Everyone Goes Home - Firefighter Life Safety Initiatives



Everyone Goes Home®-- THE 6 ROOT CAUSES OF Firefighter Line-of-Duty-Deaths

Introduction

Since 2004, the National Fallen Firefighters Foundation (NFFF) has spearheaded industry-wide efforts to reduce line-of-duty injuries and deaths among firefighters. Through its Everyone Goes Home® program, the NFFF and its fire service partners develop and deliver training courses, advance health and safety initiatives and support research that will ultimately result in increased firefighter safety. Each of these efforts is designed to substantially and quantifiably improve outcomes by promoting the individual and/or organizational changes—procedural, technical or cultural—that address the root causes of line-of-duty deaths.

When we discuss root causes, we are talking about the most basic identifiable elements of a LODD. The first step in addressing these root causes was to identify them through a thorough examination of the data found within the firefighter fatality reports issued by NIOSH, USFA, and other state and national organizations. Initially this may have seemed like a difficult task, because firefighters die in myriad ways, and no two fatalities are identical. However, as we review LODD cases we begin to find striking similarities, and the same contributing factors recur with unnerving frequency: failure to wear a seatbelt; failure to perform an adequate size-up; failure to obey traffic laws; inadequate respiratory protection; etc.

If we delve further into each of these contributing factors and ask “why?” then we can begin to identify the root factors behind each fatality. “Why wasn’t the firefighter wearing a seatbelt?” “Why did the incident commander fail to make an appropriate and thorough size-up?” “Why did the driver run the stop sign?” When we can see the answers to these questions it becomes apparent that there are often startling commonalities among fatalities that initially appeared as truly disparate scenarios. These factors are the organizational and individual situations, behaviors and attitudes that are the true root causes of the fatal incident:

➢ Ineffective Policies/Procedures

➢ Ineffective Decisions

➢ Lack of Preparedness

➢ Ineffective Leadership

➢ Lack of Personal Responsibility

➢ Extraordinary/Unpredictable Circumstances

It should be noted here that the majority of firefighter fatalities and/or serious injuries have multiple identifiable root causes. In fact, a LODD is almost never the result of a single personal mistake, procedural miscalculation or a mechanical malfunction. More likely, there was a chain of events that led up to the fatality, each link of which is characterized by the presence of one or more contributing factors. When we closely examine each of these identified missteps—or links in the chain of events—we can ultimately identify one or more root causes.

These six root causes of firefighter fatalities were first defined during the 2004 Tampa Firefighter Life Safety Summit. This meeting was coordinated by the National Fallen Firefighters Foundation in support of the United States Fire Administration’s goal of reducing the rates of firefighter deaths and injuries. At the time, approximately 100 firefighters were losing their lives annually in the line of duty in the U.S.—one every 80 hours. This Summit was an unprecedented gathering of representatives of every identifiable segment of the fire service unified behind this common goal, and included those of all major national fire service organizations, occupational health and safety experts and survivors of fallen firefighters.

For two days, participants deliberated over the cultural, philosophical, technical and procedural problems existing within the fire service, and jointly identified the most important domains. Over one hundred recommendations were put forth during the Summit, which were then narrowed into a set of key initiatives with which to define the mission of the effort going forward. By the conclusion of the meeting, the 16 Firefighter Life Safety Initiatives had been agreed upon, and the Everyone Goes Home® (EGH) program was created.

During the Summit, the six root causes of firefighter fatalities were also identified and agreed upon. In preparation for the meeting, NFFF staff and contract employees had been tasked with conducting an extensive literature review of firefighter fatality reports. Using data gleaned from these documents, they were able to identify the common factors, and named the six root causes that could then be addressed through EGH programs and initiatives.[1] In the future, defining and articulating these factors would serve as a way to attribute and classify causality in line-of-duty deaths, as well as serving as starting points for LODD prevention efforts.

As the first stage of development for the Vulnerability Assessment Program (VAP), the NFFF recently had an opportunity to revisit these definitions of root causes and to validate their ongoing relevance and applicability. The VAP, a joint effort of the NFFF, USFA and Honeywell, will ultimately be an online tool that enables fire departments to identify and address their organizational exposures and vulnerabilities to suffering a line-of-duty death and/or injury. The VAP will be scaleable, feature a user-friendly interface, and be applicable to all sizes and types of organizations. Upon completing the VAP assessment, fire department and agency personnel will then be able to use the resources that are available through the VAP to make the necessary changes in their operating policies and procedures, equipment use and maintenance, and safety culture that will reduce the likelihood of a future firefighter death or injury.

In 2011, as part of the information-gathering phase of VAP development, NFFF personnel reviewed 1252 firefighter line-of-duty death reports for fatalities that occurred between 1999 and 2010.[2] A retired chief officer from the Prince William County (VA) Department of Fire and Rescue, with 35 years of experience, was tasked with reviewing each fatality report in its entirety. He assigned an initial designation as to the one or more root causes that would be attributed to the case. A second chief officer, retired from the Fort Worth (TX) Fire Department after more than 30 years of service, then reviewed each case and provided input on the root cause classification; final determination was made by consensus.

The data collected from this study was then examined to affirm the continued applicability of the six LODD root causes derived at during the Tampa Summit, and to assess current trends. As had been found previously, in the majority of LODD events it was determined that two or more causal factors contributed to the fatality. Ineffective Decisions led to the highest number of LODDs followed by Ineffective Policies or Procedures. Ineffective Leadership and Lack of Personal Responsibility were next, followed by Lack of Preparedness and Extraordinary/Unpredictable Events. Most fatalities were associated with at least three root causes, while others included five. It should also be noted that the only category that was attributed as a sole factor was Extraordinary/Unpredictable Events.

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-Vulnerability Assessment Project, NFFF/USFA/Honeywell 2012

For clarification purposes, the criteria which was used to determine whether or not a firefighter fatality constituted a line-of-duty death during this review was that established by fire service leaders in 1997 for determination of eligibility for inclusion on the National Fallen Firefighter Memorial:

1. (a) Deaths of firefighters meeting the Department of Justice’s (DOJ’s) Public Safety Officers’ Benefits (PSOB) program guidelines, and those cases that appear to meet these guidelines whether or not PSOB staff has adjudicated the specific case prior to the annual National Fallen Firefighters Memorial Service; and (b) Deaths of firefighters from injuries, heart attacks, or illnesses documented to show a direct link to a specific emergency incident or department-mandated training activity.

2. While PSOB guidelines only cover public safety officers, the Foundation’s criteria also include contract firefighters and firefighters employed by a private company, such as those in an industrial brigade, provided that the deaths meet the standards listed above.

3. Some specific cases will be excluded from consideration, such as deaths attributable to suicide, alcohol or substance abuse, or other gross abuses as specified in the PSOB guidelines.

LODD Root Causes/Contributing Factors

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-Vulnerability Assessment Project, NFFF/USFA/Honeywell 2012

Root Cause 1: Ineffective Decision Making

Ineffective Decision Making was the most common root cause among the fatality reports reviewed, and was identified in 766 of the 1252 cases, or 61%. While not every poor decision has a negative outcome, many do. Fatality reports are rife with examples of poor decisions with lethal consequences: the firefighter who neglects to buckle his seatbelt to save a few seconds; the incident commander who skips making an accurate size-up because he is convinced that he has a complete understanding of the situation; the apparatus driver/operator who runs a stop sign to get to the fire faster; and the fire chief who foregoes equipment maintenance to meet budgetary priorities.

Firefighters and fire officers clearly risk their own lives and those of their team members when they fail to make well-informed, risk-appropriate decisions. A poor decision can be the result of many factors: it may be the outcome of a firefighter’s failure to properly analyze a situation; to control their own thought processes when responding to the situation; or an inability or unwillingness to collect the information they need to make a sound decision.

Making evidence-informed decisions that limit the exposure of a firefighter and his team members to risk during operations is integral to keeping firefighters safe. An individual’s inherent ability to make personal risk-management decisions at any particular point in time is directly impacted by variables which include training and experience, as well as leadership on the fireground. The safety culture of the department also factors into the equation: a culture which may condone or even encourage risky tactical maneuvers will increase the likelihood that a firefighter may decide to attempt an action that he is not trained to undertake, or does not have the appropriate equipment or personnel support to accomplish successfully.

It must also be noted that poor decisions can be made during any operational step, and many of the fatality reports reviewed cited multiple examples of ineffective decision-making. Poor risk management decisions made at the strategic level jeopardize the health and safety of every firefighter. During emergency response, performing the basic strategic-level safety routine found in the standard command functions should provide a framework for effective decision making, but unfortunately, we find that these functions of command were most often not employed in LODD events.

The availability of information, and the individual’s ability to process it, also play important roles in the decision-making process. Decisions made during size-up and while developing operational strategies at an incident are based on the availability of information, or lack thereof. Failure to conduct an initial size-up or failing to take adequate time to gather adequate information and process it will lead to decisions that are not fully informed, and will limit a firefighter’s ability to make decisions based upon that information.

Personality factors can also affect decision-making ability. An individual who is willing to accept or ignore inappropriately high levels of risk (the proverbial “adrenaline junkie” or thrill-seeking personality) has an increased likelihood of making a poor decision on the fireground. Similarly, a firefighter with poorly developed impulse control is also more likely to act before thinking out the consequences of a potentially dangerous action.

Root Cause Case Studies for Ineffective Decision Making are found on page 13 of the Appendix.

Root Cause 2: Ineffective Policies and Procedures

Ideally, a fire department’s activities are guided by comprehensive SOPs that support firefighter health and safety, and are consistently enforced by organizational leadership. When the entire department is operating from the same playbook, they are all following the same rules and regulations, understand organizational expectations and are working together toward a common goal. When SOPs go the extra step and articulate firefighter safety as an organizational value, it sends a strong and unified message to its members that each of their lives is valued. Conversely, inadequate and/or poorly enforced standard policies and procedures significantly increase the risk of death or injury to firefighters on the fireground, during training, and even while performing routine activities in the firehouse.

Among the case studies reviewed in 2011, Ineffective Standard Operating Policies and Procedures was the second most prevalent root cause among the cases studies, and was a factor in 640, or 53% of the 1252 cases. For a line-of-duty death to be attributed to Ineffective Standard Operating Policies and Procedures, one of two situations must be evident. First, do adequate SOPs exist within the organization? Second, do the chief and other officers actively and consistently enforce these policies? Established policies and procedures are put in place to clarify duties and performance expectations for all stakeholders, and are not intended to be explicitly technical, to provide in-depth detail about a job, or to take the place of training. Rather, they should define the basic parameters—the who, what, where, when and why—of every type of department activity, and should address any concerns that may be related to the task being performed such as safety, use of resources, and duties of members.

Without SOPs to guide their behavior, firefighters and officers often accept high levels of risk that are unwarranted. Within the cases reviewed, there are numerous examples of activities that should have been guided by the department’s policies and procedures, but weren’t: horseplay, freelancing, self-dispatching, utilization of dangerous training scenarios, not obeying traffic rules, speeding, not wearing seatbelts and others.

However, even if SOPs are in place, they are only as effective as the organizational leadership’s ability to ensure that they are adhered to by its members. Inadequate enforcement of SOPs, ignorance of their existence, and even a cultural acceptance of non-compliance all greatly increase the likelihood of serious firefighter injury or a fatality, and are frequently cited as causal factors in fatality reports.

SOPs should also comply with current health and wellness standards, including NFPA 1582 Standard on Comprehensive Occupational Medical Program for Fire Departments. Cardiac arrest is the leading cause of firefighter LODDs¸ and of the 552 heart attack cases reviewed 177 (32%) involved career firefighters and 354 (64%) were volunteer members. 219 reports indicated no NFPA 1582 medical evaluation program in place and 209 reports were left blank on this section of the USFA report filled out by the affected department. Only 124 (21%) responses indicated a full (61) or partial (63) NFPA 1582 medical evaluation program was in place at the time of the death.

The 2011 literature review indicated that the lack of effective SOPs is a more frequent occurrence in volunteer departments. This may be attributed to the financial resources and time needed to develop and write these guiding documents and to keep them current and relevant. However, there is clearly a greater cost at stake here, that of a human life. For organizations which have resisted adopting SOPs for financial reasons, reduced cost options—such as adapting those of other organizations or using pre-written SOPs—should be explored.

Root Cause Case Studies for Ineffective Policies and Procedures are found on page 15 of the Appendix.

Root Cause 3: Ineffective Leadership

It is often said that an organization is only as effective as its leadership, and this seems particularly true in fire departments. The multiple levels of command—both those within the organizational hierarchy and that of the ICS structure during incident response—all have profound effects upon the safety and well-being of the individual firefighter. Whether it is the incident commander on the fireground or the chief officer who establishes and enforces organizational priorities, every firefighter is directly impacted by the quality of his or her leaders.

Unfortunately, a lack of strong leadership anywhere in the chain of command greatly increases a firefighter’s risk of line-of-duty death or injury. Ineffective Leadership was the third most frequent root cause among the LODD reports studied, and was cited in 554 or 44% of the 1252 cases examined in the 2011 review. At the initial Firefighter Life Safety Summit cases that were attributed to ineffective leadership ran the gamut from allowing horseplay and freelancing to concerns with incident command and safety oversight. Other examples of ineffective leadership included the failure to create effective policies related to health and wellness and poor strategic and tactical direction on the fireground.

Due to the scope of this category, it is always important to carefully consider the events that lead to a LODD to ensure that this is applied appropriately as a root cause. Critical observation must be made of the qualifications of all levels of unit and department leadership, their focus and vision on department goals or missions, and communication styles both within the command structure and with the firefighters.

Ironically, it is the lowest level of leadership, and that with the least amount of experience, that most directly affects a firefighter’s safety. The company officer is usually accountable for the day-to-day activities of his or her team, ensuring that SOPs are complied with, that firefighters are trained and that equipment is properly maintained. They serve as teacher, role model and mentor for firefighters, and pass on the department’s culture—both its positive and negative aspects—to the next generation. Most importantly, company officers are tasked with ensuring that the firefighters in their unit are educated and trained to make good risk management decisions. As first line supervisors, they and the firefighters that they command are directly engaged in the operational activities that expose them to high levels of risk. It is particularly important that in this capacity, the company officer is ethically disposed to teaching and modeling safety and good personal risk decisions, and to actively limiting risk to his or her firefighters.

Unfortunately, this is the level of leadership that is most likely to demonstrate their inexperience, make risk-inappropriate decisions and fail to limit risk during operations and even during everyday activities. Compounding the situation, company officers are sometimes promoted into the position with little or no formal Incident Command training, and their lack of skills results in unnecessary risks taken on the fireground. It should also be noted here that ineffective leadership at the company officer level can be indicative of similar problems as we go up the organizational hierarchy; how can a company officer model safety in leadership, when it has never been modeled for him or her?

Ineffective Leadership can also be symptomatic of other problems within the organization, and is closely intertwined with all of the other root factors. As was discussed previously, when leaders do not enforce their compliance, SOPs are ignored. When chiefs and other officers do not prioritize training or neglect equipment maintenance, that lack of preparedness can increase the risk of a line-of-duty death or injury. When chief and company officers do not hold firefighters accountable for their own safety, lack of personal responsibility comes into play.

Root Cause Case Studies for Ineffective Decision Making are found on page 18 of the Appendix.

Root Cause 4: Lack of Personal Responsibility

Ultimately, firefighters must be accountable for their own safety. A firefighter or officer demonstrates a lack of personal responsibility when they fail to take into consideration their own health and safety when participating in any fire organization activity. A lack of personal responsibility can dramatically impact the quality and safety of job performance, and most disturbingly it can also put the life of other team members at risk.

Within the most recent literature review, Lack of Personal Responsibility was identified as a root cause in 554 reports, or 44% of the 1252 reports. It was cited in most cases where firefighter fatality is the result of an apparatus or POV accident, and speeding, failing to use seatbelts and a lack of compliance with traffic signals or laws were frequent examples. Unfortunately in the case of vehicular accidents, a lack of personal responsibility may elevate the level of injury from survivable to fatal. It can also increase the likelihood of collateral death and/or injuries when others on board the apparatus, in other vehicles, and even pedestrians are involved.

Lack of personal responsibility also manifests itself in health and wellness issues. Numerous cases were noted in which fire department members had serious medical conditions that should have precluded their participation in emergency response activities. Some of these individuals clearly ignored the symptoms of the condition and failed to get adequate medical help, while others defied doctor’s orders and continued to participate in emergency operations.

It bears repeating that heart attacks and strokes are consistently the leading cause of line-of-duty death for firefighters, and every firefighter is responsible for their own physical health. There are decades of research studies that indicate that obesity, high cholesterol levels, lack of exercise, smoking and a genetic predisposition to cardiac issues are all key coronary risk factors. Despite this well-publicized evidence, some at-risk personnel are still unwilling to take part in health and wellness programs, even when it would obviously be in their best interest.

Cost should not be a barrier to firefighter health and safety. In addition to resources available offered by the organization or municipality, there are numerous free, downloadable online resources available to firefighters and fire departments, including the National Volunteer Fire Council’s Heart Healthy Firefighter; USFA Health and Wellness Guide for the Volunteer Fire and Emergency Services; the IAFF and IAFC’s Fire Service Joint Labor Management Wellness-Fitness Task Force; and others that can be found on the NFFF’s and websites. At the very least, NFPA 1582 compliance should be mandated by departmental SOPs.

Root Cause Case Studies for Lack of Personal Responsibility are found on page 21 of the Appendix.

Root Cause 5: Lack of Preparedness

By the very nature of their duties, firefighters must be prepared to face a virtually limitless number of response situations. Unfortunately, firefighters are sometimes killed when they attempt to conduct a level of operations for which the individual or the organization is not prepared. Lack of Preparedness was cited in 389, or approximately 1/3 of the 1252 fatality reports reviewed in 2011.

Lack of Preparedness is also often symptomatic of poor decision making, because no firefighter should ever attempt to do something that they are unprepared or ill-equipped to undertake. However, many LODDs that occur on the fireground are the direct results of situations in which a firefighter attempts a maneuver, despite the lack of proper personal protective equipment or tools. Alternately, individuals may also attempt maneuvers that they are either untrained or inadequately trained to undertake.

Lack of preparedness can be evident at the organizational level. Planning is critical to safe operations, and lack of comprehensive SOPs, or the failure to follow or enforce them, is frequently a contributory factor in firefighter fatalities. Lack of pre-planning for high-hazard events and areas within a district can also lead to the assumption of inappropriate levels of risk. Failure to train for, and to utilize, command procedures, particularly not establishing incident command, are often cited as contributory factors in fatal incidents. These scenarios can occur in both career and volunteer departments, and can be indicative of a culture that accepts—or even encourages—maneuvers that are beyond the capability of that organization.

Some examples of lack of preparation include:

• A company advances a 1 ¾” line into a commercial structure and immediately need a second line to be deployed. The company is overwhelmed by volume of fire.

• Firefighter struck at the scene of a MVA. Firefighter failed to secure the scene properly with visual cues to direct traffic or create a barrier between oncoming traffic and the scene.

• Firefighter is overcome by fumes at HAZMAT incident. There was no record of training for response to hazardous materials.

• Firefighter is overcome by smoke after running out of air while operating inside a burning structure. No RIT team was in place to respond and retrieve the downed firefighter or to provide supplemental oxygen.

Root Cause Case Studies for Lack of Preparedness can be found on page 23 of the Appendix.

Root Cause 6: Extraordinary and Unpredictable Events

The last and most uncommon root cause identified is Extraordinary and Unpredictable Events, which was cited in only 150 (12%) of the fatality reports in the 2011 review. This category generally encompasses events that are what the legal profession terms “Acts of God.” These can include: events that are outside of human control; natural disasters; unavoidable events; or events against which defense may be impossible, impracticable, or would result in an insurmountable delay.

In other words, a fatality due to an extraordinary and unpredictable event can almost never be prevented. No amount of training, equipment, personnel or effort could have improved the outcome of this particular scenario. It is the only root cause that was identified in isolation. By their very nature, extraordinary events are not specific to any one age group, incident type, or department type. It should be noted that of these cases, 61 were classified as the result of criminal intent—arson, homicide or manslaughter.

Within the cases reviewed, examples included such events as:

• Civilians who inexplicitly targeted first responders.

• Collateral injuries and fatalities of incidents in which individuals targeted other populations.

• The sudden unexplained mechanical failure of aircraft or apparatus that was properly maintained.

• Motor vehicle accidents whose outcome could not be affected, and in which case the firefighter was not at fault.

• Unpredictable or undetectable medical conditions, including exposures to disease and/or carcinogens.

• Weather events including but not limited to hurricanes, blizzards, tornadoes and electrical storms.

Root Cause Case Studies for Extraordinary and Unpredictable Events can be found on page 25 of the Appendix.

Conclusion

A review of more than 1200 firefighter fatality reports was undertaken during the initial phase of development for the Vulnerability Assessment Program (VAP), a joint project of the National Fallen Firefighters Foundation and the Honeywell Corporation. The results of this study indicate that using the six root causes of firefighter fatalities defined at the 2004 National Firefighter Life Safety Summit continues to be a valid way to organize and attribute causality of LODDs.

It was also apparent from the data that that there is significant overlap that exists among the root causes; in most incidents that resulted in a LODD, at least two and up to five root causes were identified. Only in very rare circumstances were LODD incidents attributed to a single root cause, which in every case was Extraordinary and Unpredictable Events. Unfortunately, this finding also leads to a fairly obvious and rather painful conclusion—that most firefighter fatalities arose from events that were not extraordinary and unpredictable.

In other words, despite having made significant inroads in LODD prevention over the last decade, firefighters continue to die in ways that could clearly have been prevented. When assessing why these deaths happen, and how we can prevent them in the future, it is helpful to return to “chain of events” analogy. Few fatalities are the result of a sudden and violent break in the chain—or an unpredictable and extraordinary event. Instead, most LODDs are attributed to multiple root causes, which can be visualized as weak links—or vulnerabilities—in the chain. If there are just a few of these vulnerabilities, the chain will break if stretched hard enough. But if there are a significant number of weakened links, it will take far less force to break the chain. Clearly, the more vulnerabilities within the organization, the greater the likelihood is that a firefighter will suffer a serious or fatal injury.

Looking at it from an opportunistic angle, we can also view each of these vulnerabilities as a theoretical intervention point for current and future LODD prevention efforts. At any or all of these loci—at these weakened links—there most likely exists a technical, cultural, or behavioral change which might have improved the outcome for the individual involved. While it is obviously too late for the individuals cited in the reports, our industry can glean lessons learned from their deaths and use these to help us to identify current vulnerabilities, and to take action to prevent recurrences of similar situations.

So now the challenge is to identify these vulnerabilities in fire departments before a firefighter is injured or killed. In the past, fire service leaders have, for a variety of reasons, often adopted a reactive posture to firefighter safety, and it took the death of a firefighter to affect organizational change. Cultural complacency, ignorance of the problem, lack of resources and an “I never thought it could happen to us” attitude have all been cited as reasons for not taking corrective action for ongoing unsafe conditions and recurring problems. Even when the issue had been noted, there too often remained considerable obstacles to identifying, funding and implementing an appropriate intervention to correct the situation.

When the VAP is completed in 2013, it will be a game-changer, because for the first time fire departments will have a tool that enables them to determine and correct vulnerabilities proactively. The VAP will assist officers with identifying problems before a firefighter is injured, enable them to locate the needed resources to take corrective action, and provide them with the data to support needed financial investments in firefighter safety. Fire chiefs and officers will be able to conduct a confidential, free online assessment that examines every facet of organizational operations, from tangible assets such as equipment, apparatus, and facilities to all aspects of organizational activity, including training, leadership, policies and procedures and emergency operations. It will also review the intangible factors such as safety culture and individual and organization accountability, which sometimes have the greatest impact on the welfare of firefighting personnel.

Though the Everyone Goes Home® program has facilitated major advances in reducing firefighter injuries and fatalities over the last decade, preventable fatalities continue to occur. In 2013, with the introduction of the Vulnerability Assessment Program, fire departments will have a new and effective tool that will enable them to take a proactive stance to preventing firefighter injuries and deaths by addressing the root causes of LODDs. The VAP will empower chiefs and fire officers to take greater control of their own institutional safety culture, and to ensure that all of their firefighters do go home.

APPENDIX

Root Cause 1: Ineffective Decision Making Case Studies

1) May 1, 2010 – 1230hrs

John Polimine, Firefighter

Age 50, Volunteer

Scalp Level & Paint Volunteer Fire Company, Pennsylvania

Firefighter Polimine was participating in an Essentials of Firefighting program. The training included interior and exterior firefighting evolutions. The day started at 0800hrs with student briefings and the collection of baseline vitals on each student.

Firefighter Polimine was the nozzle person for an interior attack evolution. He completed fire extinguishment and ventilation tasks. His crew was instructed to back out of the room. Firefighter Polimine was sluggish and was escorted out of the burn room by an instructor.

EMS staff in rehab evaluated Firefighter Polimine and started an IV to rehydrate him. Once the IV was completed, Firefighter Polimine was re-evaluated and found to be feeling better. Firefighter Polimine was allowed to leave rehab after approximately 2 hours to participate in exterior firefighting evolutions.

Firefighter Polimine participated in a propane fire simulation as the nozzle person. At the completion of the exercise, he was directed by an instructor to drink some water as he took a break.

As the next round of exercises was started, Firefighter Polimine could not be located. A search of the area found Firefighter Polimine unconscious in a portable restroom. Firefighters and instructors removed Firefighter Polimine to the ground and began medical treatment.

An AED was applied and delivered 3 shocks. Firefighter Polimine was transported by ALS ambulance to the hospital where he later died. His death was due to a heart attack.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2010-21 ().

2) July 26, 2008, 1530hrs

Daniel Bruce Packer, Fire Chief

Age 49 – Career

East Pierce Fire & Rescue, Washington

Chief Packer was dispatched as a Division Supervisor to the Siskiyou Complex of fires on the Klamath National Forest in Northern California. Chief Packer and other firefighters were assigned responsibility for the Panther Fire.

In order to prepare to assume management responsibility for the fire, Chief Packer and another division supervisor were assigned to scout the area. At approximately 1530hrs, the fire spread quickly and burned over Chief Packer’s position.

Chief Packer deployed his fire shelter in an unsuccessful attempt to protect himself from the rapidly advancing flame front. A subsequent autopsy revealed that Chief Packer died of smoke inhalation and thermal burns.

Root Cause 2: Ineffective Policy and Procedures Case Studies

1) September 6, 2010 – 1837hrs

John Kelly, Firefighter – Chief Driver

Age 51, Volunteer

Tarrytown Fire Department, New York

A resident of the Village of Tarrytown complained that the sewer service to their home was clogged. The Department of Public Works (DPW) attempted to clear the clog in the area of the home but was not successful. The Tarrytown fire station was in the area of the sewer problems. There are three manholes in proximity to the fire station; 1 in front of the station, 1 in the station, and 1 behind the station. DPW called the fire chief and asked him to open the fire station so that DPW employees could have access to the manhole inside of the station.

Firefighters assisted DPW employees with access to the manhole behind the fire station. A DPW employee entered the manhole. The DPW employee lost consciousness as he descended the interior ladder and fell to the bottom of the manhole. The DPW foreman requested assistance from firefighters. The Fire Chief asked dispatch for EMS assistance and also started a fire department incident.

As an atmospheric meter from the fire department was prepared for use, Firefighter Kelly entered the manhole. He was not wearing an SCBA or harness. When Firefighter Kelly was half way down the ladder, he lost consciousness and fell to the bottom of the manhole. Additional resources were called to the scene and Firefighter Kelly and the DPW employee were removed from the manhole. Firefighter Kelly and the DPW employee died of asphyxiation due to an oxygen deficient atmosphere.

2) January 2, 2009 – 0213hrs

Gary Vernon Stephens, Firefighter

Age 57, Career

Elizabeth Fire Department, New Jersey

Firefighter Stephens and the members of his engine company were dispatched with other firefighters to a report of a structure fire. Firefighter Stephens was the acting captain of his company. The first-due company observed fire from a distance and requested a second alarm.

When Firefighter Stephens’ company arrived on the scene, they were directed to establish a water supply for a ladder that was already on the scene. In order to access the scene, the engine was to back down the street where the incident was located, drop a supply line, and lay out to a hydrant. The street was crowded with parked vehicles. Firefighter Stephens dismounted the engine and walked behind it to guide the apparatus driver.

As the engine backed up, Firefighter Stephens walked behind it from the officer’s side to the driver’s side. As he walked, Firefighter Stephens was facing away from the moving apparatus. Firefighter Stephens was struck and run over by the apparatus.

Firefighters at the scene witnessed the incident and quickly removed Firefighter Stephens from under the apparatus. He was treated on the scene and transported to the hospital. He was pronounced dead at 0240hrs. The cause of death was listed as multiple blunt trauma injuries.

A homeless 19 year old man was charged with setting the fire in a vacant residence as a warming fire.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2009-10 ().

3) January 9, 2009 – 1430hrs

Kevin M. Kelley, Lieutenant

Age 52, Career

Boston Fire Department, Massachusetts

Lieutenant Kelley and his ladder company had responded to an emergency medical incident. The incident was concluded and Lieutenant Kelley and the members of his crew were returning to quarters.

As the apparatus descended a steep hill, the unit’s brakes failed to slow the apparatus. When he realized that the apparatus could not be stopped, Lieutenant Kelley sounded the apparatus warning devices to warn pedestrians and other drivers and ordered his crew to brace for impact.

The ladder truck reached the bottom of the hill, crossed several lanes of traffic, crashed through several parked vehicles and an 8-foot brick fence, and came to rest embedded in a high-rise building. Lieutenant Kelley was killed in the crash. The driver and two firefighter passengers in the ladder truck were injured. The driver had to be extricated from the damaged cab of the apparatus.

Investigations after the crash revealed serious deficiencies in the management and maintenance of the Boston Fire Department fleet.

NIOSH developed a safety advisory related to the maintenance of automatic slack adjusters on brake systems (2010-102). This advisory can be found at

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2009-05 ().

A Board of Inquiry Report prepared by the Boston Fire Department can be downloaded at

4) September 24, 2007 – 1414hrs

Bryon Wayne Johnson, Lieutenant

Age 32 – Career

Sedgwick County Fire District #1, Kansas

The fire department communications center received several calls reporting a brush fire that may have been caused by downed power lines. Squad 34, under the command of Lieutenant Johnson, responded to the call but did not acknowledge the message about power lines.

When the unit arrived on the scene, power lines were visible in the street. Firefighters advanced a handline and began to control the fire. In order to access a portion of the fire, the apparatus had to be backed up. Lieutenant Johnson advanced the hose line and his engineer drove the apparatus. The 2 firefighters communicated by hand signal.

Lieutenant Johnson was hitting hot spots with the handline. His engineer viewed him in the rear view mirror. The engineer saw Lieutenant Johnson stiffen and fall. The engineer stopped the apparatus, got out, and found Lieutenant Johnson on his back.

The engineer recognized the presence of an energized power line. With some difficulty, the engineer pulled Lieutenant Johnson away from the hazard. The engineer called to another firefighter that had just arrived on the scene for help. The firefighter reported the incident, ordered the dispatch of an ambulance, and requested a command officer and additional firefighters.

Lieutenant Johnson was transported to the hospital but did not survive. The cause of death was listed as electrocution. The fallen power line that caused the grass fire was the result of a pole being struck by a truck making a U-turn.

Root Cause 3: Ineffective Leadership Case Studies

1) July 5, 2008, 1747hrs

Robert Leland Knight, Fire Chief

Age 42 – Volunteer

Teague Volunteer Fire Department, Texas

Chief Knight and the members of his fire department were dispatched to a report of a structure fire in a commercial occupancy. Chief Knight responded to the scene in a tanker (tender) apparatus from the scene of a wildland fire where he had been working. He arrived approximately 10 minutes after dispatch and found a working fire in an automotive repair and upholstery shop.

The involved structure was a wood frame building with metal siding and roof. The building measured approximately 40 feet by 140 feet. The south, front end of the building had a brick façade that rose to a peak at the roof to a height of 20 feet.

Chief Knight was operating a nozzle at a doorway of the south end of the building when the 2 story brick façade collapsed outward, pinning him as he was running away. Chief Knight was immediately extricated by fellow firefighters and civilian witnesses and treated by the on-scene medic unit. He was transported by ground ambulance to the local heli-pad and flown by air ambulance to the East Texas Medical Center in Tyler, Texas. Chief Knight succumbed to extensive traumatic and died at 2138hrs on July 5, 2008.

The Texas State Fire Marshal’s Office prepared a detailed report on this incident. The report is available at

2) February 9, 2007 – 1200hrs

Racheal Michelle Wilson, Firefighter-Paramedic Apprentice

Age 29 – Career

Baltimore City Fire Department, Maryland

Firefighter Wilson and the members of her Fire Academy Class were attending a live fire training exercise in a vacant row house in Baltimore.

Firefighter Wilson was assigned to a group of apprentices and an instructor designated as Engine 1. Her group advanced a dry attack line into the structure. As they climbed the stairs, the line was charged. Engine 1 encountered and extinguished fire on the second floor but did not check the rest of the second floor for fire prior to proceeding to the third floor. On the third floor, they encountered and began to extinguish fire on that floor.

Fire conditions began to worsen, with a marked increase in smoke and heat that appeared to be coming from the second floor. Engine 1 firefighters that were on the stairs began to receive burns from the fire conditions. The instructor for Engine 1 climbed out a window at the top of the stairs and helped one burned firefighter escape to the roof.

Firefighter Wilson appeared at the window in obvious distress and attempted to escape. The windowsill was unusually high (41 inches) and she was unable to escape. Firefighter Wilson momentarily moved away from the window, at which time she advised other firefighters to go down the stairs to escape. When she returned to the window, her SCBA face piece was off and she was beginning to receive burns. She was able to get her upper body out of the window but she could not make it through. Firefighters on the exterior were unable to pull her through until firefighters were able to gain access on the interior and assist with the effort.

When Firefighter Wilson was pulled to the roof, she was in full cardiac and respiratory arrest. She was immediately removed from the roof and received advanced life support care and transportation to the hospital. She was pronounced dead at 1250hrs.

Firefighter Wilson received total body surface burns of 50 percent. The cause of death was listed as thermal burns and asphyxiation.

3) May 19, 2007 – 1033hrs

John Francis Keane, Captain

Age 37 – Career

Waterbury Fire Department, Connecticut

Captain Keane was the company officer for Engine 8. At 1034hrs on May 22, 2007, Engine 8 and several other fire department units were dispatched to a possible kitchen fire in an apartment. Engine 8 was operating an older reserve piece of fire apparatus since their apparatus was in the shop. In addition, Engine 8 was responding from a location other then their fire station. The crew was attending a blood drive.

Engine 8 and Truck 1 entered an intersection at the same time from different directions. Truck 1 struck the left front of Engine 8. The impact caused the engine to spin clockwise approximately 180 degrees. Captain Keane and the driver of Engine 8 were ejected from the apparatus. The officer on Truck 1 was trapped in the vehicle and had to be extricated. All eight firefighters from Engine 8 and Truck 1 were injured.

Captain Keane was transported to the hospital where he remained until his death on May 22, 2007. The cause of death was listed as blunt head trauma.

A law enforcement investigation of the crash stated that Truck 1 had the green light, that a number of firefighters, including Captain Keane, were not wearing seat belts at the time of the crash, and that some lines of sight at the crash scene were obstructed by trees.

4) June 18, 2007 – 1930hrs

Theodore Michael Benke, Captain

Age 49 – Career

Charleston Fire Department, South Carolina

William H. “Billy” Hutchinson, Captain

Age 48 – Career

Charleston Fire Department, South Carolina

Louis Mark Mulkey, Captain

Age 34 – Career

Charleston Fire Department, South Carolina

Mark Wesley Kelsey, Acting Captain

Age 40 – Career

Charleston Fire Department, South Carolina

Bradford Rodney “Brad” Baity, Engineer

Age 37 – Career

Charleston Fire Department, South Carolina

Michael Jonathon Alan French, Assistant Engineer

Age 27 – Career

Charleston Fire Department, South Carolina

Melvin Edward Champaign, Firefighter

Age 46 – Career

Charleston Fire Department, South Carolina

James Allen “Earl” Drayton, Firefighter

Age 56 – Career

Charleston Fire Department, South Carolina

Brandon Kenyon Thompson, Firefighter

Age 27 – Career

Charleston Fire Department, South Carolina

At 1909hrs, the Charleston Fire Department received a report of a fire at the Sofa Super Store, 1807 Savannah Highway, in Charleston. Firefighters arriving on the scene found an exterior fire extending into the interior of the commercial structure. Firefighters at the rear of the structure extended hoselines and fought the exterior and interior fires at that location.

Other firefighters entered the front of the structure to search for building occupants and to fight the fire in the front retail area of the store. These firefighters were wearing full structural fire fighting protective clothing and SCBA. While initial conditions inside of the retail area of the store were tenable, conditions quickly worsened as the fire extended from the rear of the store into the retail area of the store.

Approximately 20 minutes after firefighters arrived on the scene, firefighters in distress could be heard on the radio requesting assistance. Smoke conditions in the interior of the store had worsened significantly and firefighters were unable to find their way to a safe exit. The fire progressed rapidly and completely involved the interior of the store.

Nine firefighters were trapped in the structure and were unable to escape. Their bodies were recovered and removed later that night from the structure after the main body of fire was extinguished. Possession of the bodies was taken by the Charleston County Coroner’s Office. The cause of death for all nine firefighters was attributed to smoke inhalation and burns.

An extensive report on this incident is available from the City of Charleston at . Follow the links to the fire department main page.

Root Cause 4: Lack of Personal Responsibility Case Studies

1) March 21, 2010 – 1503hrs

Jeremy Gordon Bolick, Firefighter

Age 23, Volunteer

Blowing Rock Fire Department, North Carolina

Charles Thomas “Tommy” Wright, Firefighter

Age 20, Volunteer

Blowing Rock Fire Department, North Carolina

Firefighter Bolick was the driver and Firefighter Wright was the front seat passenger in a 2008 Ford Mustang. The firefighters were returning from a fire certification class at a local community college.

Firefighter Bolick lost control of the vehicle. It crossed the center line, spun around twice, and was struck by a vehicle in the oncoming lane. Firefighter Bolick and Firefighter Wright were trapped in the vehicle and died of multiple traumatic injuries. Both firefighters were wearing seat belts and the vehicle’s airbags deployed. The law enforcement report on the incident cited excessive speed and poor road conditions as factors in the crash.

The passenger in the other car involved in the crash died 11 days after the crash as a result of injuries received in the incident.

Law enforcement investigators were quoted in the press saying that the crash involved street racing between the vehicle driven by Firefighter Bolick and firefighters in another vehicle. Speeds during the race on the rain-slicked highway topped 100 miles-per-hour. In December of 2010, an 18-year old firefighter was charged with one count of spontaneous speed competition and one count of misdemeanor death by vehicle.

2) July 26, 2010 – 1630hrs

Posey Wayne Dillon, Fire Chief

Age 59, Volunteer

Rocky Mount Fire Department #1, Virginia

William Daniel “Danny” Altice, Firefighter

Age 67, Volunteer

Rocky Mount Fire Department #1, Virginia

Chief Dillon and Firefighter Altice were responding to a mutual aid structure fire incident. Their engine entered an intersection on a red light and was struck by a sport utility vehicle. The collision caused Chief Dillon to lose control of the apparatus and the apparatus rolled.

Both firefighters were ejected from the vehicle. Neither firefighter was wearing a seat belt. Both firefighters died due to traumatic injuries.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2010-19 ().

3) September 29, 2008, 1345hrs

Ralph Paul Arabie, Firefighter

Age 48 – Career

David Crockett Steam Fire Co. No. 1, Gretna, Louisiana

Firefighter Arabie was assisting an insurance adjuster as they used a fire department aerial device to assess damage that the fire station has sustained in recent storms.

As the bedded the aerial device, Firefighter Arabie was crushed between the apparatus and the aerial device. He received a fatal head injury.

4) February 7, 2007 – 1830hrs

Joseph Torkos, Fire Engineer Operator

Age 47 – Career

Detroit Fire Department, Michigan

Fire Engineer Torkos and his engine company were responding to a report of a structure fire in a vacant residence. Fire Engineer Torkos was driving with the apparatus lights and siren in operation. The engine was staffed by an officer, Fire Engineer Torkos, and 2 firefighters.

As the apparatus responded, it was struck by a Chevrolet Tahoe SUV that approached from the right side of the apparatus at high speed. The force of the collision deflected the path of the apparatus and it ended up off the opposite side of the roadway.

Fire Engineer Torkos and the company officer were ejected from the apparatus. Fire Engineer Torkos was ejected through the driver’s door or the windshield. He was run over by the apparatus, trapped under the vehicle’s rear wheels, and died at the scene. Firefighters were unable to remove Fire Engineer Torkos until a large tow truck arrived at the scene.

Law enforcement reports indicate that the SUV disregarded the flashing traffic control light at the intersection and the warning lights on the apparatus. The SUV was estimated to have been travelling approximately 80 miles-per-hour at the time of the impact. The engine’s speed was estimated at 15 to 30 miles-per-hour.

The other three firefighters on the engine were injured. The driver of the SUV died in the crash and 3 passengers in the SUV were injured. The cause of the structure fire was found to be arson.

Root Cause 5: Lack of Preparedness Case Studies

1) April 11, 2010 – 0914hrs

Garrett William Loomis, Assistant Fire Chief

Age 26, Volunteer

Sackets Harbor Fire Department, New York

Assistant Chief Loomis and the members of his fire department responded to a report of a fire in a 20 foot by 60 foot oxygen limiting silo containing approximately 20 feet of high moisture corn. The fire may have been caused by embers from an earlier barn fire.

Upon arrival, firefighters found a silo with bottom and top doors open, light smoke, and burning embers visible inside the bottom of the silo. They formed a plan to close all silo doors and introduce carbon dioxide to smother the fire.

Assistant Chief Loomis climbed to the top of the silo utilizing a ladder chute attached to the silo. He closed and latched the doors at the top of the silo, reported the completion of his task by radio and began to climb back down the ladder.

An explosion occurred and Assistant Chief Loomis was thrown 20-30 feet to the ground. Assistant Chief Loomis was transported to the hospital by ambulance. He was pronounced dead at the hospital due to traumatic injuries.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2010-14 ().

2) January 25, 2009 – 1405hrs

Cory James Galloway, Firefighter

Age 23 – Career

Kilgore Fire Department, Texas

Kyle Wayne Perkins, Firefighter

Age 45 – Career

Kilgore Fire Department, Texas

The Kilgore Fire Department had recently received a new 95-foot mid-mount aerial ladder tower. Firefighters had received training from a manufacturer’s representative. The apparatus was not yet in service.

Firefighters brought the ladder truck to a high rise dormitory building at a local college. Three firefighters were in the platform of the apparatus as it ascended to the roof. When the platform arrived at the roof of the building, the operator set the platform down on the parapet of the building.

During the maneuver, the platform became stuck on the edge of the parapet. The operator attempted to free the platform. When the platform dislodged from the parapet, it moved violently away from the building and then whipped back and forth. During this time, Firefighter Galloway and Firefighter Perkins fell from the platform to their deaths.

None of the three occupants of the platform were wearing restraints or ladder belts.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2009-06 ().

Root Cause 6: Extraordinary/Unpredictable Events Case Studies

1) September 7, 2010 – 2340hrs

Donald Ray Lam, Jr., Forest Ranger Technician III

Age 58, Wildland Full-Time

Kentucky Division of Forestry

Forest Ranger Lam was working with other firefighters to contain the Scotts Chapel Road Fire in Livingston County. Forest Ranger Lam was clearing a fire break for containment at the base of a bluff when a burning snag broke loose on top and rolled downhill over a small bluff and struck Lam from behind.

Firefighter Lam was knocked out and sustained a serious head injury, fractured hip, bruises, and a 2nd degree leg burn on his calves from the burning snag. The impact left him unconscious and with serious injuries including second degree burns from which he did not recover. Forest Ranger Lam died on February 17, 2011.

2) November 13, 2010 – 1415hrs

Chance Hyatt Zobel, Firefighter

Age 23, Career

Columbia Fire Department, South Carolina

Firefighter Zobel and his engine company were dispatched to a fire in the median of a local highway. When his company and another engine arrived on the scene, they positioned their apparatus in a shielding position to protect firefighters from traffic.

A Firefighter Zobel and other firefighters were extinguishing the fire, a 2 vehicle crash occurred on the highway behind the apparatus. The crash caused one of the vehicles to slide between the guardrail and one of the engines. The vehicle entered the fire scene and struck Firefighter Zobel and another firefighter. Both firefighters were transported to the hospital. Firefighter Zobel died due to traumatic injuries.

3) January 30, 2009 – 2358hrs

Mark Bradley Davis, Firefighter-EMT

Age 25 – Volunteer

Cape Vincent Volunteer Fire Department, New York

Firefighter-EMT Davis and members of his fire department were dispatched to an emergency medical incident in a residence. As the patient was treated, he became agitated and went into a bedroom. The patient emerged from the bedroom armed with a rifle. He fired two shots at responders. One shot struck Firefighter-EMT Davis.

The gunman was placed into police custody and responders were able to begin treatment of Firefighter-EMT Davis. Despite their efforts, he was pronounced dead at a local hospital. The cause of death was listed as exsanguination (blood loss).

4) February 4, 2008 – 1550hrs

David Thomas Sherfick, Captain

Age 40 – Career

Brown Township Fire-Rescue, Indiana

Captain Sherfick was the driver of an ambulance. The unit was returning from a patient transport to Indianapolis. The lights and siren on the ambulance were not in use. As he drove on a local roadway, Captain Sherfick observed an oncoming vehicle drifting over the center line into his lane. He steered the ambulance to the right to attempt to avoid a collision but the other vehicle continued to drift and the vehicles crashed head-on.

Captain Sherfick was trapped in the ambulance and had to be extricated. He died as the result of traumatic injuries. Captain Sherfick and the ambulance’s front seat passenger were wearing seat belts. The passenger received minor injuries. The drive of the other vehicle also died and may have suffered some sort of medical emergency prior to the crash.

5) February 19, 2008 – 1213hrs

Michael James Hays, Firefighter

Age 64 – Volunteer

Brazos Canyon Volunteer Fire Department, New Mexico

On the morning of February 19th, Firefighter Hays and another firefighter were in the fire station conducting a work detail. They noticed a slight smell of propane in the fire station but could not find a source. Firefighter Hays reported the smell to two of the local propane suppliers and to the Rio Arriba County Fire Marshal’s Office.

Based on the Fire Marshal’s investigation of the explosion, Firefighter Hays arrived at the fire station at approximately noon. When he opened the door, he smelled gas. He opened the west apparatus bay door to attempt to clear the building of gas and began to shut off electrical service to the building. An explosion occurred and mortally injured Firefighter Hays. Other firefighters, responding to the noise and smoke of the explosion, found Firefighter Hays in the debris of the building and provided aid. Firefighter Hays was transported by ambulance to a meeting site where he was to be transported by medical helicopter. Firefighter Hays died in the ambulance. The cause of death cited by the coroner's report was multiple system trauma.

The New Mexico State Fire Marshal conducted independent investigation of this incident. The cause of the explosion was listed as accidental. Snow accumulation on the fire station from recent storms put pressure on a propane pipe leading into the fire station. A break occurred in the piping and allowed propane to leak into the station. The propane was ignited accidentally, likely as Firefighter Hays cut electrical service to the building.

6) March 26, 2008, 1357hrs

Brent Allen Lovrien, Firefighter

Age 35 – Career

Los Angeles City Fire Department, California

Firefighter Lovrien and the members of this engine company were dispatched along with other fire department units to investigate smoke coming from a structure in the area of 8800 South Sepulveda Boulevard. The incident occurred in the same area where another engine was assigned to an electrical vault fire in the street.

Upon their arrival on the scene, Firefighter Lovrien and another firefighter were assigned to force entry into a room that housed electrical equipment and had been emitting smoke. Firefighter Lovrien used a rotary saw to attempt to gain access. Sparks from the saw ignited combustible gases that had accumulated in the locked room and a large explosion occurred. Firefighter Lovrien was mortally injured in the explosion when he was struck both by the rotary saw and the door.

Firefighter Lovrien was transported to the hospital by fire department ambulance. Despite rapid treatment and transportation, he did not survive. The cause of death was listed as blunt force injuries to the head.

7) April 8, 2008, 1545hrs

Michael David Crotty, Deputy Chief

Age 24, Volunteer

Lawrence Park Township Volunteer Fire Department, Pennsylvania

Chief Crotty was in command of an exterior fire at a plastics manufacturing facility. The aerial ladder on a quint apparatus was set up to help with control of the fire. When the extended aerial ladder pipe was pressurized, the motorized water monitor and 30 feet of aluminum pipe were projected out the end of the ladder. The projected assembly struck Chief Crotty and he sustained fatal injuries.

The type of aerial ladder installed on this quint apparatus was capable of operating in a water tower or rescue mode. In the water tower mode, the shuttle that carried the water monitor and pipe was pinned to the fly section of the ladder to maximize the operating height of the water monitor. In the rescue mode, the shuttle was pinned to a lower ladder section so that it would not interfere with the placement of the ladder for rescue purposes. At this incident, the shuttle was not properly secured and was projected off of the ladder when the ladder’s water pipe was pressurized.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program report F2008-12 ().

8) April 15, 2008, 1545hrs

Terry W. DeVore, Fire Chief

Age 30, Volunteer

Olney Springs Volunteer Fire Department, Colorado

John Wesley Schwartz, Jr., Firefighter

Age 38, Volunteer

Olney Springs Volunteer Fire Department, Colorado

Chief Devore was the driver and Firefighter Schwartz was the front seat passenger in a 1988 GMC brush truck. The unit was responding to the Ordway wildland fire. Conditions in the area included blowing dust, smoke, and wind. During the response the crew attempted to drive over a wooden bridge over a ravine. Unbeknownst to the firefighters, the bridge had been damaged by fire and failed as the brush truck drove over it.

The truck came to rest against the embankment at the opposite side of the ravine and caught fire. According to the county coroner, both firefighters died of traumatic injuries in the crash and subsequently burned. The firefighter’s remains were recovered the next day when fire conditions permitted.

9) July 21, 2008, 0545hrs

Ryan Andrew Hummert, Firefighter

Age 22 – Career

Maplewood Fire Department, Missouri

At 0540hrs, Maplewood firefighters were dispatched to a report of a vehicle fire. The units arrived at 0542hrs and reported a vehicle fire and said that they were using a booster line. At 0546hrs, firefighters reported that they were taking gunfire. Moments later, firefighters advised that they had a firefighter and a police officer down and were still taking gunfire.

Firefighter Hummert suffered a gunshot wound to the head and was out of reach of the other firefighters on the scene. From a distance, Firefighter Hummert appeared to have died soon after being shot.

A gunman had apparently set the vehicle fire to draw responders into the scene. The gunman was barricaded in a single-family residence. An armored law enforcement vehicle was brought to the scene and extricated the trapped police officers and firefighters from the scene. The armored vehicle was also used to recover Firefighter Hummert and bring him to an EMS unit at 0737hrs. Firefighter Hummert arrived at the hospital at 0800hrs and was pronounced dead.

In addition to Firefighter Hummert’s death, 2 police officers were injured. The gunman also died in the incident.

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[1] It should be noted here that this classification method for root causes is utilized by the United States Fire Administration and the National Fallen Firefighters Foundation and its associated programs. Other fire service organizations that write and/or review line-of-duty death reports may utilize a different nomenclature system to define root causality.

[2] The first responder deaths caused by terrorist attacks on 9-11 were excluded from this analysis.

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