Case Study – 3 pages

you will need to locate an actual fire and emergency services incident report. In your response, please identify the following:The scenario: You can paraphrase the scenario, but make sure to use proper citations and references. Use the report as a reference and include corresponding citations.Major issues: Identify the major problems including their causes in this section so you can identify appropriate solutions later.Potential solutions: This section evaluates potential solutions for the identified key problems. Often there is more than one solution, so it is useful to evaluate each solution in terms of its advantages and disadvantages. This will also assist in determining your recommendations. Include consideration of the following:the importance of safety in the design of apparatus or personal protective equipment, how proactive community risk reduction efforts could have prevented the emergency response hazards,how enforcement of codes (identify the codes) could have prevented the incident, andhow risk management assessments could have been applied to prevent the loss of life or injury.Recommendations: This section should outline your recommendations for how your department can avoid a similar situation based upon the given solutions for each of the identified problems.References: Include a reference page in APA style.Your assignment should meet the following guidelines:A title page and reference page are required.Include a minimum of three pages of discussion and analysis (title and references pages do not count toward this total).Use APA formatting.Use a total of two separate sources (including the report you find).….

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November 25, 2014
Career Fire Fighter Killed by Structure Collapse While Conducting
Interior Search for Occupants Following 4th Alarm – Texas
Executive Summary
On May 20, 2013 a 51-year-old male
career fire fighter (the victim) was
conducting a primary search for
occupants after the fourth alarm at a
fire in an apartment complex and was
killed inside the building when it
collapsed. The victim and his partner
were in the first floor hallway
knocking on doors to the apartments,
which were inset from the hallway by
small vestibules. The victim’s partner
was in the vestibule knocking on the
third door to the left and the victim
was in the hallway going to knock on
the third door on the right. In an
instant the second floor walkway and
possibly the third floor walkway
collapsed into the first floor hallway
killing the victim. The victim’s partner
was trapped in the inset of the doorway.
Fire conditions at Side C prior to collapse
(Photo courtesy of fire department)
Contributing Factors
• Inadequate building construction
• Sprinkler system not working near origin of fire
• Incident command
• Communications
• Inadequate Size-up
• Tactics.
Page i
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
Key Recommendations
• Fire departments should ensure that the Incident Commander establishes a stationary
command post, maintains the role of director of fireground operations, and does not become
involved in fire-fighting efforts
• Fire departments should ensure that the Incident Commander conducts an initial size-up and
risk assessment of the incident scene before interior fire fighting operations begin
• Fire departments should ensure critical benchmarks are communicated to the
Incident Commander
• Fire departments should develop, implement and enforce clear procedures for operational
modes. Changes in modes must be coordinated between the Incident Command, the command
staff and fire fighters
• Fire departments should ensure the pre-designated Incident Safety Officer assumes that role
upon arrival on the fireground
• Fire departments should ensure that fire fighters are trained in situational awareness, personal
safety, and accountability
• Fire departments should train on and understand the use and operation of elevated master
streams and its effects on structural degradation
• Fire departments should ensure that pre-determined assignments are assumed and staffed
• Fire departments should train all fire fighting personnel in the risks and hazards related to
structural collapse
• Municipalities, Building Owners, and authorities having jurisdiction should ensure that
sprinkler systems are installed in multi-family housing units. Municipalities and authorities
having jurisdiction should consider requiring building owners to regularly inspect sprinkler
systems to ensure they are functioning properly.
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 or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page ii
November 25, 2014
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
On May 20, 2013 a 51-year-old male career fire fighter (the victim) was searching for occupants after
the fourth alarm and was killed inside the three-story residential apartment building when it collapsed.
On May 20, 2013, the U.S. Fire Administration notified the National Institute for Occupational Safety
and Health (NIOSH) of this incident. On June 17-23, 2013, two safety and occupational health
specialists and the project officer from the NIOSH Fire Fighter Fatality Investigation and Prevention
Program traveled to Texas to investigate this incident. The NIOSH investigators met with the fire
department, union members, the coroner’s office, and the state fire marshal’s office. Interviews were
conducted with fire fighters and officers who were on scene during this incident. The incident scene
was visited and photographed. NIOSH investigators also reviewed the victim’s training records, the
Incident Commander’s training records and the department’s standard operating procedures.
Fire Department
This career department consists of 1,900 members that provide their residents with fire suppression
and protection, emergency rescue capabilities, and emergency medical first responder services. There
are 57 fire stations located strategically throughout the city that serve a population of more than
1,200,000 people in a geographic area of approximately 385 square miles. A minimum of four
firefighters respond on each of the fire engine and aerial ladder truck companies. These fire stations
house 56 fire engines, 22 aerial ladder trucks, five aircraft rescue firefighting apparatus, nine Booster
pumpers, one Haz Mat Unit, as well as 40 front line Rescues/MICUs a and three Peak Demand
Training and Experience
Incident Command
The Incident Commander (IC) had more than 30 years of experience and training on topics including
Incident Command System ICS 100-400, Incident Safety Officer, instructional techniques for company
officers, and National Incident Management System NIMS 701-704.
The victim had more than 28 years of experience and training on topics including fire fighting
MICU or mobile intensive care unit is a vehicle, usually a specially designed minivan or truck, with the capacity for
providing emergency care and life support to those severely injured or ill at the scene of an accident or natural disaster
while transporting them to a medical facility where treatment may continue
Page 1
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
intermediate, National Incident Management System NIMS 701-704 and Incident Command System
ICS100 and ICS 700.
Personal Protective Equipment
At the time of the incident, each fire fighter entering the structure was wearing their full ensemble of
personal protective clothing and equipment, consisting of turnout coats and pants, structural fire
fighting protective Nomex® hood, helmet, gloves, boots, and a self-contained breathing apparatus
(SCBA) with integrated personal alert safety system (PASS) device. The NIOSH investigators
examined and photographed the personnel protective clothing and SCBA worn by the victim. Since
they were not considered to have contributed to the fatality, the fire department did not send the
personnel protective clothing and SCBA to NIOSH for further evaluation.
Battalion Chief and Command Tech Responsibilities
Based upon the fire department’s standard operating procedures (SOPs), there are specific roles for
Battalion Chiefs and their drivers, or Command Techs (CT), based on the order of arrival and
assignment at the incident. The first due Battalion Chief (BC) should always assume the role of
Incident Commander which requires him/her to set up and run the incident. Upon arrival, the
department’s SOPs also require the IC to first conduct a walk-around to size-up the incident and then
manage the fire from the back of his/her vehicle, which is the designated stationary Command Post.
While managing the fire, the IC is also responsible for monitoring and managing the radio traffic for
the fireground activities.
The first due Command Tech (CT) is responsible for setting up the Incident Command Board located
at the stationary command post. The purpose of the Incident Command Board is to direct and track all
personnel dispatched to the fire. Setting up the board should be conducted with direction from the IC.
The second due Battalion Chief has the responsibility of Incident Safety Officer. This position does
not become involved in fire fighting efforts and operates as a staff member who reports only to the IC.
The second due CT assists with Command Post functions as needed.
The third due Battalion Chief maintains communication with central dispatch for additional resources
and any pertinent information that may be relayed from Central dispatch. The position can also assist
with the command board and personnel placement as needed. The third due CT will assist at the
Command Post as needed.
The fourth due Battalion Chief reports to the Command Post and his CT has the responsibility of
establishing and managing the staging area.
The incident occurred during the early morning hours of May 20, 2013, and the approximate
temperature was 68°F with wind speeds ranging between 18 – 20 miles per hour.1
Page 2
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
The apartment complex where the incident occurred was built in 1980 and consisted of three separate
structures, each comprised of three buildings interconnected by a series of indoor stairwells and
outdoor covered walkways, for a total of nine separate apartment buildings. The structure where the
incident occurred was in the middle of the complex, specifically in Building 5, which was connected to
Buildings 4 and 6. Each apartment building consisted of three floors, with eight separate apartments
on each floor. All three buildings were connected by a fully enclosed glass atrium at the south side of
Building 5. The atrium was the primary entrance into building 5, which was also accessible by the
walkways between Buildings 4 and 6.
The apartments varied in size from 715 to 1066 square feet (see Diagram 1). Each apartment structure
was constructed on a concrete slab and was Type-V construction, which consisted of parallel-chord
trusses covered with ½-inch plywood for support of the floors and roof. The exterior and interior walls
were constructed of 2×4’s and the interior hallways were constructed with 2 x 6’s supported by
galvanized joist hangers nailed to header boards that were attached with nails to the end of the parallel
chord trusses (see Photo 1 and Photo 2). The doors that led to each apartment were recessed
approximately 30 inches, creating a vestibule at the apartment’s entrance (see Photo 3, Diagram 1). At
the time of the fire, the fire building and the other buildings in the complex were being reinforced in
the hallways to address the structural instability caused by nailing the header boards to the ends of the
parallel chord trusses. The NIOSH investigators were able to inspect many of these areas and
observed areas where a contractor had used lag screws or bolts to strengthen this connection point.
Most building hallways inspected by the NIOSH investigators also had an additional 2×6 installed by
the contractor under the original one to add additional support to the floor joists (see Photo 4). This
work had not yet been completed in the fire building. Although required, building permits were not
obtained for the work completed to structurally improve the instability in the hallways.
The buildings had a fire alarm system and there were sprinklers located in the trash chute just above
each trash chute opening located at the end of each hallway (see Diagram 1). The trash chute, which
was where the fire originated, was enclosed in the building at the end of the hallway with a dumpster
located at ground level that was accessed for removal by an outside door. The top of the trash chute
terminated in the attic space of the apartment building and did not provide any type of barrier to
prevent a fire from spreading throughout the attic. The sprinkler heads were not working at the time of
the fire because the sprinkler system did not have its own water supply, but was connected to the
building’s main water supply. At the time of the fire, a building maintenance worker was attempting
to fix a water leak in a residence on the third floor and had shut off the main water supply to the
Official pre-planning reports of these apartment buildings had not been completed. There have been
numerous fires at this complex to which the fire department had responded in the past, so the fire
fighters and the department were aware of the building’s lightweight construction features. The most
recent building permit to repair fire damage on the building where the incident occurred was filed in
Page 3
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
Diagram 1. Apartment layout.
Page 4
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
Photo 1. Hallway support construction in collapse area.
(NIOSH Photo)
Photo 2. Close-up detail of hallway support construction.
(NIOSH Photo)
Page 5
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
Photo 3. Apartment entrance recessed where victim’s partner was trapped after collapse.
(NIOSH Photo)
Page 6
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
Photo 4. Double 2×6 floor joists and lag screws added by contractor in an attempt to improve
structural integrity within the apartment complex.
(NIOSH Photo)
An approximate timeline summarizing the significant events in this incident is listed below. The times
are approximate (rounded to the nearest minute) and were obtained by studying the available dispatch
channel records, witness statements, run sheets and fire department records. These timelines are
condensed to the specific events in this incident surrounding the fatality that occurred during a
defensive mode of operations. The timeline is not intended, nor should it be used, as a formal record
of events.
0251 hours—Automatic fire alarm
0258 hours—Upgrade to structure fire, 1st alarm—E57, E28, E29, T57, T37, B04, B02, R57
Page 7
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
0259 hours—Requests 2nd alarm—684, 685, 782, 806, 820, 829, 896, B03, B07, E19, E20,
E22, E37, R19, R29, T19, T20, T56, USAR 19
0330 hours—Request 3rd alarm—E39, E55, E56, T39, 881, 784, 825
0330 hours—Defensive operations
0405 hours—Requests 4th alarm—E02, E31, E48, T53, 802
0420 hours—Defensive mode update
0450 hours—Mayday/structural collapse
On May 20, 2013 at approximately 0251 hours, central dispatch received an automatic alarm at an
apartment complex. Engine 29 (E29) and Truck 57 (T57) both responded for the auto alarm. T57
reported fire through the roof and called for a full alarm. T57 directed E29 to the north entrance where
the fire was located. The E29 officer pulled up the hydrant map and noticed all the hydrants were
locate on the south side of the complex. He told his driver to enter the complex on the north side and
they circled around to the south side to size-up the fire building.
The E29 crew stretched a 3-inch supply line to their engine and prepared to stretch a line into a glass
atrium common area where three apartment buildings joined (see Photo 5). Battalion Chief 4 (BC4)
was the first due chief officer to arrive on scene at 0305 hours. BC4 entered through the south
entrance and drove past the E29 crew to the fire building. The BC4 Command Tech (CT4) dropped
BC4 off at the A/B corner of the apartment complex where fire was extending through the roof. BC4
told his CT4 to park the vehicle and set up the command board while he donned his gear. The
driveway to the north of Side B had a carport adjacent to it across from the fire building. The height of
the carport was too low to allow the command board to be set up with the BC4’s vehicle. CT4 pulled
the vehicle to Side C of the apartment complex and set up the command board in the back of the
vehicle in a parking lot facing the fire building (see Photo 5). BC4 remained on Side A to direct the
fire attack. CT4 was a back-up driver and only drove once or twice a month. For most of the initial
response, he was alone in the parking lot without supervision or communication as to where units were
located, or knowledge of their operating instructions. As other Battalion Chiefs arrived on scene, they
began to fill the roles of Division and Group Commanders to oversee fire operations. Note: Setting up
the Command Post on Side C caused confusion since the command post and the Incident Commander
typically set up the stationary command post on Side A (see Photo 5).
Page 8
A summary of a NIOSH fire fighter fatality investigation
Report # F2013-17
Career Fire Fighter Killed by Structure Collapse While Conducting Interior
Search for Occupants Following 4th Alarm – Texas
Photo 5. Aerial View of incident scene.
(Photo – Google Maps)
At approximately 0310 hours, a Deputy Chief arrived, reported to the Command Post, and assumed
Incident Command (IC). He immediately noticed that there was no chief officer present at the
Command Post and that the Command Board was not completed. He ordered a third alarm. There
was also a discrepancy as to the division designations. He conducted a 360-degree size-up and spoke
face-to-face with the battalion chiefs in each division and told them their new divisions and
responsibilities. Note: Side A and Side C were switched to ensure Side A corresponded with the
location of the Command Post as shown in Photo 5.
Battalion Chief 2 (BC2) and Command Tech 2 (CT2) arrived on scene at 0312 hours and reported to
the Command Post. The IC assigned CT2 to assist with setting up the Command Board and BC2 was
assigned the role of Incident Safety Officer (ISO). BC2 was to walk the perimeter and walk the
interior of the …
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