fire fighter face report no. f2000-27, volunteer …controlled-burn training evolution involving the...

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F2000 Death in the line of duty... 27 Volunteer Assistant Chief Dies During a Controlled-Burn Training EvolutionDelaware May 1, 2001 A Summary of a NIOSH fire fighter fatality investigation SUMMARY On April 30, 2000, a volunteer fire department prepared to complete a controlled-burn training evolution. At 0700 hours, the following volunteer fire fighters gathered at the fire station to discuss their plan of action: the Chief, Assistant Chief (the victim), Captain, Second Rescue Lieutenant, Chief Engineer, Third Assistant Chief Engineer, and four fire fighters. At 0730 hours, they arrived on the scene of a 2‰-story farmhouse which they would use to complete the controlled-burn training evolution. After completing their setup of laying out water curtains (a stream of water projected through a pipe to cool exposures) and hoselines, the fire fighters walked through the structure to familiarize themselves with the layout. The Chief, victim, and Second Rescue Lieutenant entered the front door of the structure and placed hay on the floor. The fire fighters ignited the hay and completed the first training evolution by extinguishing the fire. The fire fighters then completed three additional training evolutions (all the same) before taking a break. The fire fighters then completed additional training using gasoline- powered saws to cut holes in the interior floors and porch roof. The fire fighters then regrouped and prepared to complete the last training evolution, which involved burning the structure from top to bottom. The victim, Second Rescue Lieutenant, Third Assistant Chief Engineer, and a fire fighter proceeded to the attic of the structure (a room approximately 1,000 square feet with an 8-foot ceiling). The victim used a small liquid sprayer to spray diesel fuel on debris, which was spread throughout the attic. The Second Rescue Lieutenant and the Third Assistant Chief Engineer struck a flare and ignited the debris in several places throughout the attic. The fire quickly accelerated and all the fire fighters in the attic, except for the victim who was wearing full turnouts and a self-contained breathing apparatus, exited. The victim stated that he was going to stay in the attic to make sure that the fire was burning adequately. The fire intensified and smoke and heat started banking down the attic stairs. The Chief and fire fighters noticed that the victim did not exit and made several Incident Site The Fire Fighter Fatality Investigation and Prevention Program is conducted by the National Institute for Occupational Safety and Health (NIOSH). The purpose of the program is to determine factors that cause or contribute to fire fighter deaths suffered in the line of duty. Identification of causal and contributing factors enable researchers and safety specialists to develop strategies for preventing future similar incidents. The program does not seek to determine fault or place blame on fire departments or individual fire fighters. To request additional copies of this report (specify the case number shown in the shield above), other fatality investigation reports, or further information, visit the Program Website at www.cdc.gov/niosh/firehome.html or call toll free 1-800-35-NIOSH Photo courtesy of the Delaware State Fire Marshals Office.

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Page 1: Fire Fighter FACE Report No. F2000-27, Volunteer …controlled-burn training evolution involving the house. Following their discussion, the owner of the farm house granted the volunteer

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F2000 Death in the line of duty...27

Volunteer Assistant Chief Dies During a Controlled-Burn TrainingEvolution�Delaware

May 1, 2001A Summary of a NIOSH fire fighter fatality investigation

SUMMARYOn April 30, 2000, a volunteer fire departmentprepared to complete a controlled-burn trainingevolution. At 0700 hours, the following volunteerfire fighters gathered at the fire station to discusstheir plan of action: the Chief, Assistant Chief (thevictim), Captain, Second Rescue Lieutenant, ChiefEngineer, Third Assistant Chief Engineer, and fourfire fighters. At 0730 hours, they arrived on thescene of a 2½-story farmhouse which they woulduse to complete the controlled-burn trainingevolution. After completing their setup of layingout water curtains (a stream of water projectedthrough a pipe to cool exposures) and hoselines,the fire fighters walked through the structure tofamiliarize themselves with the layout. The Chief,victim, and Second Rescue Lieutenant entered thefront door of the structure and placed hay on thefloor. The fire fighters ignited the hay andcompleted the first training evolution byextinguishing the fire. The fire fighters thencompleted three additional training evolutions (allthe same) before taking a break. The fire fighters

then completed additional training using gasoline-powered saws to cut holes in the interior floorsand porch roof. The fire fighters then regroupedand prepared to complete the last trainingevolution, which involved burning the structurefrom top to bottom. The victim, Second RescueLieutenant, Third Assistant Chief Engineer, and afire fighter proceeded to the attic of the structure(a room approximately 1,000 square feet with an8-foot ceiling). The victim used a small liquidsprayer to spray diesel fuel on debris, which wasspread throughout the attic. The Second RescueLieutenant and the Third Assistant ChiefEngineer struck a flare and ignited the debrisin several places throughout the attic. The firequickly accelerated and all the fire fighters inthe attic, except for the victim who was wearingfull turnouts and a self-contained breathingapparatus, exited. The victim stated that he wasgoing to stay in the attic to make sure that thefire was burning adequately. The fire intensifiedand smoke and heat started banking down theattic stairs. The Chief and fire fighters noticedthat the victim did not exit and made several

Incident Site

The Fire Fighter Fatality Investigation and PreventionProgram is conducted by the National Institute forOccupational Safety and Health (NIOSH). The purpose ofthe program is to determine factors that cause or contributeto fire fighter deaths suffered in the line of duty.Identification of causal and contributing factors enableresearchers and safety specialists to develop strategies forpreventing future similar incidents. The program does notseek to determine fault or place blame on fire departmentsor individual fire fighters. To request additional copies ofthis report (specify the case number shown in the shieldabove), other fatality investigation reports, or furtherinformation, visit the Program Website at

www.cdc.gov/niosh/firehome.htmlor call toll free 1-800-35-NIOSH

Photo courtesy of the Delaware State FireMarshal�s Office.

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Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

attempts to locate him. The Captain and SecondRescue Lieutenant were able to locate thevictim, who was unconscious on the attic floor,but were unable to remove him. Shortly after,the attic roof collapsed, forcing the fire fightersto make a defensive attack. The fire waseventually extinguished and the fire fightersremoved the victim, who was pronounced deadat the scene.

NIOSH investigators concluded that, to minimizethe risk of similar incidents, fire departmentsshould

� ensure that flammable or combustibleliquids as defined in NFPA 30 not be usedin live fire training

� ensure that proper ventilation is in placebefore a controlled burn takes place

� ensure that fires not be ignited in anydesignated path of exit

� ensure that an evacuation signal iscommunicated to all fire fighters prior toignition

� ensure that a building evacuation plan is inplace and all fire fighters are familiar withthe plan

� ensure that a method of firegroundcommunication is established to enablecoordination among the incidentcommander and fire fighters

� ensure that a safety officer be appointed forall live fire training

� ensure that each fire fighter be equippedwith full protective clothing and a SCBA

� ensure that backup personnel are standingby with equipment, ready to provideassistance or rescue

� ensure that only one person be assigned asthe �ignition officer� and it not be a firefighter participating in the training

� ensure that exterior fire attack is at aminimum during search and rescue

� ensure that fire fighters who enter ahazardous condition enter as a team of twoor more.

INTRODUCTIONOn April 30, 2000, a 27-year-old, male volunteerAssistant Chief (the victim) died while performinga controlled-burn training evolution. The victimand three other fire fighters entered the attic of a2½-story farm house to perform the last trainingevolution. The victim and fire fighters ignited theattic and the victim failed to exit. The NationalInstitute for Occupational Safety and Health(NIOSH) was notified of this incident on May 1,2000, by the United States Fire Administration.On June 5-6, 2000, two safety and occupationalhealth specialists investigated this incident.Meetings were conducted with the State FireMarshal�s Office, a representative from theNational Volunteer Fire Council, and the Chiefand fire fighters from the volunteer firedepartment. Investigators obtained a copy of thedepartment�s standard operating procedures(SOPs), the victim�s training records, departmenttraining guidelines, state burn regulations, thevictim�s death certificate, and drawings andphotographs of the incident scene. Thedepartment�s SOPs were reviewed and appearedto be sufficient. A site visit was also conductedby the investigators. The fire department involvedin the incident serves a population of

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approximately 10,000 in a geographical area of64 square miles. The department is comprised of50 fire fighters and 5 ambulance personnel whichrespond out of one station. The fire departmentplaces all new fire fighters on probation until theycomplete the Delaware State Fire School coursesentitled Basic Fire Fighting Skills (24 hours) andVehicle Rescue Course (24 hours). Beforecompletion of the fire fighters� second year ofmembership, they must complete Structural FireFighting Skills (24 hours), Hazardous MaterialsResponse Skills (24 hours), and complete adepartment orientation with the Fire Chief ordepartment training officer. Annual refreshertraining is provided by the department. Thevictim�s training records were reviewed andappeared to be sufficient. The victim had 6 yearsof combined experience as an Assistant Chief andfire fighter.

The structure involved in the incident was a 2½-story farm house with an attic. The structure wasbuilt in the late 1800s. The foundation wasconstructed of masonry block and the structurewas ballooned framed using 2- by 4-inch lumber.The roof system was raftered using 2- by 4-inchlumber and covered with ½-inch plywood. Theexterior roof was comprised of cedar shakeshingles overlapped with two layers of asphaltshingles. Vinyl siding covered the exterior wallsand the insulation was fiberglass. The structurewas approximately 3,000 square feet including thearea of the attic.

INVESTIGATIONOn April 16, 2000, the volunteer Fire Chief metwith the owner of a 2½-story farm house todiscuss the possibilities of completing acontrolled-burn training evolution involving thehouse. Following their discussion, the owner ofthe farm house granted the volunteer Chiefpermission to burn the structure and complete the

training. On the same day, the Chief completed astructural evaluation to determine the structure�sstability, did an interior walk through to determinethe combustibles, and set up a date to completethe burn. The Chief stated that the farm houseappeared to be structurally sound and was nearlyempty during his evaluation. The Fire Chiefapplied for a state burn permit, which wasapproved.

On April 30, 2000, the volunteer fire departmentprepared to complete a controlled-burn trainingevolution. At 0700 hours, the following volunteerfire fighters gathered at the station to discuss theirplan of action: the Chief, Assistant Chief (thevictim), Captain, Second Rescue Lieutenant, ChiefEngineer, Third Assistant Chief Engineer, and fourfire fighters. The Chief informed the fire fightersthat they would be setting up water curtains (astream of water projected through a pipe to coolexposures), laying hoselines, completing four liveburn evolutions (training exercises) usinggasoline-powered chain saws that a salesrepresentative was providing, and then burningthe rest of the structure from top to bottom tocomplete the training. After the briefing, firefighters responded to the burn site in two of thedepartment�s engines (Engine 3 and Engine 4),their tanker truck, and by personal vehicles. Allof the fire fighters and a sales representative (alsoa volunteer fire fighter from a mutual-aidcompany) arrived on the scene at 0730 hours andbegan setup. They laid out four water curtains toprotect existing trees and the driveway, laid outhoselines to supply the water curtains, and laidout two additional 1¾-inch hoselines (one was tobe used in the training and the other was to protectthe northwest exposure when they completed thefinal burn [see Diagram 1]). Upon completing thesetup, the Chief ordered all fire fighters to walkthrough the house on their own to familiarizethemselves with the layout and design.

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Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

In preparation to start the training evolutions, theFire Chief, victim, and the Second RescueLieutenant entered the first floor front door andplaced hay in the living room, next to the walls(see Diagram 1). The Chief exited the house andbriefed the fire fighters who would be performingthe training. He told the fire fighters to enterthrough the front door, search for the fire, andknock it down. The Chief then ordered the victimto exit the structure and wait to reenter with thefire fighters performing the training, to evaluatetheir performance. The victim was equipped withfull turnouts and a new self-contained breathingapparatus (SCBA), which the sales representativeprovided for him to use. Note: The salesrepresentative had briefed the victim on the SCBAand the victim was familiar with its operation.The victim had also used this SCBA prior to thisday. The Second Rescue Lieutenant was orderedby the Chief to start the first fire. Using a 1-gallonsprayer, filled with diesel fuel, the Second RescueLieutenant sprayed the hay and used a flare tostart the fire. The Second Rescue Lieutenant thenexited the structure. The fire fighters and thevictim entered the structure in full turnouts andSCBAs. They stretched a 1¾-inch hoseline insidethe structure, found the fire, and immediatelyknocked it down, completing the first evolution.Three additional evolutions were completed in thesame manner. The evolutions lasted approximately1 hour and the fire fighters then took a break.After the break, the sales representative providedthe department with a new gasoline-poweredchain saw to use for training. The fire fighters,including the victim, performed a series of cutson the exterior of the house. Fire fighters thentook the chain saw they were testing, along withone of their own chain saws, inside the house andproceeded to the attic to cut holes in the atticfloor. They cut two holes, 2 feet by 2 feet, directlyunder a window on the west wall and a windowunder the south wall (see Diagram 3). Note: The

fire fighters made the cuts as a part of theirtesting. The attic space was approximately 1,000square feet with 4-foot knee walls around theperimeter. The ceiling was approximately 8 feetin height and sloped with the roof pitch.Completing the cuts in the attic, the fire fighterswent back to the first floor to cut additional holesin the floor. The fire fighters met up with the Chiefwho was knocking free the base of the twochimneys with a sledge hammer (see Diagram 1).He was freeing the chimney bases because hewanted the chimneys to collapse as the houseburned. As the fire fighters cut holes in the floor,the victim, along with the Second RescueLieutenant, the Third Assistant Chief Engineer,and a fire fighter, entered the first floor and metup with the Chief. The victim was wearingcomplete turnouts with a SCBA and the otherswere just wearing turnouts. The Chief told themto go the attic and prepare it for the last burn. Hetold the victim to start spraying diesel fuel on thesouth wall and work his way back to the stairs,spraying it last. He then checked the victim�sSCBA air gauge and told the victim that it washalf full. The victim, who was equipped with thediesel fuel sprayer, the Second Rescue Lieutenant,Third Assistant Chief Engineer, and a fire fighterproceeded to the attic at approximately 0920hours. The victim walked across the attic andsurveyed the layout before returning to the stepsand met back up with the others. The victimnoticed that cardboard boxes, papers, a Christmastree, and clothing were spread throughout. Dueto the inexperience of the fire fighter, the victimtold him to return to the first floor and exit. Thevictim and Second Rescue Lieutenant walked overto the south wall of the attic as the Third AssistantChief Engineer entered a 12-foot by 8-footplayroom on the west side (see Diagram 3).Starting on the south wall, the victim sprayed thediesel fuel on the walls and debris, making hisway back around by the chimney in the middle of

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the floor (see Diagram 3). The Second RescueLieutenant struck a flare and started lighting theareas the victim had sprayed. The victim met withthe Third Assistant Chief Engineer in the playroom(near the exit) and told him to strike a flare andignite the room. Soon after, the Rescue Captainreached the attic floor. He stated that there was abreeze coming through the playroom, which hethought was coming through the playroomwindow. The Second Rescue Lieutenantconfirmed that both windows on the south andwest walls in the playroom were open before theystarted the final burn. The victim returned to themiddle of the attic as the Third Assistant ChiefEngineer lit various objects (e.g., a small, driedout shrub, a poster hanging on the ½-inch particleboard wall, a piece of flex duct, and debris on thefloor). The Engineer stated that the room quicklybecame engulfed in flames and the heat forcedhim to exit and shut the room�s door. The ThirdAssistant Chief Engineer met back up with thevictim and stated that he could see a small fire inthe south section of the attic. The Third AssistantChief Engineer told the victim that the playroomwas lit and the fire was intensifying. The two ofthem remained in the middle of the attic beforethe Third Assistant Chief Engineer noticed thatthe smoke was starting to get heavy and the heatwas intensifying. The Rescue Captain noticed thesame conditions and exited down the stairs to thesecond floor. At approximately 0930 hours, theThird Assistant Chief Engineer exited the attic andmet up with the Chief on the first floor, relatingto him that the attic was lit. The Second RescueLieutenant finished igniting the south section ofthe attic and noticed the victim was sprayingadditional fuel on the small fires in the samesection. The Second Rescue Captain stated thatthe smoke was banking down and there wasmoderate heat in that area. He told the victim thatthey should exit and he started toward thestairway. The victim told him that he was going

to stay in the attic a little longer. Note: The victimwas wearing full turnouts and a SCBA. It wasnoted in the investigation that this was the firsttime the victim had worn a SCBA while ignitinga controlled burn. The Second Rescue Lieutenantnoticed the heat intensifying and the smoke wasbanked to the floor as he made his way closer tothe stairway. He went halfway down the stairsbefore stopping, exposing his back to theplayroom area, and yelled to the victim. He toldthe victim that he should exit because it wasgetting worse by the stairs. Immediately afteryelling to the victim, the Second RescueLieutenant was forced down the stairs by a suddenblast of heat. The heat came from the direction ofthe playroom. The Second Rescue Lieutenantmade it down the stairs and onto the second floorwhere he met the Rescue Captain (see Diagram2). The Second Rescue Lieutenant was coughingfrom the smoke and told the Rescue Captain thatthe victim was still upstairs and he (the SecondRescue Lieutenant) was exiting. The RescueCaptain saw heavy, black smoke followed byflames, emit from the attic stairway. He statedthe he heard three loud thumps from the attic floorand then exited the house due to the heat andsmoke. The Second Rescue Lieutenant told theChief that the victim was not with him and he didnot know where he was. After a short search, theycould not locate the victim and determined he wasstill inside. The Chief noticed heavy fire insidethe playroom window and the south side windowof the attic (see Photo). The Chief radioed dispatchand requested mutual-aid companies to respond.The Rescue Captain and the Third Assistant ChiefEngineer pulled a 1¾-inch hoseline to the southside and applied water to the south side atticwindow. The sales representative also grabbed a1¾-inch hoseline and applied water to the attic�splayroom window from the west side. The Chiefordered the Captain and the Chief Engineer tothrow a ladder to the second floor roof, which

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Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

covered the south side porch. The Second RescueLieutenant donned his SCBA, grabbed the 1¾-inch training hoseline, and stretched it up theladder. At approximately 0941 hours, the SecondRescue Lieutenant pulled the hoseline through anopen window and stretched it halfway up the atticstairs. The hoseline was only 150 feet in lengthand would not reach up to the top of the stairs.The Second Rescue Lieutenant applied waterfrom the bottom of the stairs to heavy fire in theplayroom section of the attic before running outof air. After donning their SCBAs, the Captainand a fire fighter climbed the ladder and enteredthe same window on the second floor. As theSecond Rescue Lieutenant exited, he passed theCaptain by the base of the stairs. The Captainreached the nozzle of the same hoseline andapplied water to the playroom area. Shortly afterthe fire fighter met up with the Captain, theCaptain dropped the nozzle and entered the atticarea to search for the victim. The fire fightergrabbed the nozzle and opened it, attempting tohold back the fire as the Captain searched. TheCaptain located the victim in the middle sectionof the attic. The victim was found on his backwith his head facing northwest and his feet facingsoutheast. The Captain attempted to pull him tothe attic stairway, but was unsuccessful. TheCaptain noticed heavy fire throughout the atticand stated that the heat was very bad. Heattempted to move the victim a second time andagain was unsuccessful. After the second attempt,the Captain had to exit the attic due to the extremeheat, fire conditions, and low air. The Captainstated that the victim was badly burned and wasunconscious. The fire fighter manning the hoselineon the attic stairs also exited due to low air. Thefire fighters all exited onto the second floor porchroof (see Diagram 2). The Captain related thevictim�s condition to the Second RescueLieutenant and the Chief, who was on the ground.The Second Rescue Lieutenant changed his air

bottle, reentered the second floor window, andproceeded up the attic stairs to search for thevictim. The Second Rescue Lieutenant statedthere was still heavy fire and a lot of heat. Heentered the attic area and located the victimapproximately 10 feet from the stairs. In anattempt to remove him, he grabbed the victim�sSCBA straps, pulled, and they broke. TheSecond Rescue Lieutenant�s low air alarm thensounded which forced him to exit. He exitedonto the second floor�s porch roof when theChief ordered all fire fighters out of the house.The mutual-aid companies arrived on the sceneand took over operations. The operation wasthen declared as a recovery and the volunteercompany was relieved from their duties. Shortlyafter the mutual-aid companies took over, theattic roof collapsed, pinning the victimunderneath the debris. The fire was extinguishedand the mutual-aid companies completed therecovery process. The victim was pronounceddead on the scene.

CAUSE OF DEATHThe death certificate listed the cause of deathas asphyxiation and thermal burns. The victim�scarbon monoxide level was listed at 41%.NOTE: Because of several factors�the lengthof time the victim was exposed to heat and fire,the collapsed debris, and the severity of thedamage to the SCBA�it is unclear if the victim�sSCBA facepiece was removed, SCBA hoselinesmelted, or if the SCBA malfunctioned. Due tothe condition of the SCBA unit, no furtherevaluation could be completed. The SCBA wasnew and the victim had been using it prior tothis incident. No problems with the SCBA werereported by the victim in the past or throughoutthe entire training operation.

RECOMMENDATIONS/DISCUSSIONRecommendation #1: Fire departments

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should ensure that flammable or combustibleliquids as defined in NFPA 30 not be used inlive fire training.1, 2

The National Fire Protection Associationstandard 1403, 2-3.3, notes that the use offlammable or combustible liquids, as defined inNFPA 30, shall not be permitted for use in livefire training evolutions in acquired structures.Additionally, the NFPA notes that fuel materialsshall be used only in the amounts necessary tocreate the desired fire size. Pressure-treatedwood, rubber, plastic, and straw or hay treatedwith pesticides or harmful chemicals shall notbe permitted to be used. The fuel load shall belimited to avoid conditions that could cause anuncontrolled flashover or backdraft.

Recommendation #2: Fire departmentsshould ensure that proper ventilation is inplace before a controlled burn takes place.2

The Delaware Fire Prevention Commissionregulation 3-3.3 regarding live fire trainingstates that adequate ventilation openings shallbe made in the roof. Regulation 3-3.4 also notesthat roof ventilation openings that are normallyclosed, but can be opened in the event of anemergency, may be utilized. These may consistof panels or hinged covers. Proper ventilationshould be in place before ignition occurs torelease heat and gases that can build up andpossibly cause a flashover or backdraft.

Recommendation #3: Fire departmentsshould ensure that fires not be ignited in anydesignated path of exit. 1

The National Fire Protection Associationstandard 1403, 2-4.15, notes that fires shall notbe ignited in any designated exit paths. In theevent that the ignition officer or other fire

fighters would need to exit, the path should beclear of any debris, obstacles, or fire.

Recommendation #4: Fire departments shouldensure that an evacuation signal iscommunicated to all fire fighters prior toignition.1, 2

The National Fire Protection Association standard1403, 2-4.10 and A-2-4.10, notes that anevacuation signal shall be demonstrated to allparticipants prior to the ignition of live fire trainingevolutions. When an evacuation signal iscommunicated, all participants should beinstructed to report to a predetermined locationfor a roll call. Instructors should immediatelyreport any personnel not accounted for to theIncident Commander or the instructor-in-charge.Examples of an evacuation signal that could beused include a whistle, apparatus air horn, or high-low electronic siren.

Recommendation #5: Fire departments shouldensure that a building evacuation plan is inplace and all fire fighters are familiar with theplan.1, 2

The National Fire Protection Association standard1403, 2-4.10, and the Delaware Fire Preventionregulation 3-7.3 notes that a building evacuationplan shall be established and fire fighters shouldconduct a walk-through to familiarize themselveswith the structure. In the event that an evacuationtakes place, fire fighters should have knowledgeof all exits and a predetermined location to meetfor a roll call.

Recommendation #6: Fire departments shouldensure that a method of firegroundcommunication is established to enablecoordination among the incident commanderand fire fighters.1

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Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

The National Fire Protection Association standard1403, 2-4.9, notes that communication shall beestablished between the incident commander andfire fighters performing any interior operations,sector leaders, and the safety officer. Propercommunication is a must at any incident site.Portable radios should be used to keep allpersonnel on the scene in communication with theincident commander.

Recommendation #7: Fire departments shouldensure that a safety officer be appointed for alllive fire training.1, 2

A safety officer should be appointed by theauthority having jurisdiction for all live fire trainingevolutions. The safety officer should have theauthority, regardless of rank, to intervene andcontrol any aspect of the operations when, in hisor her judgement, a potential for an unsafecondition exists. The safety officer should providefor the safety of all persons on the scene includingstudents, instructors, visitors, and spectators. Thesafety officer shall not be assigned any other dutiesthat interfere with safety responsibilities.

Recommendation #8: Fire departments shouldensure that each fire fighter be equipped withfull protective clothing and a SCBA.1, 2

Each participant in a training evolution should beequipped with full protective clothing and self-contained breathing apparatus. All participantsshould be inspected by the safety officer prior toentry into a live fire training evolution to ensurethat the protective clothing and SCBA are beingworn properly and are in serviceable condition.Although it is recommended that all fire fightersinvolved in live fire training evolutions beequipped with full protective equipment and aSCBA, fire fighters must still evaluate conditionsat all times and beware of the possibilities that

the protective equipment can give a falseimpression of temperatures and conditions.

Recommendation #9: Fire departments shouldensure that backup personnel are standing bywith equipment, ready to provide assistance orrescue.1, 2

Backup personnel, trained and equipped, shouldbe on the scene of a live fire training evolution incase an emergency would occur. The backuppersonnel, also known as a rapid intervention teamor crew, should stand by with a backup hoselineand other necessary equipment to ensure adequateprotection for personnel on training attack lines.The backup hoseline should be long enough toreach any interior component of the structure.

Recommendation #10: Fire departments shouldensure that only one person be assigned as the�ignition officer� and it not be a fire fighterparticipating in the training.1

The National Fire Protection Association standard1403, 2-4.24, notes that one person shall bedesignated as the �ignition officer� to control thematerials being burned and the ignition officer shallnot be a fire fighter participating in the training.

Recommendation #11: Fire departments shouldensure that exterior fire attack is at a minimumduring search and rescue.3

Once search and rescue operations are in place,fire departments should ensure that the fire fighterscompleting the search and rescue are not placedin danger by the fire attack. It is a complicatedprocedure to determine, from outside a structure,the position of the fire fighters completing thesearch and rescue operations in the interior. If anexterior fire attack is being performed while theinterior search and rescue operations are taking

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place, there is a possibility that the fire could shiftand place the interior fire fighters in an unsafeposition. Additionally, the use of an exteriorhoseline placing water through a window couldpossibly cause a collapse, placing the interior firefighters in danger. Command and operations mustalways be in communication at all times on thefireground to eliminate confusion of tactics.

Recommendation #12: Fire departments shouldensure that fire fighters who enter a hazardouscondition enter as a team of two or more.4

The National Fire Protection Association (NFPA)recommends that four persons (two in and twoout), each with protective clothing and respiratoryprotection, is the minimum number essential forthe safety of those performing work inside astructure. The team members should be incommunication with each other through visual,audible, or electronic means to coordinate allactivities and to determine if emergency rescue isneeded. Also, the recently promulgated standardby the Occupational Safety and HealthAdministration (29 CFR 1910.134) states thatwhen two or more workers enter an immediatelydangerous to life and health (IDLH) atmosphere,

such as the atmosphere commonly found instructural fire fighting, two will remain on theoutside and maintain visual or voice contact toassist in emergency rescue activities.

REFERENCES1. NFPA 1403, Standard on live fire trainingevolutions. 1997 ed., Quincy, MA: National FireProtection Association.

2. Delaware Fire Prevention Commission [1997].Regulations for live fire training. Dover, DE:Delaware State Fire School.

3. Coleman J [1997]. Incident management forthe street-smart fire officer. Saddle Brook, NJ:Fire Engineering.

4. 29 Code of Federal Regulations 1910.134,OSHA Respirator Standard.

INVESTIGATOR INFORMATIONThis incident was investigated by Frank C.Washenitz II and Nancy Romano, Safety andOccupational Health Specialists, Division ofSafety Research, Surveillance and FieldInvestigations Branch, NIOSH.

Page 10: Fire Fighter FACE Report No. F2000-27, Volunteer …controlled-burn training evolution involving the house. Following their discussion, the owner of the farm house granted the volunteer

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Investigative Report #F2000-27Fatality Assessment and Control Evaluation

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Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

Photo. Structure Involved in This Incident

Photo courtesy of the Delaware State Fire Marshal�s Office.

Page 11: Fire Fighter FACE Report No. F2000-27, Volunteer …controlled-burn training evolution involving the house. Following their discussion, the owner of the farm house granted the volunteer

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Investigative Report #F2000-27Fatality Assessment and Control Evaluation

Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

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CHIMNEY

CLOSET

CL.

CHIMNEY

42’-0"

39’-0"

16’-0"

15’-0"37’-0"

23’-0"

LIVING ROOM

TRAINING FIRES

KEY

NOT TO SCALE

1 3/4-INCHHOSELINE

1 3/4-INCHHOSELINE

2 1/2-INCHHOSELINE

2 1/2-INCHHOSELINE

2 1/2-INCHHOSELINE

2 1/2-INCHHOSELINE 1 3/4-INCH

HOSELINEUSED FORTRAINING

1 3/4-INCHHOSELINE

STRETCHED TOTHE WEST SIDE

FOR LASTEVOLUTION

WATER CURTAIN

3-INCH HOSELINETO PUMPER

FRONT ENTRANCE

N

Diagram 1. First Floor Layout

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Investigative Report #F2000-27Fatality Assessment and Control Evaluation

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Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

CHIMNEY

NOT TO SCALE

CLOSETSHOWER

STALL

CLOSET

CLOSET

STEPS TO 1ST FLOOR

STEPS TO1ST FLOOR

PORCH ROOF

TO ATTIC

TO 1ST FLOOR

N

Diagram 2. Second Floor Layout

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Investigative Report #F2000-27Fatality Assessment and Control Evaluation

Volunteer Assistant Chief Dies During a Controlled-Burn Training Evolution�Delaware

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NOT TO SCALE

CHIMNEY

OPENING CREATED BYREMOVAL OF CHIMNEY

CHIMNEY

18’-0"

24’-0"

39’-0"

50’-0"

PLAYROOM8’X13’

PARTICLEBOARD

COVEREDWALLS

UNCOVERED WALL

UNCOVERED WALL

UNCOVERED

WALL

SIDES OF STAIRSOPEN TO KNEE WALLS

CUT INFLOOR

CUT INFLOOR

VICTIM

TRAINING FIRES

KEYN

Diagram 3. Attic Layout