1. Maryland FF Fatality October 10, 2006

2. Investigation  NIOSH General Engineer  NIOSH Occupational Safety & Health Specialist  Fire Department Safety Chief  City Arson Officers  Union Representatives

3. Examination and Review  Victim’s PPE, SCBA and PASS  Scene Photographs  Interviews with on scene personnel  Review of Standard Operating Guidelines  Arson Investigator’s Report  Officer and Victim’s Training Records

4. Examination and Review  Witness Statements  Dispatch transcriptions  Coroner’s report  Amateur Video of the incident

5. Incident Information  October 10, 2006  0222 hours  Residential 2-story row house on a basement  Possible parties trapped

6. Apparatus Assigned  Battalion Chief 1 – 0225 hours  E41 – 4 personnel – 0225 hours  M20 – 2 personnel – 0225 hours  Squad 11 – 4 personnel – 0226 hours  Truck 20 – 4 personnel – 0226 hours  E51 – 4 personnel – 0227 hours  Truck 3 – 4 personnel - 0227

7. Apparatus Assigned  E5 – 4 personnel – 0228 hours  Battalion Chief 2 – 0228 hours  Medic 10 – 2 personnel – 0232  E50 – 4 personnel – 0237  28 personnel within 6 minutes  34 personnel within 15 minutes

8. Incident Timeline  0222 hours dispatch  0225- B1, E41, Sq11 on scene B1 did drive-around, row house, middle of block, heavy black smoke. 1 citizen jumper and 1 walking wounded

9. Incident Timeline  E41 – water supply  E41-C & D with Sq 11-D advanced 1 3/4” hand line for an interior attack  E41-A – Entered and requested ventilation  S11-A & C – Gearing up

10. Incident Timeline  0228 hours – B2 assigned side C Truck 3, E5 and E51 all to C side  Heavily involved basement fire moving to 1 st and 2 nd floor on C side  0231 hours – numerous electrical lines C side, IC request 2 nd alarm and utility co  Truck 20 to roof for ventilation and ground ladder to 2 nd floor side “A”

11. Incident Timeline  E41-C to top of stairs, E41-D and Sq11- D at base of stairs with hand line  No fire visible from interior attack team  No apparent impingement to front of structure  Some skylights opened by Truck 20, some already venting

12. Incident Timeline  0231 – Crew learned fire originated in basement and advised to back out  0232 – Conditions rapidly worsened, E41-C down stairs past E41-D landing on top of Sq11-D against metal front door  Hose line pinched in door with door closed  IC requested RIT (not established)

13. Incident Timeline  E41-A and other FF’s that had just exited began to force and remove door  0232 hours E41-D and Sq11-D removed from structure with severe burns  0235 hours door removed E41-C removed, SCBA mask off and hood missing  CPR immediately started  13 minutes from dispatch time to CPR

14. PPE Findings  Witnesses state upon entry victim had face piece on, clicked in and gloves on.  During Incident: cylinder valve shut off, right glove missing, mask dislodged, hood missing (unknown if on in beginning)

15. Side A

16. Side B

19. Recommendations  Ensure TIC’s are used in size up for information to locate seat of fire  Ensure ventilation is in coordination with fire attack. When and Where ?  Ensure exits are not blocked by inadvertent closing doors (wedges)

20. Recommendations  RIT teams should be available  “Many firefighters who die from smoke inhalation, from a flashover, or from being trapped by fire actually become disoriented first. They are lost in smoke and their SCBA’s run out of air, or they cannot find their way out through the smoke, become trapped, and then fire or smoke kills them. The primary contributing factor, however, is disorientation.”

21. Recommendations  Fire departments should ensure that department policies and procedures are followed. “Every department member should have a copy of or easy access to SOP’s, and each member should sign a statement indicating that he/she has read, understands, and agrees to abide by them.”

22. Questions & Thoughts