A summary of a NIOSH fire fighter fatality investigation
Report # F2013-04
Two Career Lieutenants Killed and Two Career Fire Fighters Injured Following a Flashover at an Assembly Hall Fire—Texas
- Risk management principles not effectively used
- High-risk, low-frequency incident
- Fire ground strategy, tactics, and ventilation
- Rapid fire progression
- Fire burned and spread undetected above the ceiling
- Crew integrity
- SCBA air management
- Fire ground communications
- Flashover.
Key Recommendations
- Fire departments should use risk management principles at all structure fires.
- Fire departments should ensure that incident commanders and fire fighters understand the influence strategy and tactics (e.g., ventilation) may have on fire behavior and fire fighter safety and consider whether traditional firefighting tactics are appropriate.
- Fire departments should ensure that an established incident management system on a fireground is appropriate and effective as it relates to that specific incident.
- Fire departments should ensure that a complete situational size-up is conducted on all structure fires.
- Fire departments should ensure that crew integrity is properly maintained by face-to-face contact or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere.
| The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH "Fire Fighter Fatality Investigation and Prevention Program," which examines line-of-duty deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire fighter deaths in the future. The agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do not name the victim, the fire department or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit. |
For further information, visit the program Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
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