offices, 9.0


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for vacant/special, 8.8 public assembly, 6.8 in manufacturing, and 1.3 in storage. This shows

an almost 5 fold increase in risk of death for firefighters in stores and offices over residential.

(448%).vii

What contributes to this added risk to firefighters in the non-residential occupancies?

• Larger floor spans

o Lightweight or engineered elements that fail faster in fire.

o Increased disorientation risk. Firefighters must use guidance by hose or

guideline.

o Larger void spaces above ceilings

o Firefighters are deeper into hazardous environment and more distant from

safe exit


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o Command system organization needs are increased

o Reliance of sectoring, information feedback, and reconnaissance is increased

Of note in reviewing these firefighter fatality reports is the relative lack of success of

firefighters that must depend on rescue efforts from RIT, FAST or RAT teams for their

survival. Prevention of these situations is key and a renewed emphasis on doing our job using

proper strategies and tactics is of paramount importance if we are going to eliminate these

unnecessary deaths of these heroes. Looking at these events in totality, the same things are

happening over and over again. The advent of the information age will undoubtedly improve

our awareness and ability to learn by other’s experiences. The goal of this review is to boil

these reports down to the common factors so they can be more easily digested as critical

factors to avoid in our operations.

CONCLUSIONS

This research may be added to the body of knowledge that is accumulating as the

result of much post incident analysis. As the review of the fatality reports referenced within

were being conducted, various factors were found that to a varying degree, in combination or

by themselves contributed to these tragic outcomes. This list accumulated to about 28

categories. The factors themselves were reviewed to determine duplicative results, and

combined with others where appropriate. The frequency of occurrence was tabulated. The

numbers derived are not scientifically true as to frequency of occurrence. As noted earlier, the

decision tree allows that not all incidents are investigated. Also, recommendations listed by

NIOSH were not consistent from the early years until now. However, this report included

more factors observed in earlier incidents that are only apparent now. One example is thermal

imaging camera use that was not widely used early on. An attempt was made to compensate


18

for this. The point to be made is that the conclusions of factor frequency can not be

statistically proven, but reasonably formed.

The list was then refined to 25. These are the most common factors found to be

present in the firefighter fatality investigative reports conducted by NIOSH. The body of

reports was reviewed in chronological order from most recent backwards. It was found that

we have generally improved on the way we do things, the protection that we have, and the

availability of technology we have. However, there are many examples of tried and true

principles being violated. Why are we repeatedly violating these principles? Are we unaware, or

are we forced to?


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TOP 25 Firefighter Fatality Factors in Structure Fires

3%

3%

5%

8%

10%

14%

14%

17%

19%

21%

22%

25%

25%

29%

32%

32%

35%

35%

38%

38%

43%

44%

46%

48%

51%

0% 10% 20% 30% 40% 50%

Utility Control

Fire Attack crew large distance from entry (safe point)

Pulled Attack Line out prior to all FFs out.

Opposing Attack Directions

Delayed Alarm

Defensive Offensive Overlap

Backup Line

Search w/out water

LTWT Structural Members

Water Problem

Operating Above Fire

Search w/out hose or guideline

Basement Fire - 1st Floor Entry

Pre-Incident Planning

IC involved in tasks

Buddy System/Crew Integrity

Inappropiate Strategy

No Separate Safety Officer

Accountability

Thermal Imager

Collapse

Staffing Inadequacy or Delayed

Ventilation

RIT

Command System, Organization, Transfer of Command

Communications is obviously a vital part of how we manage incidents. This was not

isolated as a separate factor as it is such a fundamental need for anything we do on the

fireground. However, early reports frequently mentioned the need for interior firefighters to

have portable radios. In later times, it was seen that only officers that lead interior crews had

portable radios, and still later reports rarely mentioned the absence of portable radios by

firefighters. So we have less of the communication problems created by the absence of radios,


20

but do have communication problems such as too much radio traffic, need for additional

channels, or the lack of reporting of remote or interior conditions back to command. Since

command has a need to be generally stationary, command must have others do reconnaissance

and report back credible information.

With the totality of the entire report information in mind, it becomes very apparent of

the need to separate proactive preventative measures from reactive rescue measures. The

factor that was listed as very frequently present was RIT. RIT itself is obviously a reactive

approach. This absence or implementation difficulty of a rapid intervention team was seen,

however the successful remedy or bearing on the outcome of the situation could not be

determined. There is no doubt that the presence and effectiveness of this concept is critical

because it is the last resort to turn a desperate situation around. There are several documented

rescues of firefighters in trouble. However, we must remember that prevention efforts have a

much greater degree of impact on saving firefighters. We are being forced by society to

practice unsafely, and then react to the results. We do not have the resources to practice safely,

or even rescue ourselves from the bad situations created. There are many examples that show

how fast firefighters can be killed, where a rapid intervention, however skillful, will not change

the outcome, while putting more firefighters under greater risk than what caused the original

need for their involvement.

We are also faced with the dilemma of a decision to assign early arriving firefighters to

RIT, or instead to early needs related to prevention of adverse events on the fireground, while

attempting to manage a personnel deficit. This includes ventilation, second or back-up lines,

forcible entry, ladder placement, etc. There are examples of futile attempts at rescue, and

research that shows the time and difficulty involved in interior firefighter rescue. The Phoenix

fire departmentviii found that there are severe limitations with the firefighter rescue concept

even in a relatively well-trained, motivated, adequately staffed department. In research that


21

they conducted they recorded data on several rescues of a pair firefighters from inside a

building with partially obscured vision. None of the firefighters to be rescued were entrapped

in any way and generally located within 100 feet of the exit.

The research showed the following:

Rapid Intervention Team Dataii Average Time

Task

21.8 Time it takes to locate, package, transfill and extricate a downed firefighter out of a commercial structure from Mayday call.

18.5 Amount of Work Time With a 3000 psi Bottle

2.5 Time for RIT to Prepare for Rescue

2.6 Time for RIT to Enter After Mayday

12 : 1 Ratio of Rescue Firefighters to Victim Firefighter

5 : 1 Ratio of Rescue Firefighters To Those Who Get Into Trouble

We must focus on increased awareness and use of tried and true, scientifically

researched preventative measures. This includes good strategic decision-making and

coordinated good practice tactics.

FACTORS PER REPORTS REVIEWED

SORTED BY DATE (LATEST TO EARLIEST)

Report No.

Incident Date

Title Total Factor Count

F2007-07 11/16/07 Volunteer fire fighter dies after falling through floor supported by engineered wooden-I beams at residential structure fire - Tennessee

8

F2007-12 4/16/07 Career fire fighter dies in wind driven residential structure fire - Virginia 7

F2007-08 2/4/07 Career fire fighter dies when trapped by collapsed canopy during a two alarm attached garage fire – Pennsylvania

9

F2007-01 12/30/06 Career fire fighter dies and chief is injured when struck by 130-foot awning that collapses during a commercial building fire - Texas

6

F2006-28 10/10/06 Career fire fighter dies in residential row house structure fire - Maryland 8

F2006-27 8/27/06 Floor collapse at commercial structure fire claims the lives of one career lieutenant and one career fire fighter – New York

2

F2006-26 8/13/06 Career engineer dies and fire fighter injured after falling through floor while conducting a primary search at a residential structure fire – Wisconsin

10


22

F2006-24 6/25/06 Volunteer deputy fire chief dies after falling through floor hole in residential structure during fire attack - Indiana

12

F2006-19 5/14/06 Career Lieutenant dies in residential structure fire - Colorado 3

F2006-07 2/21/06 Two volunteer fire fighters die when struck by exterior wall collapse at a commercial building fire overhaul - Alabama

2

F2005-34 11/7/05 Career fire fighter killed while riding manlift to assess a silo fire - Missouri 2

F2005-13 4/18/05 A volunteer fire fighter and volunteer assistant lieutenant die after a smoke explosion at a town house complex - Wyoming

8

F2005-09 2/19/05 Career fire captain dies when trapped by partial roof collapse in a vacant house fire – Texas

3

F2005-07 2/13/05 Career captain electrocuted at the scene of a residential structure fire – California

3

F2005-04 1/23/05 Career fire fighter dies while exiting residential basement fire - New York 2

F2005-03 1/23/05 Career lieutenant and career fire fighter die and four career fire fighters are seriously injured during a three alarm apartment fire - New York

6

F2005-05 1/20/05 Career captain dies after running out of air at a residential structure fire – Michigan

8

F2005-02 12/20/04 One probationary career firefighter dies and four career firefighters are injured at a two - alarm residential structure fire - Texas

4

F2004-37 4/8/04 Volunteer chief dies and two fire fighters are injured by a collapsing church facade – Tennessee

5

F2004-14 4/4/04 Career fire fighter dies and two career captains are injured while fighting night club arson fire – Texas

2

F2004-10 2/18/04 Career fire fighter dies searching for fire in a restaurant/lounge - Missouri 11

F2004-05 1/9/04 Residential basement fire claims the life of career lieutenant – Pennsylvania

7

F2004-04 12/16/03 Career fire fighter dies of carbon monoxide poisoning after becoming lost while searching for the seat of a fire in warehouse - New York

7

F2004-02 11/29/03 Basement fire claims the life of volunteer fire fighter - Massachusetts 6

F2003-18 6/15/03 Partial roof collapse in commercial structure fire claims the lives of two career fire fighters – Tennessee

7

F2003-12 3/31/03 Career fire fighter dies and two career fire fighters injured in a flashover during a house fire – Ohio

5

F2003-04 1/20/03 Career firefighter dies from injuries received during a chimney and structural collapse after a house fire - Pennsylvania

3

F2003-03 1/19/03 Volunteer fire fighter dies following nitrous oxide cylinder explosion while fighting a commercial structure fire – Texas

10

F2002-50 11/25/02 Structural collapse at an auto parts store fire claims the lives of one career lieutenant and two volunteer fire fighters - Oregon

6

F2002-49 11/1/02 Volunteer lieutenant dies following structure collapse at residential house fire – Pennsylvania

4

F2002-44 9/30/02 Parapet wall collapse at auto body shop claims life of career captain and injures career lieutenant and emergency medical technician - Indiana

3

F2002-40 9/14/02 Career fire fighter dies after roof collapse following roof ventilation - Iowa 8

F2002-07 2/11/02 One career fire fighter dies and another is injured after partial structural collapse – Texas

3

F2001-33 10/13/01 High-rise apartment fire claims the life of one career fire fighter (captain) and injures another career fire fighter (captain) - Texas

6

F2001-23 6/17/01 Hardware store explosion claims the lives of three career fire fighters - New York

2


23

F2001-18 5/9/01 Career fire fighter dies after becoming trapped by fire in apartment building - New Jersey

10

F2001-16 3/8/01 Career fire fighter dies after falling through the floor fighting a structure fire at a local residence – Ohio

6

F2001-08 2/17/01 Two volunteer fire fighters die fighting a basement fire - Illinois 7

F2001-04 1/11/01 Volunteer fire fighter (lieutenant) killed and one fire fighter injured during mobile home fire – Pennsylvania

9

F2001-03 12/28/00 Roof collapse injures four career fire fighters at a church fire - Arkansas 8

F2000-44 11/25/00 Residential house fire claims the life of one career fire fighter - Florida 8

F2000-43 10/29/00 A volunteer assistant chief was seriously injured and two volunteer fire fighters were injured while fighting a townhouse fire - Delaware

7

F2000-26 4/20/00 Residential structure fire claims the life of one career fire fighter – Alabama

9

F2000-23 3/31/00 Career fire fighter dies and three are injured in a residential garage fire – Utah

12

F2000-16 3/3/00 Arson fire claims the life of one volunteer fire fighter and one civilian and severely injures another volunteer fire fighter - Michigan

7

F2000-13 2/14/00 Restaurant fire claims the life of two career fire fighters - Texas 12

F2000-04 12/22/99 Structure fire claims the lives of three career fire fighters and three children – Iowa

11

99-F48 12/18/99 Warehouse fire claims the life of a battalion chief - Missouri 7

99-F47 12/3/99 Six career fire fighters killed in cold-storage and warehouse building fire – Massachusetts

10

99-F04 12/31/98 Roof collapse in arson church fire claims the life of volunteer fire fighter – Georgia

7

98-F21 8/29/98 Commercial building fire claims the lives of two volunteer fire fighters – Mississippi

9

98-F18 7/11/98 Vacant dwelling fire injures two fire fighters - Virginia 2

98-F07 3/8/98 Commercial structure fire claims the life of one fire fighter - California 7

98-F05 2/11/98 Backdraft in commercial building claims the lives of two fire fighters, injures three, and five fire fighters barely escape - Illinois

1

98-F06 2/5/98 Single-family dwelling fire claims the lives of two volunteer fire fighters – Ohio

13

98-F04 1/21/98 Supermarket Fire Claims the Life of Volunteer Fire Fighter - West Virginia

9

98-03 10/27/97 Two fire fighters die of smoke and soot inhalation in residential fire – Pennsylvania

9

97-09 8/19/97 Restaurant/tavern fire results in the death of one fire fighter and serious injuries to three other fire fighters – Indiana

7

97-16 7/4/97 One fire fighter dies of smoke inhalation, one overcome by smoke while fighting an attic fire - New York

5

97-04 2/17/97 Floor collapse in a single family dwelling fire claims the life of one fire fighter and injures another – Kentucky

12

96-17 3/18/96 Sudden roof collapse of a burning auto parts store claims the lives of two fire fighters - Virginia, March 18, 1996

9

F2001-28 12/23/95 Fire fighter receives severe electrical shock causing cardiac complications, forcing his retirement, and eventually causing his death – Massachusetts

1


24

85-49 8/27/85 Three fire fighters killed fighting silo fire in Ohio 2

63 TOTAL

FACTORS PER REPORTS REVIEWED

SORTED REPORTS WITH MOST FACTORS TO LEAST

Report No.

Incident Date

Title Total Factor Count

98-F06 2/5/98 Single-family dwelling fire claims the lives of two volunteer fire fighters – Ohio

13

F2006-24 6/25/06 Volunteer deputy fire chief dies after falling through floor hole in residential structure during fire attack - Indiana

12

F2000-23 3/31/00 Career fire fighter dies and three are injured in a residential garage fire – Utah

12

F2000-13 2/14/00 Restaurant fire claims the life of two career fire fighters - Texas 12

97-04 2/17/97 Floor collapse in a single family dwelling fire claims the life of one fire fighter and injures another – Kentucky

12

F2004-10 2/18/04 Career fire fighter dies searching for fire in a restaurant/lounge - Missouri 11

F2000-04 12/22/99 Structure fire claims the lives of three career fire fighters and three children – Iowa

11

F2006-26 8/13/06 Career engineer dies and fire fighter injured after falling through floor while conducting a primary search at a residential structure fire – Wisconsin

10

F2003-03 1/19/03 Volunteer fire fighter dies following nitrous oxide cylinder explosion while fighting a commercial structure fire – Texas

10


10

99-F47 12/3/99 Six career fire fighters killed in cold-storage and warehouse building fire – Massachusetts

10

F2007-08 2/4/07 Career fire fighter dies when trapped by collapsed canopy during a two alarm attached garage fire – Pennsylvania

9

F2001-04 1/11/01 Volunteer fire fighter (lieutenant) killed and one fire fighter injured during mobile home fire – Pennsylvania

9

F2000-26 4/20/00 Residential structure fire claims the life of one career fire fighter – Alabama

9

98-F21 8/29/98 Commercial building fire claims the lives of two volunteer fire fighters – Mississippi

9


9

98-03 10/27/97 Two fire fighters die of smoke and soot inhalation in residential fire – Pennsylvania

9

96-17 3/18/96 Sudden roof collapse of a burning auto parts store claims the lives of two fire fighters - Virginia, March 18, 1996

9

F2007-07 11/16/07 Volunteer fire fighter dies after falling through floor supported by engineered wooden-I beams at residential structure fire - Tennessee

8


25

F2006-28 10/10/06 Career fire fighter dies in residential row house structure fire - Maryland 8

F2005-13 4/18/05 A volunteer fire fighter and volunteer assistant lieutenant die after a smoke explosion at a town house complex - Wyoming

8

F2005-05 1/20/05 Career captain dies after running out of air at a residential structure fire – Michigan

8

F2002-40 9/14/02 Career fire fighter dies after roof collapse following roof ventilation - Iowa 8

F2001-03 12/28/00 Roof collapse injures four career fire fighters at a church fire - Arkansas 8

F2000-44 11/25/00 Residential house fire claims the life of one career fire fighter - Florida 8

F2007-12 4/16/07 Career fire fighter dies in wind driven residential structure fire - Virginia 7

F2004-05 1/9/04 Residential basement fire claims the life of career lieutenant – Pennsylvania

7

F2004-04 12/16/03 Career fire fighter dies of carbon monoxide poisoning after becoming lost while searching for the seat of a fire in warehouse - New York

7

F2003-18 6/15/03 Partial roof collapse in commercial structure fire claims the lives of two career fire fighters – Tennessee

7

F2001-08 2/17/01 Two volunteer fire fighters die fighting a basement fire - Illinois 7

F2000-43 10/29/00 A volunteer assistant chief was seriously injured and two volunteer fire fighters were injured while fighting a townhouse fire - Delaware

7

F2000-16 3/3/00 Arson fire claims the life of one volunteer fire fighter and one civilian and severely injures another volunteer fire fighter - Michigan

7

99-F48 12/18/99 Warehouse fire claims the life of a battalion chief - Missouri 7

99-F04 12/31/98 Roof collapse in arson church fire claims the life of volunteer fire fighter – Georgia

7

98-F07 3/8/98 Commercial structure fire claims the life of one fire fighter - California 7

97-09 8/19/97 Restaurant/tavern fire results in the death of one fire fighter and serious injuries to three other fire fighters – Indiana

7

F2007-01 12/30/06 Career fire fighter dies and chief is injured when struck by 130-foot awning that collapses during a commercial building fire - Texas

6

F2005-03 1/23/05 Career lieutenant and career fire fighter die and four career fire fighters are seriously injured during a three alarm apartment fire - New York

6

F2004-02 11/29/03 Basement fire claims the life of volunteer fire fighter - Massachusetts 6

F2002-50 11/25/02 Structural collapse at an auto parts store fire claims the lives of one career lieutenant and two volunteer fire fighters - Oregon

6

F2001-33 10/13/01 High-rise apartment fire claims the life of one career fire fighter (captain) and injures another career fire fighter (captain) - Texas

6

F2001-16 3/8/01 Career fire fighter dies after falling through the floor fighting a structure fire at a local residence – Ohio

6

F2004-37 4/8/04 Volunteer chief dies and two fire fighters are injured by a collapsing church facade – Tennessee

5

F2003-12 3/31/03 Career fire fighter dies and two career fire fighters injured in a flashover during a house fire – Ohio

5

97-16 7/4/97 One fire fighter dies of smoke inhalation, one overcome by smoke while fighting an attic fire - New York

5

F2005-02 12/20/04 One probationary career firefighter dies and four career firefighters are injured at a two - alarm residential structure fire - Texas

4

F2002-49 11/1/02 Volunteer lieutenant dies following structure collapse at residential house fire – Pennsylvania

4


26

F2006-19 5/14/06 Career Lieutenant dies in residential structure fire - Colorado 3

F2005-09 2/19/05 Career fire captain dies when trapped by partial roof collapse in a vacant house fire – Texas

3

F2005-07 2/13/05 Career captain electrocuted at the scene of a residential structure fire – California

3

F2003-04 1/20/03 Career firefighter dies from injuries received during a chimney and structural collapse after a house fire - Pennsylvania

3

F2002-44 9/30/02 Parapet wall collapse at auto body shop claims life of career captain and injures career lieutenant and emergency medical technician - Indiana

3

F2002-07 2/11/02 One career fire fighter dies and another is injured after partial structural collapse – Texas

3

F2006-27 8/27/06 Floor collapse at commercial structure fire claims the lives of one career lieutenant and one career fire fighter – New York

2

F2006-07 2/21/06 Two volunteer fire fighters die when struck by exterior wall collapse at a commercial building fire overhaul - Alabama

2

F2005-34 11/7/05 Career fire fighter killed while riding manlift to assess a silo fire - Missouri 2

F2005-04 1/23/05 Career fire fighter dies while exiting residential basement fire - New York 2

F2004-14 4/4/04 Career fire fighter dies and two career captains are injured while fighting night club arson fire – Texas

2


2

98-F18 7/11/98 Vacant dwelling fire injures two fire fighters - Virginia 2

85-49 8/27/85 Three fire fighters killed fighting silo fire in Ohio 2

98-F05 2/11/98 Backdraft in commercial building claims the lives of two fire fighters, injures three, and five fire fighters barely escape - Illinois

1

F2001-28 12/23/95 Fire fighter receives severe electrical shock causing cardiac complications, forcing his retirement, and eventually causing his death – Massachusetts

1

63 TOTAL

25 FACTORS

Command System, Organization, Transfer of Command Just over half (51%) of all the reports included this factor. One problem reported was

when command was transferred to personnel that had not yet arrived at scene. This becomes

a source for confusion involving location, action, and function of personnel already at the

scene. It does not follow proper principles of transfer of command. It is usually a function of

a staffing deficit. Ideally, an officer should be directing the scene that is available to properly


27

hand over this function to a higher ranking officer if needed. This also results from the “fast-

attack” mode, and the “nothing showing, investigating mode”.

The “fast attack mode” is called “fast-action mode” by Chief Alan Brunacini and may

be indicated when the incident commander personally performing at the task level “can

quickly solve or stabilize the problem”. Chief Brunacini goes on to state “the operation is now

in a somewhat compromised, nonstandard command status”. Klaene and Sandersix state that

“It would certainly be desirable if the first-arriving company officer could establish a formal

command post outside of the structure and direct operations. However, few departments have

sufficient staff to allow the company officer to establish a stationary command post on

arrival.”

When the first arriving officer uses the “nothing showing, investigating mode”, once

something is found that requires attack, this command mode should be converted into a

stationary mode or fast attack mode. When these modes are not converted early or without

transfer of information is when problems ensue, such as in strategic decision making,

accountability, or lack of a coordinated one-directional, one strategic mode attack.

As stated earlier, NIOSH also notes that command functioning difficulty increases

with the number of separate departments are operating on one scene increases. In one report,

a mutual aid dept looked on their own Chiefs as the incident command. We must keep in

mind that separate companies or crews in one department are not the same as multiple

companies or crews from multiple departments. Ideally we all operate, and have standard

capabilities, but in reality is not the case. We talk about the importance of proper command

transfer. This concept also applies to whenever someone else takes over any functional

responsibility. In one case, a transfer of sector responsibility may have hindered A Side

accountability. The separation of roles from strategic, to tactical, to task must be respected. A


28

factor found was a when an officer performing as a sector officer also became involved in

tasks that adversely effected the performance as the sector officer.

In general, scenes need to be organized. Our job is to find chaos wherever it exists,

and organize it. One report stated how crews were getting confused as to geographic

directions. This involved designations such as north, south, east, and west. The address for the

subject building should always be designated the “A” side, then B, C, & D as we travel around

the building in a clockwise fashion. Numerical designations should be reserved for vertical

floors. We should not use “Side 2”, as the officer for responsibility of the 2nd floor, may also

be called “Division 2” or “Sector 2”. This will eventually be the subject of a problem on a

fireground.

Part of the officer’s job as a crew leader is to solve problems for the crew. If solving

the problem, takes out your ability to lead and supervise sufficiently, the problem solving

needs to be delegated. When a RIT scenario has occurred, the scene organization must be

maintained and reinforced. In one case, the RIT operation became chaotic as all hands wanted

to help. There should be a formal assignment of functions. There must be no question of who

is commanding and must be one individual that directs the operations. This must be enforced

as it has been shown to be deadly for firefighters.

Firefighters from the start of their career must be shown how discipline in the

command system is a life and death issue. Several of the reports showed how well intentioned

“free-lancing” can be deadly not only for the freelancer but others as well. There needs to be a

strong effort to impress on officers rising through the ranks of the need to let go of task level

actions, and concentrate on the role that they must play. Part of this difficulty is that

individuals frequently perform at all vertical levels of a department. One day, they are incident

command, the next they are driving the truck, the next day they are putting a hole in a roof.

This task level involvement goes back to staffing deficits. We are trying (forced) to do


29

strategic, tactical, and task level work at the same time. In one incident the incident

commander was faced with running the fire or getting a rescued child to a hospital. A decision

was made that should not have had to be made. We need to practice (tabletop) the command

system at structure fire scenarios. All personnel need to do a better job of reporting conditions

to their superiors. This will help the commanders and sector officers concentrate on decision

making rather than recon.

Inadequate available staffing leads to disorganization, and we are all trying to do more

than we are capable of. The time we have for education at out level of function is also

decreased because we are performing non-emergency function needs of lower levels.

Command System, Organization, Transfer of CommandRate of Factors Per Year of

FF Fatalities Studied in a Particular Year

1996 thru 2007

11 Year Trend

100%

75%

100% 100%

50%

20%

67%

40%

29%

0% 0%

71%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Rapid Intervention Teams

Again, about half (48%) of all the reports included this factor. As stated earlier, the

factor was noted; however, the prevention of the fatality related to this factor is unknown and

would vary greatly from one situation to another. Many of the reports listed noted that a rapid

intervention team was not assigned prior to the need for firefighter rescue. There were reports


30

where the operation of the RIT was disorganized. Organization of the operation is essential

for efficiency, chances of success, and minimization of risk to the victim and rescuers. In

some reports, the RIT was formed by pulling firefighters from other assignments. This

abandonment of these assignments may increase danger to all involved and these firefighters

may be fatigued and be low on air. We must remember that any attack lines in any area may be

the only source of orientation for lost firefighters attempting to escape, serve as protection

from heat by downed firefighters, and the quickest method to find lost or trapped firefighters.

This line IS their lifeline. Any firefighting required in the rescue attempt prior to locating

downed firefighters must be by additional lines brought in by the Rapid intervention Team.

Attack lines with differing colors are helpful in identifying crews.

Reports indicated requests for RIT that went unanswered by command. This

invariably is due to radio communication difficulties. These may include scene noise, such as

PPV gas fans, truck engines, etc. It may include too much radio traffic on the same frequency.

It may include command distractions, talking or monitoring one channel, while the request is

given by a second channel. We need to insure that hazard zone personnel are the listening

priority. We need more thermal imagers. There are many uses for the TIC. It is a technological

advancement that is analogous to the SCBA of the 1960s. TICs are needed for exterior size-up

and reassessment, interior assessment, interior orientation for rescue and attack, overhaul, and

firefighter rescue. Many of these occur simultaneously on a fire scene. We need to emphasize

the need for the liberal opening up of a building to provide for later emergency escape needs.

At the same time, additional ventilation created by this must be coordinated through

command, because the next fatality factor expanded on is ventilation (too much or too little).

All preparatory operations should be coordinated with command. Preparatory tasks should

not inhibit readiness of the team, and should not put the team in hazardous situations, as most

likely no secondary RIT will be assigned with the first one not deployed.


31

RIT teams need to think of 3 modes of their function, firefighter rescue preparation,

hazard zone firefighter safety enhancement, and firefighter rescue. The first two should always

occur, the third when called upon. In the prep mode, the RIT crew needs to assemble

anticipated equipment needs and make estimates on probable firefighter trouble scenarios. In

this mode, RIT may consult with the safety sector officer as they are also making similar

considerations. The minimization of distances from hazard zone rescue to safe areas must be

emphasized. This reduces risk, and maximizes efficiency. Wall breaches by additional teams

should be assigned, and reporting to the RIT officer. This all takes added staffing.

Rapid Intervention TeamRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

75%

67%

100%

67%

20%

33%

60%

29% 29%

33%

57%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Ventilation

The third most prevalent factor (46%) in the firefighter fatality reports pertained to

ventilation. It is the number 1 factor related to the science of fire behavior. There are deaths

related to too much, too little, or uncoordinated ventilation. We have learned and been taught

for decades that ventilation must be coordinated with fire attack. We need to have a much


32

better emphasis on the science of fire behavior. Ventilation often gets nixed due to staffing

shortages, or gets modified to a form that fits the tactic that can be performed with lesser

equipment and staffing available, and this is killing us. We must be cognizant of the fact that

positive pressure ventilation will push heat and combustion products into spaces and out of a

building. This is good and bad. Eliminating heat and combustion products is good. Putting

oxygen in deficient spaces is bad. Flashovers and backdrafts are both prevented and caused

from PPV use.

We must remember that the air goes in, and heat and smoke comes out. If we don’t let

it out, it is forced into somewhere else in the structure. We must control the exit point. The

ideal exit point is horizontally at the point where the seat of the fire is at, and vertically as high

as practical and safely accomplished. This is the hottest part of the fire, and where the most

hazard and damage is, and where the margin of survivability is the lowest. Knowing this, the

technique used to make the exit point at this location must fit into safety for firefighters. Wind

must be considered. Natural wind direction may change the ideal exit point at a less than ideal

location, and may change the attack direction. Firefighters must have a safe are to retreat back

to that correlates to enough air for escape back to this area. If this area is a stairwell, the

stairwell must be vented. Elimination of smoke must be greater than entrance of smoke.

Firefighters can not count on a chimney for an escape path. This includes the interior stairs to

a basement fire. Uncoordinated ventilation tactics without fire behavior considerations are

deadly in serious fires. Windows that are used for significant venting should not be counted

on for escape.

There are times when the impossibility of proper venting should be an indicator for a

shift in strategy from offensive to defensive. Due to our need to check void spaces such as

above false ceilings, we need to be prepared for smoke explosions, backdrafts or flashovers,

when checking. Where there are spaces rich in heated combustion by-products, the venting


33

needs to be on the exit point, rather than the air entrance point. This lets heat out, without

letting oxygen in. This is easier said than done. There were a couple of reported backdrafts

from necessary lifting of ceiling tiles for fire extension checks. Subsequent adverse sudden

change in conditions caused deadly disorientation, and untenable environments. Firefighters

need to remember three killers with all PPE in place: explosion, flashover, and collapse.

Ventilation also causes accumulated fine fuels such as dust to be stirred up, and increase their

surface areas exposed to oxygen, causing rapid combustion up to and including explosions.

VentilationRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

100%

67%

71%

67%

20%

50%

20%

29%

43%

0%

29%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Staffing Inadequacy or Delayed Staffing

Of the incidents studied, 44% had firefighting staff deficits that affected the poor

outcome. Many preventable known factors come in to play because there aren’t bodies

available to do what we know is right. Klaene and Sandersiii say, “Offensive attacks are people

intensive”. There is also a possible loss of experience and knowledge at the top of the chain of

command as this level of personnel are indirectly forced out from the physical demands of

firefighting task needs of a lower level because of lower level staffing deficits.


34

The fire service needs a comprehensive campaign to educate the general public on the

need for people to fight fires. It is our need and theirs.

In one report, the crew took an aggressive approach to insure adequate fire flow, and

deployed a 2 ½” line. The staffing available for this line was 2 personnel. It is recommended

that 3 to 4 handle a line of this size. In several reports staffing numbers ramped up to higher

numbers, but only after several minutes in the critical stages of the incidents elapsed.

Department performance indicator criteria should include staff number arrival times. It does

no good to have 50 firefighters on the scene with an initial arrival of 3. The common staffing

of 3 on an engine prevents any meaningful task in a hazardous area due to OSHA “2 in, 2

out” considerations. It also means, these departments are planning and expecting exceptions

to this rule be made in life threatening rescue situations, which happens to be our primary

mission.

As mentioned earlier, there are limitations with operations that routinely depend on

multiple mutual aid companies for relatively routine incidents. The incident command

importance has been stressed in theses factors previously. Critical task needs force leaders to

abandon critical management functions, or at least cause their effectiveness to diminish. We

must refrain from attempting to handle multiple incidents with inadequate personnel. This

practice lowers everyone’s safety. We need to have an automatic tactical reserve operation or

move-up established. One report involved an agency whose personnel were cross-trained as

law enforcement and firefighters. This author believes there are severe limitations of the

effectiveness of this type of operation in terms of capacity for needed expertise, experience,

and availability when emergencies occur that commonly require complements of both

functions.

There were reports that specifically addressed incidents that aggressive tactics were

employed that suffered from inadequate apparatus, equipment, and staffing. There are


35

undoubtedly many jurisdictions that are capable of only properly and safely employing

defensive tactics. This is firefighting of decades previous, without the advent of the modern

breathing apparatus.

Staffing Inadequacy or DelayedRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

50%

33%

43%

50%

20%

33%

60%

29%

43%

67%

43%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Structural Collapse Tied for the third most prevalent factor (43%) in the firefighter fatality reports studied

pertained to structural collapse. It is also tied for the number 1 factor related to the science of

fire behavior. There are numerous reports of firefighters falling through burned floor

structures. These floor failures had no mention of trusses as a major contributor in the

failures. They included joisted full dimension structures. The reports did not specify if the

structures were protected by encasement of drywall. Many roof collapses were present with

the usual weakness indicators of lightweight metal and wood truss construction, as well as

large open, long span areas.

Facade, porch roof, and wall collapse examples were included. We must recognize and

respect these hazards. We must designate and enforce collapse zones. Vertical roof ventilation


36

is still conducted at the most dangerous, structurally damaged area of a building on fire. This

should only be performed when personnel are supported by something other than the burned

roof structure, such as a roof ladder, or aerial device. Full PPE including SCBA, at least one

buddy, and a hose line must be in place. The firefighting community should move building

construction education to the top of the list for structural firefighting.

According to a 2003 studyx conducted by the National Institute of Standards and

Technology (NIST); the number of collapse fatalities on an annual basis has declined since

1979. Compared to limited historical data, the percentage of collapse fatalities that occurred in

residential properties has increased. Collapse fatalities are generally caused two ways: by being

caught or trapped in the structure or by being struck by an object. Compared to limited

historical data, the percentage of collapse fatalities caused by being caught or trapped in the

structure has increased. A majority (over 65 %) of collapse fatalities occurred during fire

attack. Over half of collapse fatalities occurred during the first three months of the year and

over 42 % occurred in the first eight hours of the day (Midnight to 8:00 AM).

CollapseRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

25%

0%

43%

17%

100%

33%

60%

29%

57%

67%

43%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


37

Thermal Imager Not Used About 38% of the fatality reports were of incidents where thermal imaging technology

was not used. The first thermal imagers were introduced to the fire service in the early 1990s,

after being developed by the military. We are experiencing phases in this technology. We have

experienced the rarity of a department possessing one, to departments struggling to afford one

then eventually purchasing one, to interior crews’ overdependence on one, to forgetting to

pull it off the truck. We now see the need to increase its use in exterior size-up and other

fireground applications. Departments now are more commonly having one for each

apparatus. The technology is progressing to the point that every firefighter will have their own

miniature thermal imager much the same as the U.S. soldier does. It is very sad in today’s

world to see firefighters still getting lost in smoke, unable to escape before running out of air.

When considering what we primarily deal with – darkness and heat, the TIC should be

a primary required tool for every firefighter, as basic as the fire helmet.

Thermal Imager Not Used

Exterior Size-Up and/or InteriorRate of Factors Per Year of


1996 thru 2007

11 Year Trend100% 100% 100%

29%

17%

40%

17%20%

43% 43%

67%

29%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


38

Accountability of Firefighters Not Maintained Tied for 7th most frequent factor of the 25 is related to accountability. This was 38%

of all the reports. A more common problem in earlier years was a total lack of any system.

More recently, as accountability is earnestly attempted to be maintained, a member is

accidentally misidentified. A personal accountability report by all members results in “all

accounted for”, only to later discover a missing member. In one report, an electronic

accountability system showed vulnerability as there was a misidentified firefighter. The I.C.

received a PAR when in actuality the member was still missing. The system at the basic level

relies on the crew leader to know who they have and this does not change until out of the

hazard area and the crew is formally disbanded and put back into the pool of standby, tactical

reserve, rehab, or “on-deck” resources. Some of the reports showed when crews inter-mix in

the hazard area, or one crew member runs out of air, exits, and is replaced, confusion occurs.

This concept is “crew integrity”. The leader can not keep track of changing personnel in the

darkness and chaos of the fire environment. You get ready together, enter, and leave together.

You stay together until officially regrouped.

Large areas, both horizontally and vertically require subdivision of the scene or

sectoring. This assists with management and accountability. No personnel in the hazard area

should be without a crew of least two or more. Accountability also means that personnel in

the hazard area or being paid attention to. We must keep close tabs on the status of these

personnel. Every person on the incident must have an assignment, even if that assignment is

“standby”. Personnel can not perform without direction. This is termed “freelancing”.

Arriving firefighters unconsciously assess the level of control that is exerted by command, and

quickly learn what degree of free-lancing is acceptable. Early strong command presence is

needed to avoid this phenomenon.


39

Command also needs to be able to know at all times for each member, their location,

function, level of hazard, who they report to, who reports to them, their radio identifier if

applicable, and name. Various tools may be used to assist in this. At the basic level are tags

that are given to their sector officer or command. A command board or tactical worksheet can

be used. These can show all functional and geographic positions filled, and the name that is

filling the position. Crews reporting to these positions can also be shown. However, below the

crew leader, individual members are usually not shown on larger incidents. The crew leaders

will be shown on the accountability board along with the detail of what members are actually

in the crew.

When a personal accountability report or “PAR” is called for by the incident

commander, the I.C. asks each individual holding a position for a check of resources reporting

to them. They in turn do the same. An example is included below. A limited number of

positions are included for illustrative purposes.

The I.C. radios to all to the effect, “standby for a PAR. The crew leaders such as FF

Andrews, leader of “Crew Andrews” checks the 4 individuals he has responsibility for and

makes sure he knows their 4 names by whatever method he cares to use. He then has a PAR

of 5, including himself. Division 2 will call Crew Andrews and ask for a PAR. Crew Andrews

will advise a PAR of 5. Command will call Division 2 and ask for a PAR. When Division 2 has

checked for a PAR from both Crew Franks and Crew Andrews. Division 2 will report a PAR

of 10. This includes all personnel he has responsible for including himself. After getting a

report from 4 individuals he has reporting to him, he will match this to his accountability

board and see if the number matches. He should know the number in each position under

him by using the accountability system. The total number should be 22 including himself. The

command board should show relationships of positions. The accountability board should

show each individual in each crew and the crew leader. Members not accounted for at any


40

level will be discovered by count, then by name to isolate where the missing member is. This

has to be practiced along with command procedures at the tabletop level using something to

represent the individuals at the bottom.

I.C.

Ass’t Chief

Division 1

Captain Parker

Division 2

Captain Bennett

Salvage Sector

Lt. King

Crew Franks

Lt. Franks

FF Smith

FF Jones

FF Adams

Crew Andrews

FF Andrews

EMS Sector

Chief Hill

FF Brown

Eng Grove

FF White

FF Masters

Medic 680

FF/Medic

FF/Medic

Pickler

Fire Attack Div 1

Captain Newman

S & R Division 1

FF Watson

FF Webster

FF Shepherd

FF Zorn

FF Specht

3

10

1 7

On

Accountability

Board


41

AccountabilityRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

50%

67%

86%

33%

20%

50%

60%

14%

0% 0%

43%

-20%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Incident Safety Officer Not Assigned For the reports studied, 35% of them had reported that the position of Safety was not

assigned. This means this function is not the sole focus of any individual on the scene. When

this is the case, the incident commander retains this function, even though the I.C. always

retains responsibility for safety of all responders. Nothing in the reports states that the

absence of a safety officer in itself directly caused adverse events. They do point out that this

helps put more focus on safety. When the incident commander retains the safety function,

command at times has competing interests. These competing interests are the benefits of

fulfilling the mission vs. the risks to safety of responders.

One example of a need for a safety officer is at a scene with a live wire down. Word of

mouth about safety concerns are not enough, as we are distracted, and lose focus. Strong

physical barriers and/or strong, direct enforcement of exclusionary zones for safety concerns

like wires down or collapse hazards need to take place. Safety is a mobile position that may be


42

arranged as a stationary CP position with safety assistants that are mobile or sectored. The

buddy system in hazardous areas still applies to safety personnel

.

No Safety Officer AssignedRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

75%

67%

29%

50%

60%

17%20%

14%

0%

33%

43%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Strategic Decision Making

The reports showed that strategic decision making as an area in need of improvement

in 35% of the reports. Once the initial strategy is decided, a continual re-evaluation needs to

be undertaken as conditions change and additional information is received. According to an

articlexi in “everyonegoeshome.com”, acceptable risk is stated this way:

1. What is the survival profile of any victims in the involved compartment? 2. We will not risk our lives at all for buildings or lives that are already lost. 3. We may only risk our lives a little, in a calculated manner, to save savable

property. 4. We may risk our lives a lot, in a calculated manner, to save savable lives.


43

NFPA 1500 - Standard on Fire Department Occupational Safety & Health Program

includes these principles:

1. Significant risk only for potential to save lives.

2. Activities to protect property have inherent risks, that we should reduce or

avoid.

3. No risk if no possibility to save lives or property.

Another simple concept to our acceptance of risk was stated by Jeff Goins in an article titledxii

“Risk Analysis at Normally Occupied Structure Incidents” -

“We will risk a lot to save a lot.

We will risk a little to save a little.

We will risk nothing to save nothing”.

One fact bears repeating, “…three killers with all PPE in place: explosion, flashover,

and collapse. In Structural Firefighting, the authors stateiii, “From a fire fighter safety viewpoint

the worst case scenario is one in which the fire fighter arrives near the end of the buildup to

flashover with occupants’ lives at risk in a large, undivided area.”

There were several reports where no lives were at risk with significant firefighter risk.

Situations were experienced where the fire department received repeated reports of occupants

in the building. The incident commander needs to recognize the areas where, and the point in

time reached that is beyond victim survivability. Firefighters need to emphasize and train

dispatchers to thoroughly question callers as to the status of occupants. The mere possibility

of occupants that need rescue may suffice at some level of risk; however situations with higher

risk to firefighters require an assessment of information credibility and accuracy. There are

many examples of firefighter fatalities and injuries from significantly risky rescue attempts

based on questionable information. If the firefighters themselves do not have time to

thoroughly question reporting parties, or have access to them, which is the case most all the


44

time, then others need to be assigned to do this, and understand the importance, such as

dispatchers, police, or other responsible persons

Interior conditions need to be reported to command. All members need to be trained

to recognize pertinent info and be able to succinctly communicate it to the I.C. Another

concept that also must be emphasized is that situations presented must be paired with

resources available. While we may recognize very similar situations on different days and can

see them as “standard” events, resource availability and capability may be very different from

one day to the next. Most departments have a constantly dynamic resource list to draw from,

except for the larger metropolitan departments who may assign “standard resources” to

“standard events”. These dynamics make an offensive mode fire today and a defensive fire

tomorrow. All departments should have a goal to standardize staffing, apparatus, and rank

structures, on standardized responses. Strategic decisions do not involve black or white

decisions, but many shades of gray. There is not a card system to use or a flip book to consult.

The time factor involved in a building must be evaluated. Increased time in a burning

building without a catastrophic event should not increase our confidence, but decrease it.

Incident commanders are being forced to make very tough decisions to provide a service level

the public expects, but doesn’t support with the operational resources to provide that service

following best practices and industry standards. Fire departments may be pushing the

envelope not only to save lives, and save property, but also to justify their existence to the

public. We need to educate the public on how we should be operating, so that they may make


45

an informed decision on expectations.

Strategic Decision MakingRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

0%

33%

86%

17%

40%

33%

20%

29%

14%

33%

57%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Buddy System/Crew Integrity Concept Not Maintained About a third (32%) of all firefighter fatality reports from structure fires contained

incidents where either the crew integrity was lost or firefighters worked in hazard areas

without a partner in close contact working together. When working in the hazard zone, the

minimum number of members in a crew is two. This is called the buddy system. If one

member gets into trouble, the other is there to assist. Many tasks take a minimum of two to

complete. Each other’s personal protective equipment should also checked by their buddy

prior to entry. This concept has been a tried and true firefighter safety concept for many

decades.

Crews may have more than two members up to a manageable span of control for the

task and environment. There must be a leader. The leader must know who is in the crew, and

the crew members must know who the leader is. In a zero visibility, hostile environment, this


46

number may be limited to a maximum crew size of 1 leader and about 5 subordinates. We

commonly work with total crew sizes of 2, 3, and 4 members.

Most departments do not (although we should) have the luxury of crews that match

companies that respond. In this case, a pool of personnel must be assembled into crews,

assigned a radio designation, and briefed on assignment (by SOP or other). This crew should

stay together through assignment, rehab, and on to “On Deck”. At this point they may stay as

a crew or be re-assembled. When one firefighter gets low on air, all should exit together, and

all bottles should be refilled. Obviously, if this does not occur, as soon as the crew returns,

another firefighter will need air, etc. When you’re family is on a road trip, everyone goes when

one of the kids has to stop at the gas station. According to Klaene and Sanders, “splitting

crews inside the hazard area is inviting disaster”.

Firefighters must instinctively stay associated with their crew and their source of

orientation, even in relatively good conditions. There were several examples of sudden

unexpected changes of conditions to hostile zero-visibility conditions where firefighters could

not orient themselves to their hose line or their respective crew members. Fire scene

personnel accountability was another factor that was elaborated on earlier. Crew integrity is

essential if this system is to work. We need to remember that mistakes made in this system,

cause false missing personnel reports. A report of a missing firefighter, initiates a harrowing

search with the greatest of risks to other firefighters. This is very important to understand.


47

Buddy System or Crew IntegrityRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0% 0%

33%

43%

50%

0%

67%

20%

57%

14%

0%

43%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Incident Commander Involved in Tasks One out of three (32%) of all the reports contained incidents that had the incident

commander involved directly in performing at the task level. The incident commander needs

to appreciate and be able to focus on performing the functions of this level of responsibility.

This also applies to, sector, group leaders, or division officers. However, the greater the gap

between levels of command, the greater the detriment to operations, such as the I.C.

constrained in their job by performing task level functions. This includes pumping the truck,

attack line deployment, ventilation, interior size-up, etc.

The “nothing showing” mode of operation is when the first company must

investigate, because there is no indication of fire or smoke that must be dealt with. Once, the

investigation reveals otherwise, the I.C. needs to deploy additional resources, assign his crew

members as needed, and revert to a stationary, strong command mode. Hopefully, there will

be resources near that are at level 1 staging. Incident commanders should guard against

overzealous task involvement under the “fast-attack” mode. When the I.C. can not avoid


48

being involved in tasks, these tasks should ideally be ones that allow him to be in a position to

see the overall picture, available to receive information, and direct others. Firefighters must

develop a level of mastery at their level so the supervisors have confidence that tasks will be or

are being performed as well as or better than they could. While we need to mitigate relatively

simple problems, early, before they get out of hand, and save lives, we should always take a

second and make this consideration. Many of these examples are plain and simple staffing

deficits.

Incident Commander Involved at Task LevelRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

50%

33%

43%

0%

20%

33%

20%

43%

14%

67%

43%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Pre-Incident Planning Needs 29% of the reports showed needs involving pre-incident planning. This was the 8th

most frequent factor of the 25. Every department should have a pre-incident planning

program. A good source list for development, that combined covers the subject

comprehensively and from a practical approach includes, NFPA standard 1620 – Pre-Incident

Planning, Alan Brunacini’s “Fire Command”, and NFPA’s , “Structural Firefighting”, by

Bernard J. “Ben” Klaene & Russell E. Sanders.

We need to start our size-up before the incident ever happens. Pre-incident planning

does not have to only involve buildings and structure fires. It may also cover typical non-


49

building fires, technical rescue, or hazardous materials incidents. Frank Brannigan, author of

“Building Construction For The Fire Service” strongly encouraged us to “Know your

buildings”. We want to ascertain things like construction features, obscure hazards, and

ventilation profiles prior to a middle of the night emergency. There are varying amounts of

information we want or need at the scene on each of our properties. Some we will want

“complex” pre-incident plans, such as strip malls, hospitals, and industrial complexes. In most

cases, we will only want a single building pre-plan. This could be the layout of a typically

constructed house in our response district. Some may require only a partial plan, or a small bit

of information or a note, for example an owner or tenant has called us to let us know about

oxygen tanks or there is a handicapped person on the second floor.

Priority criteria for properties to preplan are based on complexity, civilian life hazard,

and firefighter hazard. Each property could be assigned a judged numerical value of 1 through

5. The properties with higher totals would be prioritized and completed first, and so on. The

fire service needs to take advantage of modern technology to decrease our risk and add to

efficiency. This is another example of a staffing deficit that hinders our ability to enhance the

way we do our job. This takes an educated fire safety professional to coordinate a program

from design, to information gathering, to system implementation, to final plan production,

and ongoing revisions.

Pre-Incident Planning DeficiencyRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

0%

33%

14%17%

60%

50%

40%

14%

43%

0%0%

-20%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


50

Basement Fire - 1st Floor Entry About a fourth of the fatality reports pointed out the issue of entering the first floor

over a basement fire. Many firefighters fall through the first floor after making entry. Many

times the actual location of the fire is unknown. This lack of information can be eliminated

with a proper size-up with a walk around and use of a thermal imager. Firefighters should not

enter an area over the fire until the area below is at least under the control of hose attack

crews on the same floor, and preferably when the structural integrity has been reasonably been

confirmed. I know of a few examples in years passed, where firefighters fell through the floor,

but there were numerous firefighters and hose lines in place where they fell through. The

firefighter was injured but not killed. Now, when the same thing occurs, there is no crew or

hose line beneath. The firefighter succumbs to an untenable fire environment and/or

disorientation.

We also teach firefighters to use a roof ladder when ventilating a roof. This is to keep

him or her from sliding off, and to spread out the load of the firefighter to prevent collapse,

or in case it collapses. In this case we recognize we are cutting a hole over the hottest part of

the fire. We are careful of this potential failure of the roof structure, and similarly we should

be very wary of floor structures over basement fires.

When the basement is on fire and other floors are involved, the basement should be

the first attack entry point. An attempt should be made to vent the basement preferably on the

hottest (burn) side to the outside. The concept of protecting the interior stairs from the rest of

the building must be accomplished by a second crew, only after the basement is well

controlled, or enough where a fall through firefighter will not lose his life from burns or

asphyxiation. There will be crews below with coverage of the entire basement area. Fires need

to be fought from the lower levels up, because we all know heat rises. There are many

examples of firefighters killed operating above the fire floor.


51

When a basement on fire has an exterior entrance, this should be the fire attack point.

When a basement has an exterior stair entrance and an interior stair entrance, the exterior

stairs is our best bet for safety. This is because both may cause us to descend stairs (down a

chimney), but the exterior has less chance to be burned out. The path to the interior stairs may

not be structurally sound, and a fall through leaves one needing to ascend out a hole for

orientation and escape out of the hazard. The exterior stair entrance will provide an escape

path more often even with structural collapse of the floor above. A fall through the floor

many times leaves you without your hose line for protection, and orientation back to the

safety escape. Whereas, a first floor collapse when you have entered the basement, at least

leaves you with your hose line. When a flashover occurs in the basement, an exterior stair

escape path provides a much shorter, direct, albeit untenable path to safety, than the interior

stairs (chimney). In the interior stairs, when the stairs are ascended, we still have to maneuver

on the first floor to get to safety. We will likely have to endure a second untenable

environment on the first floor while attempting to escape.

We should consider wall breaches in basement fires more often depending on

construction.


52

Basement Fire - First Floor EntryRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

50%

0%

29%

50%

0%

33%

20%

14%

43%

67%

14%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Searching Without Either a Hose or Guide Rope One fourth of reports had firefighters becoming disoriented when not following a

hose line or rope line back to an area of safety. Firefighters should not overly rely on a right to

left or left to right search, except for the smaller area, simplest, “open” buildings. An “open”

building is one with a good set of windows. Windows serve as orientation guideposts, and

sources of emergency escape and access to help. A common finding is a non-line search above

the fire. This is the typical scenario in the 3am house fire. Fire is on lower levels, occupants are

probably on upper levels. This is performed on moderately sized homes routinely and even

those have experienced deadly disorientation. These same tactics on the modern, larger open

layout homes, businesses, and larger commercial stores, etc, become very dangerous.

Firefighters also became disoriented with sudden environmental changes to

“prolonged zero visibility”xiii. The concept of staying with a hose line or rope has limits also.

When the distance is greater, the chances of a firefighter losing the hose are also greater. The

concept of strict attack from unburned to burned areas must be revised in larger structures


53

such as commercial, supermarkets, or warehouses. These occupancies should probably have

been sprinklered. A few examples of excessive attack line loops in the interior and

intermingled, crossed attack lines contributed to disorientation or at least confusion and delay

of firefighter escape. Staffing must be available to properly advance, and withdraw attack lines.

We would prefer a straighter path of line to the exit with most of the extra line outside, but

this requires the extra staff to feed, retrieve, and withdraw line as needed.

When the fire is knocked down, smoke is vented high, fresh air is coming in low,

before the structural integrity is affected, search will be more successful. However, we must

have the staffing, and coordination of tactics to make this happen. It begins to look like a

“chain of survival” for interior firefighting.

Search Without Hose or GuidelineRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

25%

100%

29%

17%

0%

17%

0%

29% 29%

33%

43%

-20%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Cold Storage

Warehouse Fire.

Wooster, Mass.

Operating Above Fire Simply operating above the fire was a factor in 22% of all firefighter fatality reports.

This includes first floor entry above a basement fire, searching the upper floors over a fire,

and a vent crew on a roof. We are well aware that heat rises; causing smoke to rise, and this

weakens our work platform. Many of these tragedies can be avoided if “Operating Above


54

Fire” became “Operating Above a Well Under Control Fire”. This does not address the

structural weakness, but the fire and disorientation/asphyxia is usually the real killer in these

cases. Whether operating above a fire with or without a hose line, the danger is increased with

the rise in elevation in relation to the seat of the fire. However, the presence of available water

decreases risk. The added distance and need to descent through a chimney like area for escape

adds to this risk.

Operating Above The FireRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

25%

33%

29%

33%

0% 0%

20%

14%

43%

67%

14%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Water Problems About 21% of the fatality reports showed where water delivery problems were a

factor. Attack line kinking contributes to loss of water when needed. Fire behind attack crews

have burned through their attack line. This calls for a second or back-up line. Firefighters

must know the water is at the nozzle with air bled, before making entry into the fire

environment. Supply line tactics must be practiced at the pump hookup and at the hydrant.

We are emphasizing attack lines with adequate fire flow, but aren’t supplying the staffing to

handle these larger lines. We can deliver the needed fire flow through single large lines or


55

multiple, smaller more maneuverable lines, however may not have the staffing for either

option. Pumps, hose, and nozzles all need to be maintained like our lives depend on them.

Water Problem at AttackRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

25%

33%

14%

33%

0%

33%

0%

14% 14%

33%

29%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Lightweight Structural Members (Truss and Others) Ten cases of the sixty three had lightweight material assemblies involved in collapse.

These include bar joist trusses, 2” x 4” wood trusses, pre-fabricated wood I-joists, weight

suspended by metal rods, and both roofs and floors. This category is a subset of the overall

collapse factor that is the number 1 factor related to the fire science and the expected

outcomes of fire behavior.

Modern construction design’s challenge is to balance construction cost with structural

fire integrity. In a very broad, general sense, it is a struggle of mass vs. math. Overall, fire

resistance rises with more material mass, and construction cost rises with more material mass.

This applies to all building materials, specifically including wood and steel. As technology

advances, and advancements in computerization are realized, more precise design is made

possible that enables more and more efficient structural design. In this case, efficiency means


56

less material is constructed in a method that provides superior strength as an assembly. An

assembly requires connections to remain assembled. Many times these connections are the

first to go in a fire, and there goes the structural strength that was dependent on the assembly

being in place. Also, components with less mass react poorly in fire. Hence, more efficient,

lighter weight (mass) structural assemblies and components don’t do as well in a fire. The late

Frank Branniganxiv said, “In recent years, the economics of using geometry (e.g. truss shapes)

over mass had a tremendous effect on structures”.

FIRE RESISTANCE - Mass vs. Math

MATH

HIGH

LOW

MASS

HIGH

LOW

FIRE RESISTANCELOW HIGH

As more is known about actual fire severity, efficiency of fire safe design will increase,

however this will place more burden on inspection of construction and maintenance of the

same. This puts additional burden on the fire service to provide staffing properly. A good

example with the fallacy of design assumptions is the World Trade Center collapse. Fire

service experts predicted a catastrophic failure of these specific buildings with the right

circumstances long before it actually occurred. They compared these high rises to another

famous high rise, the Empire State Building. The Empire State Building was an example of the

use of more mass, whereas the WTC was a clever, efficient design. The Empire State Building

weighs about 23 lbs. per cubic foot, and modern high rises weigh about 8 lbs. per cubic foot.vii


57

The assumptions that had to be made did not imagine the fire load that occurred, with

the simultaneous loss of passive and active fire protection. A strong argument could be made

that the Empire State Building would have survived structurally to allow many more

occupants and rescuers to escape.

We are moving from a lower surface to mass ratio to a much higher surface to mass

ratio. Trusses are used for roof and floor structures. Compounding the problem is the fact

that they are also used to assist in spanning long distances to enable wide open spaces. The

connections of members are depended on for

the assembly strength. Steel connections are

vulnerable to heat, as well as adhesives are

also vulnerable in heat. Modern buildings

today are so dependent on compartmentation

that nearly any fire that breeches the inner

fire barrier into the structural frame will force

decisions with 2 bad choices, quick decisions for defensive attacks, or an increase even further

of firefighter injuries and fatalities. These newer buildings will not have much structural fire

resistance when you take away the inner shell and active fire protection.

Lightweight structural components have added to the building collapse hazard that

firefighters have always had to contend with. Staffing needs to contend with this challenge

relate to enhanced code development, code compliance inspections and enforcement to insure

protection of structural components, pre-incident planning so that we are aware of its

existence, and the ability to mitigate the problem rapidly before we fall through the building,

or the building falls on us and the public.


58

Lightweight Structural MembersRate of Factors Per Year of


1996 thru 2007

11 Year Trend

100%

0% 0%

43%

0% 0%

17%20%

0%

29%

67%

14%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Searching a Smoke Filled Area Without the Protection of Water This factor was present in about 1 out of every 6 fatality reports. Searching the fire

floor away from the attack line contains a degree of hazard as extension can get beyond the

attack crew’s coverage. This factor was more frequently seen while conducting search on the

floors above the fire floor without a hose line. Residential fires contain the vertical chimney

effect with the interior stairs. The protection of the stairs is critical, as well as availability of

firefighter emergency escapes at windows, and controlled ventilation of the upper stories. This

all takes proper staffing, and coordination by seasoned officers. When doing anything above

the fire, we must use extreme caution. When entering a window from a ladder or roof,

consider the difficulty of getting back out the window when needed.

Upper floor window escapes frequently require large rear or side ground ladder

placement on sides inaccessible by aerial ladders, or without porch roofs. The rear of many

apartment buildings or homes have greater height from ground. This also takes staffing. An

argument could be made that ladder work has fallen off in departments with staffing deficits.


59

Search Without WaterRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0% 0%

67%

29%

17%

0%

17%

0%

14% 14%

33%

14%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Cold Storage

Warehouse Fire.

Wooster, Mass.

No Backup Line Provided 14% of reports contained this factor. The attack crew is entering an unknown hostile

environment. Bad things can happen. The fire can intensify. The crew can fall through a hole.

There can be nozzle problems or kink in the line thereby diminishing flow. The flow needed

may have been underestimated. The attack crew may be blocked from behind by flare-ups.

The second line should be of the same or greater size as the first, and staffed properly. The

second line is not a back-up if it goes in a different direction. One out of every six scenarios

contained this factor. This included back-up lines that were uncharged, roof vent crews with

no protection line, and backup lines that ended up on the wrong floor. There were firefighters

being severely burned when falling through a floor, and unable to use their first line for

protection, and simply losing water in their attack line because of kinking, with no back-up

line and crew. This fundamental tactic has been sacrificed due to limited staffing.


60

Back-up LineRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

25%

0% 0%

17%

20%

17%

20%

0%

43%

33%

14%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Defensive Strategic Mode While Also Offensive Strategic Mode 14% of the reports contained this factor. Defensive mode tactics contain opposing

hose streams, large and dense streams that cause structural collapse. Most defensive

operations are “surround and drown” type events. The natural upward and outward escape of

heat and combustion products is reversed when streams are initiated from elevated streams

that many times are necessarily directed downwardly. This is no place for firefighters to be

conducting offensive operations. Exterior attacks in one portion of a building usually affect

interior firefighters in other parts of the building.

All members must be aware of the strategic mode of operations. All members must be

accounted for and in safe positions when switching from offensive to defensive.


61

Defensive Offensive Strategy OverlapRate of Factors Per Year of


1996 thru 2007

11 Year Trend

0%

50%

0%

14%

17%

20%

0%

20%

0% 0%

33%

14%

-10%

0%

10%

20%

30%

40%

50%

60%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Delayed Alarm 10% of the cases had this as a factor in firefighter fatalities. Delayed alarms let the fire

intensify. The recommended response time recognized by NFPA is centered on making an

interior attack prior to flashover. Delayed alarms push attacking firefighters into the flashover

point in time, or past flashover into the period of time where passive fire protection has been

compromised and fire affects the structural components. This is a crucial concept to teach the

general public. Many concepts are in place to allow occupant escape. Delayed alarms directly

cut in to firefighter escape time. Public use of portable fire extinguishers has good points and

bad. The good is that small fires can be stopped. The bad is FD notification can be delayed,

and occupants may become trapped while attempting self-extinguishment. In one case,

extinguishers were used for 15 minutes before the fire dept. was notified and a firefighter died.


62

Opposing Attack Directions Five of the reports had issues with opposing attack direction or opposing lines. This

has been a tactical error for many decades. Coordination and prevention of free-lancing will

go along way in preventing this.

Attack Line Pulled Out of Hazard Zone Prior to Exit of All Firefighters In three separate instances the chance for distressed, lost firefighters to find their way

to the exit using the hose line was prevented. This sometimes occurs because poor

accountability and control was carried out. No one knew there were still firefighters that were

finding their way out. Attack lines must not be removed until command approves it, and this

is only after a Personnel Accountability Report reveals all hands are safe. We must always

consider the attack line as a “lifeline”.

Fire Attack Entry (Safe Point) Large Distance to Fire Attack At least a couple of the reports showed where entering a smoke filled building a long

distance from the fire attack is asking for trouble. The longer the distance, the greater the risk

of disorientation, underestimating the escape air needed, and increasing the difficulty in

firefighter rescue when bad things occur. A very long hose line is difficult to advance, and

takes many firefighters. Part of this may be using the everyday residential fire as a model of

success on commercial fires. In these fires, we can enter the front door, attack from the

unburned side, and push it out the burned side. This is still ideal, but the distance factor on

larger occupancies effects safety. We may do better in these cases by attacking from the flank,

and attempting to push the fire to the closest exterior wall. The vent still needs to be close

horizontally and high, above the fire as safety permits. If this can not be accomplished, we

should fight it defensively. It probably should have been sprinklered. One case was a large


63

warehouse, and another was a front door entry of a supermarket to fire in the rear of the

store.

Electrical Utility Control Two fatalities were caused by electrocution. One fatality was delayed about 5 years, as the

firefighter suffered significant heart damage from the injury years before death. Fire command

must call for electrical service companies to shut down power as early as possible in a fire

incident. Power utility companies must be encouraged to decrease response times, and our

dependence on them must be stressed. Firefighters should shut off power at circuit panels in

buildings if possible to do so safely while awaiting power crews. This will at least power down

most of the building. When lines are down, a safety officer should be stationed in close

proximity to the hazard, but in a safe position to guard others from coming in contact.

Alternatively, physical barriers may be placed around a dangerous hot zone.


64

The following is an abbreviated list of the 25 factors with associated action items.

ACTION ITEMS

FACTOR PROACTIVE PREVENTATIVE PRACTICES

Refine use proper command system use

Provide for command personnel arrival earlier in incident

1 Command System, Organization, Transfer of Command

Insure transfer of critical information from one individual in command to another.

Minimize transfer of command

Provide enough staffing for incident Equip and anticipate needs for rescue

Use RIT to make scene safer for working crews

When RIT is used, assign second RIT

Stay out of unsafe areas

2 Rapid Intervention Team RESCUE (REACTIVE)

Maintain readiness

Have enough staffing for an adequate “ON Deck” complement or “Tactical Reserve”

A key factor. A poor location of the exit will be adverse

A lack of or an increase in ventilation can trigger rapidly changing conditions, such as flashover, backdraft, smoke explosion, or sudden zero visibility.

PPV must be used with extreme caution 3 Ventilation

Location of Vent in relation to seat of fire generally should occur vertically higher and horizontally closest to exterior in relation to fire

Fire location should be known and controllable prior to PPV.

4 Staffing Inadequacy or Delayed Follow NFPA standards on staffing. Consider NFPA 1710 & 1720 as minimum standards

Know building construction and reaction to fire

Designate & Enforce Collapse Zones 5 Collapse

Proper Strategic Decision Making Good Command and Control

6 Thermal Imager Use this technology for exterior size-up and interior assessment and orientation assist.

7 Accountability Command should be able to know at All Times for each FF: Location, Function, Level of Hazard, Who They Report To, Who reports to them, Radio Identifier

8 No Separate Safety Officer Provide enough staffing for incident Educate officer on role of ISO

Perform risk analysis Adjust strategy as needed

9 Inappropriate Strategy Re-evaluate risk analysis continually

Make decisions based not only on possibilities, but consider probabilities.

All FFs in Hazardous Location to be Within Close Proximity of Buddy.

Crews of 2 to 5 should stay together into hazard, and out of hazard. 10 Buddy System/Crew Integrity Good Accountability

Provide enough staffing for incident Enforce officer discipline at scenes 11 IC involved in tasks

Educate officers with importance of command functions

Gather and organize pre-incident information Prioritize planning. 12 Pre-Incident Planning

Anticipate technical questions and find answers prior to critical need


65

Be Aware of Fire Location.

Do Not Make Attack Line Entry Down Chimney (Interior Stairs)

Good Size-Up Only enter above fire when floor is known to be intact. 13 Basement Fire - 1st Floor Entry

Use TIC Enter on lowest level of fire location

14 Search w/out hose or guideline Discourage use of this tactic and utilize this only for the smallest, simplest, open spaces.

Be aware of Danger Above Fire Avoid Operating Above Fire

Be Aware of Fire Location Operate with Attack Line 15 Operating Above Fire

Good Size-Up. Use TIC Control Fire Below Prior to Entry Above

16 Water Problem Avoid Attack line kinks. Insure pump operability Insure use of prompt water source

Know building construction and reaction to fire

Proper Strategic Decision Making 17 LTWT Structural Members Encourage safer building design and construction standards

18 Search w/out water Have adequately staffed attack line coverage in spaces where there is a possibility of a heat related untenable environment development

19 Backup Line Provide for adequately staffed second line or backup line

Good Accountability of Location of All FFs. 20 Defensive Offensive Overlap

Make all FFs Aware of Strategy

Ensure All FFs are in safe positions

21 Delayed Alarm Teach Importance of Early FD Notification to the Public

Coordinate Attack Don’t mix exterior attacks with interior attacks 22 Opposing Attack Directions

Attack in 1 direction. Be aware of all crew locations

23 Attack Line Pulled Out Prior to ALL FFs out.

Account for all personnel’s Locations.

Last Out Crew Removes line While Protecting their Retreat.

24 Fire Attack crew large distance from entry (safe point)

Fight Fire from Unburned to Burn. However, in large spaces: MINIMIZE DISTANCE FROM SAFE AREA (OUTSIDE) TO ATTACK POINT

Shorten response time of utility services 25 Utility Control

Make the fireground environment as safe as possible as soon as possible for all FFs. Shut down utilities as soon as possible


66

Number of Factors Found Added From All Reports Per Each Year

24

43

32

29

38

24

40

63

28

48

0

10

20

30

40

50

60

70

2007200620052004200320022001200019991998

Factors Per Report - Timeline Trend

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Jan-

85

Jan-

86

Jan-

87

Jan-

88

Jan-

89

Jan-

90

Jan-

91

Jan-

92

Jan-

93

Jan-

94

Jan-

95

Jan-

96

Jan-

97

Jan-

98

Jan-

99

Jan-

00

Jan-

01

Jan-

02

Jan-

03

Jan-

04

Jan-

05

Jan-

06

Jan-

07


67

Factors Per Report 1998 - 2007

0

2

4

6

8

10

12

14

Jan-98

Apr-98

Jul-98

Oct-98

Jan-99

Apr-99

Jul-99

Oct-99

Jan-00

Apr-00

Jul-00

Oct-00

Jan-01

Apr-01

Jul-01

Oct-01

Jan-02

Apr-02

Jul-02

Oct-02

Jan-03

Apr-03

Jul-03

Oct-03

Jan-04

Apr-04

Jul-04

Oct-04

Jan-05

Apr-05

Jul-05

Oct-05

Jan-06

Apr-06

Jul-06

Oct-06

Jan-07

Apr-07

Jul-07

Oct-07

Factors Per Report 1998 - 2007

0

2

4

6

8

10

12

14

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


68

Factors Per Report - Timeline Trend

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Jan-

85

Jan-

86

Jan-

87

Jan-

88

Jan-

89

Jan-

90

Jan-

91

Jan-

92

Jan-

93

Jan-

94

Jan-

95

Jan-

96

Jan-

97

Jan-

98

Jan-

99

Jan-

00

Jan-

01

Jan-

02

Jan-

03

Jan-

04

Jan-

05

Jan-

06

Jan-

07

FIREFIGHTER FATALITIES PROPORTION BY DUTY

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

Fireground, Firefighting

Responding, returning

On scene, at non-fire calls

Training

Other on-duty


69

FF Deaths By Fireground Duty

43%

47%

50%

49%66%

54%

55%52%

53%50%

49%40%

41%48%

50%44%

49%

51%

58%

43%33%

41%

44%50%

38%

37%

27%

29%

29%43%

35%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

FF Deaths by Responding or Returning

27%

20%

26%28%

16%27%

26%31%

23%

31%

26%35%

28%

29%25%

22%

24%28%

18%33%

33%

27%19%

29%

23%

25%

35%

34%30%

20%29%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007


70

FF Deaths by On Scene Non-Fire

10.1%

10.3%

8.9%11.0%

7.2%

6.5%

5.9%6.3%

10.6%

6.7%7.0%

5.0%9.1%

7.4%

5.1%15.7%

7.4%

5.3%

6.7%

12.2%

8.3%12.1%

16.5%

8.9%7.8%

1.9%

8.5%8.6%

4.6%

6.7%

6.9%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

FF Deaths By Training

8.9%

11.3%

6.4%2.9%

2.4%

2.9%

5.1%4.7%

3.5%2.5%

4.7%

5.0%12.9%

8.1%10.2%

7.4%13.0%

6.7%

6.7%4.1%

8.3%

7.1%

12.1%

3.6%13.6%

11.7%

11.3%11.4%

12.6%9.0%

12.7%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007


71

FF Deaths By Other On Duty

11.4%

11.3%

8.9%

9.8%

8.0%

10.1%8.1%

5.5%

9.7%

10.1%

13.3%

14.3%9.1%

8.1%

10.2%10.2%

6.5%

9.3%

10.5%

8.2%16.7%

12.1%8.8%

8.9%17.5%

24.3%

17.9%

17.1%24.1%

21.3%15.7%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007


72

ACKNOWLEDGEMENTS

i International Association of Fire Fighters, “NFPA 1710 A Standard for Every Professional Fire

Department”

http://www.iaff.org/et/modules/1710/index.htm and

National Fire Protection Association, “NFPA Standard 1710: Standard for the Organization and Deployment

of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by

Career Fire Departments”, http://www.nfpa.org/freecodes/free_access_document.asp?id=171004

ii National Fire Protection Association, “NFPA Standard 1720: Standard for the Organization and

Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the

Public by Volunteer Fire Departments, 2004 Edition”,

http://www.nfpa.org/freecodes/free_access_document.asp?id=172004

iii National Fire Protection Association, Fire Analysis and Research Division, U.S. Fire Service Fatalities in

Structure Fires, 1977-2000, Rita F. Fahy Ph.D., July 2002,

iv National Fire Protection Association, Fire Analysis and Research Division, “The U.S. Fire Problem”

http://www.nfpa.org/itemDetail.asp?categoryID=953&itemID=23072&URL=Research%20&%20Reports/Fi

re%20statistics/The%20U.S.%20fire%20problem

v National Institute For Occupational Safety and Health, Fire Fighter Fatality Investigation and Prevention

Program, Fire Fighter Fatality Investigation Reports

http://www2a.cdc.gov/NIOSH-fire-fighter-face/state.asp?state=ALL&Incident_Year=ALL&Submit=Submit

Report

No.

Incident

Date

Title

F2007-07 11/16/07 Volunteer fire fighter dies after falling through floor supported by engineered wooden-I beams

at residential structure fire - Tennessee

F2007-12 4/16/07 Career fire fighter dies in wind driven residential structure fire - Virginia

F2007-08 2/4/07 Career fire fighter dies when trapped by collapsed canopy during a two alarm attached garage

fire - Pennsylvania

F2007-01 12/30/06 Career fire fighter dies and chief is injured when struck by 130-foot awning that collapses

during a commercial building fire - Texas

F2006-28 10/10/06 Career fire fighter dies in residential row house structure fire - Maryland

F2006-27 8/27/06 Floor collapse at commercial structure fire claims the lives of one career lieutenant and one

career fire fighter - New York

F2006-26 8/13/06 Career engineer dies and fire fighter injured after falling through floor while conducting a

primary search at a residential structure fire - Wisconsin

F2006-24 6/25/06 Volunteer deputy fire chief dies after falling through floor hole in residential structure during

fire attack - Indiana

F2006-19 5/14/06 Career Lieutenant dies in residential structure fire - Colorado

F2006-07 2/21/06 Two volunteer fire fighters die when struck by exterior wall collapse at a commercial building

fire overhaul - Alabama

F2005-34 11/7/05 Career fire fighter killed while riding manlift to assess a silo fire - Missouri

F2005-13 4/18/05 A volunteer fire fighter and volunteer assistant lieutenant die after a smoke explosion at a town

house complex - Wyoming

F2005-09 2/19/05 Career fire captain dies when trapped by partial roof collapse in a vacant house fire - Texas


73

F2005-07 2/13/05 Career captain electrocuted at the scene of a residential structure fire - California

F2005-04 1/23/05 Career fire fighter dies while exiting residential basement fire - New York

F2005-03 1/23/05 Career lieutenant and career fire fighter die and four career fire fighters are seriously injured

during a three alarm apartment fire - New York

F2005-05 1/20/05 Career captain dies after running out of air at a residential structure fire - Michigan

F2005-02 12/20/04 One probationary career firefighter dies and four career firefighters are injured at a two - alarm

residential structure fire - Texas

F2004-37 4/8/04 Volunteer chief dies and two fire fighters are injured by a collapsing church facade - Tennessee

F2004-14 4/4/04 Career fire fighter dies and two career captains are injured while fighting night club arson fire -

Texas

F2004-10 2/18/04 Career fire fighter dies searching for fire in a restaurant/lounge - Missouri

F2004-05 1/9/04 Residential basement fire claims the life of career lieutenant - Pennsylvania

F2004-04 12/16/03 Career fire fighter dies of carbon monoxide poisoning after becoming lost while searching for

the seat of a fire in warehouse - New York

F2004-02 11/29/03 Basement fire claims the life of volunteer fire fighter - Massachusetts

F2003-18 6/15/03 Partial roof collapse in commercial structure fire claims the lives of two career fire fighters -

Tennessee

F2003-12 3/31/03 Career fire fighter dies and two career fire fighters injured in a flashover during a house fire -

Ohio

F2003-04 1/20/03 Career firefighter dies from injuries received during a chimney and structural collapse after a

house fire - Pennsylvania

F2003-03 1/19/03 Volunteer fire fighter dies following nitrous oxide cylinder explosion while fighting a

commercial structure fire - Texas

F2002-50 11/25/02 Structural collapse at an auto parts store fire claims the lives of one career lieutenant and two

volunteer fire fighters - Oregon

F2002-49 11/1/02 Volunteer lieutenant dies following structure collapse at residential house fire - Pennsylvania

F2002-44 9/30/02 Parapet wall collapse at auto body shop claims life of career captain and injures career lieutenant

and emergency medical technician - Indiana

F2002-40 9/14/02 Career fire fighter dies after roof collapse following roof ventilation - Iowa

F2002-07 2/11/02 One career fire fighter dies and another is injured after partial structural collapse - Texas

F2001-33 10/13/01 High-rise apartment fire claims the life of one career fire fighter (captain) and injures another

career fire fighter (captain) - Texas



F2001-16 3/8/01 Career fire fighter dies after falling through the floor fighting a structure fire at a local residence

- Ohio

F2001-08 2/17/01 Two volunteer fire fighters die fighting a basement fire - Illinois


74

F2001-04 1/11/01 Volunteer fire fighter (lieutenant) killed and one fire fighter injured during mobile home fire -

Pennsylvania

F2001-03 12/28/00 Roof collapse injures four career fire fighters at a church fire - Arkansas

F2000-44 11/25/00 Residential house fire claims the life of one career fire fighter - Florida

F2000-43 10/29/00 A volunteer assistant chief was seriously injured and two volunteer fire fighters were injured

while fighting a townhouse fire - Delaware

F2000-26 4/20/00 Residential structure fire claims the life of one career fire fighter - Alabama

F2000-23 3/31/00 Career fire fighter dies and three are injured in a residential garage fire - Utah

F2000-16 3/3/00 Arson fire claims the life of one volunteer fire fighter and one civilian and severely injures

another volunteer fire fighter - Michigan

F2000-13 2/14/00 Restaurant fire claims the life of two career fire fighters - Texas

F2000-04 12/22/99 Structure fire claims the lives of three career fire fighters and three children - Iowa

99-F48 12/18/99 Warehouse fire claims the life of a battalion chief - Missouri

99-F47 12/3/99 Six career fire fighters killed in cold-storage and warehouse building fire - Massachusetts

99-F04 12/31/98 Roof collapse in arson church fire claims the life of volunteer fire fighter - Georgia

98-F21 8/29/98 Commercial building fire claims the lives of two volunteer fire fighters - Mississippi

98-F18 7/11/98 Vacant dwelling fire injures two fire fighters - Virginia

98-F07 3/8/98 Commercial structure fire claims the life of one fire fighter - California

98-F05 2/11/98 Backdraft in commercial building claims the lives of two fire fighters, injures three, and five fire

fighters barely escape - Illinois

98-F06 2/5/98 Single-family dwelling fire claims the lives of two volunteer fire fighters - Ohio


98-03 10/27/97 Two fire fighters die of smoke and soot inhalation in residential fire - Pennsylvania

97-09 8/19/97 Restaurant/tavern fire results in the death of one fire fighter and serious injuries to three other

fire fighters - Indiana

97-16 7/4/97 One fire fighter dies of smoke inhalation, one overcome by smoke while fighting an attic fire -

New York

97-04 2/17/97 Floor collapse in a single family dwelling fire claims the life of one fire fighter and injures

another - Kentucky

96-17 3/18/96 Sudden roof collapse of a burning auto parts store claims the lives of two fire fighters - Virginia,

March 18, 1996

F2001-28 12/23/95 Fire fighter receives severe electrical shock causing cardiac complications, forcing his

retirement, and eventually causing his death - Massachusetts

85-49 8/27/85 Three fire fighters killed fighting silo fire in Ohio


75

vi National institute for Occupational Safety and Health, Fire Fighter Fatality Investigation and Prevention Program, Fire Fighter Fatality Investigation Reports, “Partial Roof Collapse in Commercial Structure Fire

Claims the Lives of Two Career Fire Fighters – Tennessee,

http://www.cdc.gov/niosh/fire/reports/face200318.html vii National Fire Protection Association, Fire Analysis and Research Division, “FIREFIGHTER

FATALITIES IN THE UNITED STATES – 2007”, Rita F. Fahy, Paul R. LeBlanc, Joseph L. Molis, June

2007, http://www.nfpa.org/assets/files/PDF/osfff.pdfl viii Steve Kreis, Asst. Chief, Phoenix Fire Dept., Fire Times, “Rapid Intervention Isn't Rapid”, May, 2003

http://www.firetimes.com/story.asp?FragID=8399

ix National Fire Protection Association, Bernard J. “Ben” Klaene & Russell E. Sanders, “Structural

Firefighting”, 2000.

x National Institute of Standards and Technology, “Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002”, NISTIR 7069 (November, 2003),http://fire.nist.gov/bfrlpubs/fire03/PDF/f03024.pdf

xi http://everyonegoeshome.com

xii Jeff Goins, Fire Engineering, “Risk Analysis at Normally Occupied Structure Incidents”, October 29,

2007 http://www.fireengineering.com/display_article/310355/25/none/none/BRNIS/Risk-Analysis-at-Normally-Occupied-Structure-

Incidents

xiii Captain William R. Mora, San Antonio Fire Department, San Antonio, Texas, “U.S. Firefighter

Disorientation Study

1979 – 2001”, July 2003

xiv Brannigan, Francis L., “Building Construction For The Fire Service” 3

rd Edition, N.F.P.A., 1992

Documents

Proper Staffing Makes Proper Tactics Makes Firefighters ...ceas.uc.edu/content/dam/aero/docs/fire/Papers/Staffing_Tactics_FF... · Proper Staffing Makes Proper Tactics Makes Firefighters