NIOSH SUMMARY
On October 29, 2007, four male career fire fighters ranging in ages from 23 to 38 years were injured while providing interior exposure protection at a residential row house fire. The victims had
advanced a 1 ½-inch handline up to the second floor of the exposure building where they encountered heavy smoke and fire in a room in the back of the structure.
Fire fighting and search activities commenced and shortly thereafter and without warning, the fire progressed up the stairwell from the first floor and up the exterior back wall temporarily trapping the victims. All four victims retreated down the stairwell and out of the building where they were met by other fire fighters who provided assistance. Each of the victims suffered burn injuries.
NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should:
•ensure adequate size-up, including in exposure buildings, to reduce the risk of fire fighters
being trapped
• ensure that fire fighters are trained on the hazards of operating on the floor above the fire
without a charged hoseline, and to follow associated standard operating guidelines (SOGs)
• ensure ventilation is coordinated with the interior attack
• provide fire fighters with station/work uniforms (e.g., pants and shirts) that are compliant
with NFPA 1975 and ensure the use and proper care of these garments
• ensure that fire fighters are trained on initiating Mayday radio transmissions immediately
when they are in distress, and/or become lost or trapped
Recommendation #1: Fire departments should ensure adequate size-up, including in exposure buildings, to reduce the risk of fire fighters being trapped.
Discussion: Vincent Dunn’s Safety and Survival on the Fireground lists several precautions that fire
fighters can take to reduce the risk of being trapped. These precautions include, but are not limited to, the following:1-2
1. Notifying your officer when you go above a fire. Even if your assignment has been preplanned,
inform your officer by portable radio. This information is a form of fireground control that increases fire fighter safety. An IC should know where all of his assigned fire fighters are operating during a fire.
2. Sizing up the fire. Most fire fighters are trapped on a floor above a fire because they failed to size up the fire below them. The condition on the fire floor should be analyzed before going above. Firefighters should attempt to determine the approximate location of the fire.
Next, the size and intensity of the fire should be observed to see if the fire can be extinguished by the hose attack team. If the fire appears beyond control of the fire fighters operating the hose line, they should not go above.
3. Sizing up the stairway design. The type of stairway leading to the floor above must also be
evaluated by the fire fighter. An open stairway, such as the one found in this structure, is the most
dangerous stairway a fire fighter can climb when operating above a fire. It becomes a chimney flue,
allowing the flame, heat, smoke, and toxic gases generated by the fire below to flow up the open
stairway leading to the second-floor rooms.
4. Sizing up a second exit for escape. If the interior stairs used by fire fighters to go above a fire
suddenly become filled with heat and flames, they cannot use this path to get back down. They must locate a second exit for their emergency escape.
Before entering a burning building to search above the fire, fire fighters should examine the front of the structure and look for a second exit. A portable ladder already raised to a second floor bedroom window, a porch roof, or fire escape may provide an escape if the interior stairs become impassable because of fire.
5. Building construction size-up. The degree of danger or threat of being trapped above a fire is
greatly influenced by the construction of the building. A wood-frame building poses the greatest
threat to fire fighters who must search above a fire. Vertical fire spread is more rapid in this type of structure. The three common types of vertical fire spread are stairways, windows, and concealed
spaces.
In addition to these three, the wood-frame construction offers a combustible exterior that
would also allow vertical fire spread on the exterior of the building. In order for fire fighters to work safely, efficiently and effectively on the fireground above a fire, they must at a minimum, follow the aforementioned precautions which include, but are not limited to:
1 Notifying your officer when you go above a fire,
2 Sizing up the fire,
3 Sizing up the stairway design,
4 Sizing up a second exit for escape, and 5 Sizing up building construction. Fire departments should
train and routinely retrain fire fighters on the importance of following standard operational guidelines for size up.
Recommendation #2: Fire departments should ensure that fire fighters are trained on the
importance of using a backup hoseline when operating on the floor above a fire, and to follow
associated departmental standard operating guidelines (SOGs).
Discussion: The most dangerous location on the fire ground is operating above the fire, especially
during operations without the protection of a backup hoseline.1,3 Before operating above a fire, it is a good practice to deploy a backup hoseline. Where there is risk of extension to concealed spaces, a backup hoseline is needed. According to Dunn, fire fighters are most often trapped on a floor above a fire because they fail to size-up the fire below them.1,3
Fire fighters should determine whether suppression teams are capable of extinguishing the fire and notify command. If not, then command should not permit fire fighters above the fire until conditions change. In this incident, fire fighters advanced to the second floor (floor above the fire) and commenced fire fighting and search activities without having first determined if there was vertical or horizontal fire extension in the exposure building, and reporting the conditions to the IC as prescribed in the standard operating guidelines. Additionally, fire fighting and search activities commenced without first having a backup hoseline in place and operational.
Recommendation #3: Fire departments should ensure ventilation is coordinated with the interior attack.
Discussion: Ventilation is performed to relieve the products of combustion, allowing fire fighters to
advance on the fire. When venting, the principle is to pull the fire, heat, smoke, and toxic gases away from victims, stairs, and other egress routes.
Horizontal ventilation does not release the heat and smoke directly above the fire; therefore, it is imperative that horizontal ventilation is coordinated with the interior crew to ensure that it doesn’t block their escape routes.
In this incident, shortly after the door on side-C of the exposure building was opened, the fire
immediately intensified forcing the victims to run down the stairs trying to escape. The victims were on the second floor when flames erupted up the stairway and up the outside wall on side-C of the exposure building, momentarily trapping the victims and putting them in distress.
Opening the door may have provided oxygen to ignite the unburned fuel on the first floor of the exposure building, and contributed to the rapid fire spread up the stairwell, which acted like a natural chimney, and up the outside wall on side-C.
Recommendation #4: Fire departments should provide fire fighters with station/work uniforms
(e.g., pants and shirts) that are compliant with NFPA 1975 and ensure the use and proper care ofthese garments.
Discussion: Fire fighters involved in structural fire fighting and other emergency activities should be provided, at a minimum, with station/work uniforms that are certified and compliant with NFPA 1975 in order to avoid the potential for burn injuries that are more severe as the result of using thermally unstable or rapidly deteriorating materials (e.g., fabrics that contain a significant portion of polyester or other synthetic easily melting fabrics).
Ideally, the prescribed station/work uniforms should also be flame resistant, certified to the optional requirements specified in NFPA 1975. The use of NFPA 1975-compliant station/work uniforms is specified in NFPA 1500 (paragraphs 7.1.5 and 7.1.6), which also requires departments to provide for the adequate cleaning of station/work uniforms provided to its members (7.1.7).5-6 In this case, the fire fighters were not supplied with nor were they wearing station/work uniforms that were compliant with NFPA 1975. Although not a specific factor in this incident, the wearing of polyester-based uniforms can contribute to significant potential for severe burn injury (see Appendix).
Recommendation #5: Fire departments should ensure that fire fighters are trained on initiating
Mayday radio transmissions immediately when they are in distress, and/or become lost or trapped.
Discussion: According to the fire department’s standard operating guidelines section on “Mayday,”
fireground communications can become very hectic and confusing when a fire fighter is in distress,
becomes lost or trapped. The term “Mayday” is the international distress signal, and should only be
used when a member is in trouble and needs immediate assistance. In this incident, a Mayday radio
transmission was made by an Officer when he encountered a fire fighter who was in distress on the
first floor of the exposure building.
A rapid intervention team was on scene and was activated, but the victims were already exiting the exposure building at that time. As soon as fire fighters become lost or disoriented, trapped or unsuccessful at finding their way out of the interior of structural fire, they must initiate emergency radio transmissions.7-8 They should announce "Mayday-Mayday-Mayday" over the radio and manually activate their personal alarm safety system (PASS) device. A Mayday call will receive the highest communications priority from dispatch, the IC, and all other units.
The sooner the IC is notified and a rapid intervention team is activated, the greater the chance of the fire fighter being rescued. A transmission of the Mayday situation should be followed by the fire fighter providing his last known location. A crew member who initiates a Mayday call for another person should quickly try to communicate with the missing member via radio and, if unsuccessful, initiate a Mayday providing relevant information.
A radio transmission reporting a trapped fire fighter is the highest priority transmission that command can receive. Mayday transmissions must always be acknowledged and immediate action must be taken. Although the victims never became trapped inside the structure they were in distress for some period of time and did not initiate a Mayday call. It is unknown whether initiation of a Mayday call in this instance would have resulted in either reduced rescue time and/or less severe injuries. Although the following does not appear to have been a contributing factor in the injuries resulting from this incident, NIOSH recommends that as a good safety practice
Recommendation #6: Fire departments should ensure all fire fighting personal protective equipmentensembles meet NFPA 1971 and are cleaned and maintained according to NFPA 1851.
Discussion: NFPA 1500 is clear on the requirement for fire departments to provide personal protective equipment ensembles that meet NFPA 1971 and are cleaned and maintained according to NFPA 1851.9-10 Though not specifically identified as a factor in this incident, the cleanliness of structural firefighting PPE has been a contributing factor in other burn injury incidents suffered by fire fighters. A cleaning and maintenance program that follows NFPA 1851 ensures to a greater degree that a soiled, carbon impregnated structural fire fighting PPE ensemble will not be a contributing factor.
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