Lessons learned from a July 28, 2011 fire in a multi-story office building
NIOSH Fire Fighter Fatality Investigation and Prevention
On July 28, 2011, a 37-year-old career captain died and 9 fire fighters were injured in a 6-story medical building fire while searching for the seat of the fire. At 1228 hours, dispatch sent four companies (2 engines, 1 truck, and a squad company) to an automatic fire alarm at a multistory medical building.
Engine 2 reported a working fire with heavy smoke and fire showing on the top floor rear of structure and requested a second alarm. Instead, the dispatch center sent a Division Chief, Battalion Chief, Safety Officer, Engine Company, Rescue company, and Fire Marshal as the complement for a working fire first alarm. Engine 2 fire fighters connected 100 feet of 2½-inch hoseline to the standpipe in the stairwell on the top floor. Engine 2 flowed water for several seconds when their low-air alarms went off and they exited the structure. Rescue 3 took the hoseline but had issues getting water to flow. The top two floors and north stairwell were now heavy with smoke.
Ladder 1 was setting up at the A/B corner to access a window on the 6th level (labeled 5th floor), side B. Two of Rescue 3’s members were getting low on air, and the crew moved to the stairwell to exit the building. Two of the members exited the stairwell, but the captain (the victim) went down the hallway and two fire fighters followed him. The low-air alarms of the victim and two fire fighters were sounding when they reached the hallway that was connected to the fire rooms.
One of the fire fighters grabbed the victim, who was acting confused, and started back to the stairwell. The other fire fighter got separated in heavy smoke, went toward the fire room, and made it to a window where the platform of Ladder 1 was located just as he ran out of air.
The victim ran out of air and told his partner they needed to buddy breath. The victim unclipped his regulator as his partner connected the buddy breather and all the partner’s air escaped through the victim’s SCBA. The victim transmitted a Mayday and activated his PASS (personal alert safety system). The fire fighter also attempted to activate his PASS, called several Maydays prior to removing his mask and began looking for an escape path.
At some point, the victim vomited in his facepiece and removed it. The fire fighter crawled down a hallway trying to open several doors unsuccessfully until he found a door he could open to the south stairwell. The fire fighter placed his axe in the door and then returned to the victim. The fire fighter grabbed the victim and pulled him to the south stairwell where he collapsed and the pair fell down a flight of stairs.
The victim and the fire fighter were eventually located in the south stairwell by another officer who had exited the north stairwell and heard the victim’s PASS alarm sounding. Medic units transported the victim and the fire fighter to the hospital.
Lack of an automatic fire suppression system
Multistory/high-rise standard operating procedures not followed
Air management doctrine not followed
Reverse stack effect in stairwell
Inadequate strategy and tactics
Task saturation of the incident commander
Ensure that the existing standard operating procedures for high-rise fire-fighting operations are reviewed, implemented, and enforced.
Ensure that a deployment strategy for low-frequency/high-risk incidents is developed and implemented.
Ensure that the incident commander develops an incident action plan, which is communicated to all fire fighters on scene, and includes effective strategy and tactics for high-rise operations, a timely coordinated fire attack, and a coordinated search plan.
Ensure that the incident commander utilizes division/group supervisors for effective tactical-level management.
Ensure that fire fighters are properly trained in air management.
Ensure that fire fighters are properly trained in out-of-air SCBA emergencies and SCBA repetitive skills training (e.g., buddy breathing and clearing a facepiece)
Ensure that the incident commander is provided a chief’s aide to assist in incident management, including communications and personnel accountability.
Ensure that the incident commander establishes a stationary command post for effective incident management, which includes the use of a tactical worksheet, enhanced fireground communications, and a personnel accountability system.
Ensure that fire fighters are properly trained in Mayday standard operating procedures and survival techniques.