This Day in LODD, Structure Fire HistoryPre-Planning and Disorientation, New York 2003

Ladder company firefighter is lost approximately 30 feet away from nozzle team.

On this day in 2003 a New York firefighter became disoriented and went missing while fighting a fire on the second floor of a commercial structure. The victim was part of the first-due truck company and was assigned the “Irons” position. After gaining entry and moving into the second floor the victim, along with the officer and another firefighter, began to search for the fire.

From the NIOSH report:

“At 1240 hours, E95 entered the warehouse with a charged 2 ½-in hand line. At approximately 1241 hours, the L36 officer heard the victim say something to him in a non-urgent tone which he did not understand. At 1242 hours, E95 brought their hand line up to where the L36 crew was located. At this time, the victim was on the side of the line opposite his crew members – toward the interior. Initially E95 did not open their line because they could not see the fire. At about 1243 hours, however, they were ordered to open their line to cool down the structure and began spraying the ceiling where they could hear fire crackling. At about the same time, E75 brought a back-up 2 ½-inch hand line up to the landing. At 1247 hours, E75 entered the warehouse, positioned its line to the left of E95, and began operating toward the two exposures."

"At approximately 1249 hours, due to high heat conditions, the L36 officer yelled for his crew to get out. He then turned to the left and moved toward the stairwell. At approximately 1251 hours, when the L36 officer did not see the victim in the stairwell, he sent his can man to the street to look for him and tried radioing the victim and yelling into the structure. At about the same time, E75 withdrew its line to the stairs and the L36 officer began checking exiting members from the fire floor in an effort to locate the victim."

"At approximately 1253 hours, the officer and nozzle man from E95 thought they heard a scream from inside the fire building. They shut down their line and yelled into the structure for about 30 seconds and, receiving no response, began suppression operations again. At 1255 hours, the IC ordered an evacuation. At 1256 hours, the L36 can man returned to the stairwell and reported that he could not find the victim in the street. The L36 officer verbally informed B13 that he had a missing member. At 1257 hours, B13 transmitted a missing member message to the IC (D7) via an “Urgent” radio transmission. Shortly thereafter, the L36 officer mistakenly identified one of the exiting engine crew members (nozzle man) as his missing member and cancelled the emergency stating that his crew member had been found. At about 1258 hours, the L36 officer yelled into the occupancy and told the two remaining E95 members inside to leave, that he had found his missing member. B13 verified from the L36 officer (face to face) that the missing member had been accounted for and radioed the information to the IC. By approximately1259 hours, all remaining members had left the fire floor and by 1301 hours everyone was off the roof. At about the same time, the IC ordered a defensive operation and L46 began master stream application through the windows."

"At 1303 hours, after doing a second personnel accountability report (PAR) at street level, the L36 officer realized that his irons man was still missing and probably on the fire floor. He reported this verbally to the B13 Chief and, at 1304 hours, Rescue 3 and the L36 officer returned to the fire floor and began searching for the victim with E75 operating a hand line to protect them. L46 continued to operate into the fire floor. At this time visibility had improved as a result of the vertical and horizontal ventilation. At approximately 1309 hours, the IC ordered L46 to shut down and for all trains to be stopped. Note: Commuter trains, which passed nearby about every two minutes, were causing radio interference.”

“At 1313 hours, R3 located the victim who was about 30 feet from the stairs near the center columns (Diagram 1). He was lying beneath a skylight, face down in a pool of water with his head in the direction of the front windows. Two pieces of the tin ceiling were covering him. His face piece was off and the manual shut off switch on the regulator was depressed. The PASS alarm was not audible. When the victim was turned over, the PASS device emitted a faint, monotonous sound. Note: According to the manufacturer (as communicated to the department), this sound indicates a dead-short in the electronics of the PASS. The victim’s radio was on and his left glove was off. The rescue team administered cardio-pulmonary resuscitation (CPR) and then removed the victim from the structure via a rescue basket. He was taken by ambulance to a nearby hospital where he was pronounced dead at 1349 hours."

The total time the victim was in the structure from the time he was noted to be missing to when he was found was estimated to be approximately 30 minutes.”

NIOSH investigators concluded that to minimize the risk of similar occurrences, fire departments should:

• ensure that pre-incident planning is performed on commercial structures

• ensure that Incident Commanders (ICs) conduct a risk-versus-gain analysis prior to committing fire fighters to an interior operation, and continue to assess risk-versus-gain throughout the operation

• use guidelines/ropes securely attached to permanent objects and/or a bright, narrow-beamed light at all entry portals to a structure to guide fire fighters during emergency egress

• instruct fire fighters on the hazards of exposure to products of combustion such as carbon monoxide (CO) and warn them never to remove their face piece in areas in which such products are likely to exist

• ensure that team continuity is maintained during fire suppression operations

• train fire fighters on proper radio discipline and operation, and on when and how to initiate emergency traffic when in distress

• train fire fighters on actions to take while waiting to be rescued if they become lost or trapped inside a structure • ensure that accountability is maintained on the fire ground

• establish a system to facilitate the reporting of unsafe conditions or code violations observed by fire fighters during fire suppression activities

In addition, manufacturers, researchers, and standard setting bodies should:

• investigate the performance of PASS devices/alarms under extreme conditions such as those encountered in structural fires

Manufacturers and researchers should:

• continue to refine existing and develop new technology to track and locate lost fire fighters on the fireground

• continue to develop and refine durable, easy-to-use systems to enhance verbal and radio communication in conjunction with properly worn SCBA Additionally, fire prevention personnel should

• enforce current building codes to improve the safety of occupants and fire


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