U.S. Fire Administration/Technical Report Series

Three Firefighters Die in 

Pittsburgh House Fire

Pittsburgh, Pennsylvania

USFA-TR-078/February 1995

Homeland

Security

U.S. Fire Administration Fire Investigations Program

T

he U.S. Fire Administration develops reports on selected major fires throughout the country. 

The fires usually involve multiple deaths or a large loss of property. But the primary criterion 

for deciding to do a report is whether it will result in significant “lessons learned.” In some 

cases these lessons bring to light new knowledge about fire--the effect of building construction or 

contents, human behavior in fire, etc. In other cases, the lessons are not new but are serious enough 

to highlight once again, with yet another fire tragedy report. In some cases, special reports are developed to discuss events, drills, or new technologies which are of interest to the fire service.

The reports are sent to fire magazines and are distributed at National and Regional fire meetings. The 

International Association of Fire Chiefs assists the USFA in disseminating the findings throughout the 

fire service. On a continuing basis the reports are available on request from the USFA; announcements of their availability are published widely in fire journals and newsletters.

This body of work provides detailed information on the nature of the fire problem for policymakers 

who must decide on allocations of resources between fire and other pressing problems, and within 

the fire service to improve codes and code enforcement, training, public fire education, building 

technology, and other related areas.

The Fire Administration, which has no regulatory authority, sends an experienced fire investigator 

into a community after a major incident only after having conferred with the local fire authorities 

to insure that the assistance and presence of the USFA would be supportive and would in no way 

interfere with any review of the incident they are themselves conducting. The intent is not to arrive 

during the event or even immediately after, but rather after the dust settles, so that a complete and 

objective review of all the important aspects of the incident can be made. Local authorities review 

the USFA’s report while it is in draft. The USFA investigator or team is available to local authorities 

should they wish to request technical assistance for their own investigation.

The fire investigation reports are developed by USFA staff and by Varley-Campbell & Associates 

and TriData Corporation, their staff and consultants, who are under contract to assist the Fire 

Administration in carrying out the Fire Reports Program.

Appreciation goes to Chief Charlie Dickinson and all of the members of the Pittsburgh Fire Bureau 

for their assistance in preparing this report. The author wishes to acknowledge the assistance that 

was provided by the members of the Board of Inquiry, headed by Deputy Chief John Gourley, and the 

support of the officers and members of Local 1, International Association of Fire Fighters.

For additional information contact Mr. Kenneth Kuntz, Major Fires Investigations Project Officer at 

the U.S. Fire Administration, 301-447-1000.

For additional copies of this report write to the U.S. Fire Administration, 16825 South Seton Avenue, 

Emmitsburg, Maryland 21727. The report is available on the Administration’s Web site at http://

www.usfa.dhs.gov/

Three Firefighters Die in

Pittsburgh House Fire

Pittsburgh, Pennsylvania

Investigated by: J. Gordon Routley

This is Report 078 of the Major Fires Investigation Project conducted 

by Varley-Campbell and Associates, Inc./TriData Corporation under 

contract EMW-94-C-4423 to the United States Fire Administration, 

Federal Emergency Management Agency.

Homeland

Security

Department of Homeland Security

United States Fire Administration

National Fire Data Center

U.S. Fire Administration

Mission Statement

As an entity of the Department of Homeland 

Security, the mission of the USFA is to reduce life and economic losses due to fire 

and related emergencies, through leadership, advocacy, coordination, and support. 

We serve the Nation independently, in coordination with other Federal agencies, 

and in partnership with fire protection and 

emergency service communities. With a 

commitment to excellence, we provide public education, training, technology, and data 

initiatives.

Homeland

Security

Table of Contents

OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SUMMARY OF KEY ISSUES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

BUILDING DESCRIPTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Fire Origin and Spread. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Arrival. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Fire Extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Firefighters in Distress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

First Rescue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Second and Third Rescues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Missing Firefighter Located. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

CHRONOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ANALYSIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Known and Unknown Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

SAFETY EQUIPMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Self-Contained Breathing Apparatus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

PASS Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Portable Radios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

INCIDENT MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

EMS Coordination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

SAFETY AND ACCOUNTABILITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Crew Integrity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

TEMPORARY ASSIGNMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

EMERGENCY SURVIVAL ACTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

RAPID INTERVENTION TEAMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

LESSONS LEARNED AND REINFORCED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

APPENDIX A: Bureau Initiatives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

APPENDIX B: Photographs of Fire Scene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1

Three Firefighters Die in 

Pittsburgh House Fire

February 14, 1995

Local Contact: Chief Charlie Dickinson

Pittsburgh Bureau of Fire

200 Ross Street, 5th Floor

Pittsburgh, PA. 15219

(412) 255-2860

OVERVIEW

Three Pittsburgh firefighters died on February 14, 1995, when they ran out of air and were unable 

to escape from the interior of a burning dwelling. The three victims were all assigned to Engine 

Company 17 and had advanced the first hoseline into the house to attack an arson fire in the basement. When found, all three were together in one room and had exhausted their air supplies. Three 

other firefighters had been rescued from the same room, which caused confusion over the status of 

the initial attack team.

This incident illustrates the need for effective incident management, communications, and personnel 

accountability systems, even at seemingly routine incidents. It also reinforces the need for regular 

maintenance and inspection of self-contained breathing apparatus, emphasizes the need for PASS 

devices to be used at every fire, and identifies the need for training to address firefighter survival in 

unanticipated emergency situations.

This incident also reinforces a concern that has been identified in several firefighter fatality incidents 

that have occurred where there is exterior access to different levels form different sides of a structure. 

These structures are often difficult to “size-up” from the exterior and there is often confusion about 

the levels where interior companies are operating and where the fire is located. In these situations it 

is particularly important to determine how many levels are above and below each point of entry and 

to ensure that the fire is not burning below unsuspecting companies.
2

SUMMARY OF KEY ISSUES

Issues Comments

Incident Command Command was not established by the first arriving company. The acting battalion chief was 

coming from another call and had a delayed arrival. All first alarm companies had self-committed before the acting battalion chief assumed command of the incident.

Accountability Accountability procedures were not implemented. The locations and functions of companies 

operating inside the house were not known to the Incident Commander. It was not realized that 

members were missing.

Crew Integrity All crews did not function as single tactical units. Some of the individual members from these 

companies performed unrelated tasks and were not under the supervision of their company 

officers. Most of the personnel were working in temporary assignments for that shift.

Emergency Survival The actions of the three victims when they realized they

Action were in trouble are not known; however, they do not appear to have initiated emergency 

procedures that could have improved their chances of survival or made other firefighters aware 

of their need to be rescued.

Rapid Intervention Some fire departments have adopted procedures to assign a Teams rapid intervention team 

at working fires. The objective of this team is to be ready to provide immediate assistance to 

firefighters in trouble.

Communication There was a lack of effective fireground communications at this incident. There was no 

exchange of information with the interior crews after they entered the dwelling. All of the first 

alarm companies were operating before the acting battalion chief arrived and assumed command. The Incident Commander did not receive any progress reports from these companies.

Portable Radios Although two of the three firefighters who died had portable radios, they do not appear to have 

attempted to use them to summon assistance. (One of the radios was found to be inoperative 

after the incident.)

Interagency Coordination The communications problems were complicated by the fact that EMS units on the scene of a 

fire report to their own supervisors and communicate on their own radio channels. The interaction and communications between fire and EMS units were inadequate.

SCBA Maintenance Examination of the SCBA units used by the three victims and one of the injured firefighters 

indicate that improvements are needed in maintenance, inspection, and testing programs.

PASS Devices All three victims had PASS devices, however they were not turned on. It is likely that a functioning PASS device would have alerted other firefighters in the immediate area to the unconscious 

victims.

BUILDING DESCRIPTION

The Homewood section of Pittsburgh is a densely populated residential area. Most of the structures 

in the area are one- and two-family wood frame dwellings that are at least 75 years old. The streets 

are narrow and the houses are closely spaced. Most of the houses appear to be two stories, but many 

are built on sloping ground and have additional floor levels that cannot be seen from the street.

The fire occurred in a single family dwelling that was approximately 20 feet wide and 33 feet deep 

and had three occupied floor levels above a partially finished basement. The interior walls were lath 

and plaster, and the exterior walls were aluminum siding over asphalt shingles attached to balloon 
USFA-TR-078/February 1995 3
4
USFA-TR-078/February 1995 5

frame wood construction. The separation to the neighboring house on the left side was only 27 

inches wide, which created a significant exposure problem. On the right side there was a 12 foot 

wide side yard between houses.

Because the house was built on a slope, the front entrance at 8361 Bricelyn Street was actually at 

the second floor level. When viewed from the front, the house appeared to have only two stores; 

however, from the rear most of the basement was exposed above grade level and the house appeared 

to be the equivalent of four stories. The first floor was one level up from the back yard and one level 

down from the front door. (Refer to the building diagram and floor plans on the following pages for 

details of the arrangement.)

A stone retaining wall was built along the front of the property and served as the front wall of the 

basement and first floor levels. The side yard was approximately 12 feet lower than the sidewalk in 

front of the house.

Doors to the exterior were provided on three levels. The front door, on the second floor, opened to 

a narrow front porch adjacent to the sidewalk. There was a rear porch with exterior stairs from the 

first floor down to the back yard. Immediately below the rear porch was an access door into the 

basement.

The kitchen and family room were located on the first floor, the living room and one bedroom were 

on the second floor, and two additional bedrooms were on the third floor. The heating equipment, 

a washer and dryer, and storage areas were located in the basement. The furnace, water heater and 

clothes dryer were all fueled by natural gas.

The three stair sections were stacked, one directly above another, and divided each floor into front 

and rear sections. A wood door at the top of the basement stairs opened into a narrow vestibule on 

the first floor; when this door was open it blocked the opening between the kitchen at the rear and 

the family room at the front. There were no doors in the stairways between the first and second or 

the second and third floors.

The basement had one small window facing the rear yard. On the first floor, there were two windows 

in the family room, one on each side of the house, and two in the kitchen. The family room windows 

were approximately five feet above grade level and had been covered-over on the inside with a clear 

acrylic plastic (plexiglass) 3/32 inches thick to create the effect of storm windows. There were also 

windows on the second and third floors.

The house was occupied by two adults, one teenage, and one child; only one adult and the child 

were at home when the fire was discovered. The contents were ordinary household furnishings. The 

rooms were small and crowded with furniture. The home was equipped with battery powered smoke 

detectors.

THE FIRE

The weather on the night of February 14 was cloudy with a moderate wind and a temperature of approximately 15 degrees Fahrenheit. The ground was partially covered with snow at the time of the fire.

Fire Origin and Spread

The fire was determined to have been caused by arson and originated in the basement, directly 

under the kitchen. This would place the point of origin close to the gas-fired appliances. The fire first 
6

involved contents in the basement, then extended upward through void spaces in the exterior walls 

and around the stairway. The void spaces allowed the fire to extend directly to the attic. It later broke 

through the walls and/or ceiling and involved the bedrooms on the third floor.

There was some fire involvement in the kitchen, particularly under the counters, which were attached 

to the wall where the largest void space was located. A partial floor collapse occurred in the kitchen 

directly over the point of origin, during the later stages of the fire. The fire extended via the walls 

from the basement directly to the attic, then involved the third floor; there was no fire involvement 

in the family room or in any of the rooms on the second floor.

The occupants reported that the first indication of fire was smoke seeping into a bedroom on the 

upper floor. The occupants exited from the house and called 9-1-1 from a neighbor’s telephone to 

report the fire. The first alarm assignment was dispatched to 8366 Bricelyn Street at 0022 hours.

Response

The initial response consisted of Engines 17, 18, and 19, Truck 17, and Battalion Chief 2 (Unit 4042). 

Engine 19 was dispatched in place of Engine 15, which was on another call, and Battalion Chief 2 

was responding in place of Battalion Chief 3. Battalion Chief 3 (Unit 4043) became available after 

the call was dispatched and replaced Battalion Chief 2 on the assignment. The Emergency Medical 

Services Division dispatched Medic 11 and Rescue 1 on the first alarm, each with two paramedics on 

board. (Pittsburgh EMS is a separate division of the Department of Public Safety.)

The first alarm assignment included a total of 17 personnel, including the acting battalion chief. The 

three engine companies and the truck company each had four personnel on duty. On this particular 

night, only fire of the 17 Fire Bureau personnel responding on the first alarm were in a normally 

assigned position; all of the others were temporarily detailed, acting in a higher classification, working on overtime, or had traded shifts or assignments with another member for the night.

Engine 17 was staffed by a captain and three firefighters. The captain and the driver were in their 

regular assignments, while the other two firefighters had been detailed from Engine Company 8. 

The officer in charge of Truck 17 was a firefighter moved-up to acting lieutenant, while a captain 

who is normally assigned to Engine 8 on a different shift was working on overtime and riding as a 

firefighter on Truck 17. He had previously been assigned as a captain on Engine 17.

The crews of Engine 18 and 19 also included several personnel who usually rode in different positions. A battalion chief was acting as the deputy chief in charge of the shift and a captain was acting 

as Battalion Chief 3.

Arrival

Engine 17 was first to arrive at 0027 hours, just ahead of Truck 17. The homeowner was standing 

outside and directed Engine 17 to 8361 Bricelyn Street. The captain went to the front porch to investigate and heavy smoke became evident when the front door was opened. Truck 17 entered from the 

opposite end of the block because Bricelyn Street is very narrow and provides room for only a single 

traffic lane between parked cars. (See fire scene diagram on following page.)

The captain entered the house briefly, then returned to the front porch and motioned to his crew to 

advance a 1-3/4 inch preconnect line. He used his portable radio to report that Engine 17 was on the 

scene with “smoke from the first floor” and directed Engine 15 to lay a supply line to Engine 17.
USFA-TR-078/February 1995 7

Recognizing that Engine 15 was not on the assignment, the dispatcher relayed this assignment to 

Engine 18. The dispatcher did not advise Engine 17 that Engine 15 was not responding on the call. 

In this area Engine 15 usually arrives very soon after Engine 17, while Engines 18 and 19 take several 

minutes longer to reach the location.

The captain and two firefighters from Engine 17 went in the front door with the initial attack line, 

all wearing full protective clothing and self-contained breathing apparatus, while the pump operator 

remained outside. The 1-3/4 inch hoseline was advanced to the top of the stairs and then made a 

right turn to go down the stairs to the family room. It is not known if the crew spent any time on 

the second floor before they went down to the first floor.

Truck 17 began operations by laddering the front of the structure with portable ground ladders 

and ventilating the third floor windows above the front porch. The aerial ladder could not be used 

because of overhead power lines. Two of the crew members then used a ground ladder to go to 

the roof to begin vertical ventilation. Another crew member from Truck 17 worked with two crew 

members from Engine 18 to lower a ladder down to the side yard of the house to provide access to 

the rear yard.

Engine 18 had arrived at 0032 hours. The crew stretched a 5 inch supply line from a hydrant and 

connected it into their pump, and then stretched another 5 inch line from Engine 18 to Engine 17. 

After positioning the ground ladder, they advanced a 1-3/4 

inch attack line from their apparatus down the ladder to the side yard and around to the rear of the 

involved house. They observed the fire in the basement and operated the hose- line through the rear 

basement window. The captain went to the roof to assist Truck 17, leaving the two firefighters to 

operate the line.

Engine 19 reported on the scene immediately after Engine 18 and parked behind Engine 18. The 

crew advanced a second 1-3/4 inch attack line from Engine 17 to the front porch. At the front door 

they encountered heavy smoke and heat which prevented them from advancing.

The acting battalion chief arrived at 0037 hours and took a position at the front of the house. At 

0038 hours he reported “...a three story house, exposures 2 and 4,...right now we have heavy 

smoke coming out of the second and first floor.”

At 0039 hours Medic 11 reported on the scene and assumed a stand-by position near the front of 

the house. Rescue 1 arrived several minutes later and was directed by Medic 11 to take a position in 

the rear alley (Exley Way).

Fire Extension

At 0046 hours the acting battalion chief requested a second alarm, based on his observation of heavy 

smoke coming from the third floor and the attic. He directed the second alarm companies to come 

in via the alley in the rear.

The crew of Truck 17 was on the roof and could see the increasing smoke and heat conditions in the 

attack. The captain who was working as a firefighter on Truck 17 advised the acting lieutenant that 

the fire was in the walls and was coming up through the void spaces. He said that he would go inside 

to check on fire conditions on the lower floors and advise Engine 17 of the vertical extensions.
8
USFA-TR-078/February 1995 9

Firefighters in Distress

The captain came down from the roof, donned an SCBA, picked up an axe, and entered the house 

through the front door. He followed the charged hoseline down the hallway then made the right 

turn down the stairs. As he descended toward the family room he felt the stairs give way under his 

weight; the fire had weakened the stair supports. He fell approximately 10 feet and landed on the 

basement stairs.

He had fallen into the basement, close to the seat of the fire. Although he could see the flames and 

feel the heat, there was spray from a hose stream that provided partial protection. He was able to 

climb back up the stairs to the family room level where he encountered the captain of Engine 17 

who was operating the hoseline. Although the smoke was too heavy to see clearly, he later stated that 

he was aware of the presence of all three crew members from Engine 17 in the immediate area.

It is not clear what happened during the next few minutes. At some point all three personnel from 

Engine 17 realized they were running short of air and needed to leave, but could not find a way 

out of the family room. They were unable to find a window or any other exit and exhausted their 

air supplies. At some point the hoseline, which was suspended over the breach in the stairs, burned 

through.

At least one of the firefighters is believed to have removed or loosened his facepiece and some 

attempts were made to share the air that was available by buddy breathing. All three crew members 

from Engine 17 were rendered unconscious due to carbon monoxide inhalation and/or oxygen 

deficiency. The captain from Truck 17 was also incapacitated by carbon monoxide and was down on 

his hands and knees, almost unconscious.

First Rescue

Engine 18’s line had been successful in knocking down most of the visible fire in the basement, 

and the crew was preparing to advance into the basement through the rear door to complete extinguishment. At approximately 0056 hours a firefighter from Engine 18 broke one of the family room 

windows to provide additional ventilation. When the window was broken he heard the taps from 

the low pressure alarm bell on an SCBA and a moan. He entered through the window and discovered 

the semi-conscious captain down on the floor, close to the window.

Assisted by another firefighter and the EMS personnel from Rescue 1, he was able to pull the captain 

out the window and lower him to the ground. The first radio report of a firefighter down was transmitted by Battalion 3 at 0058 hours. At 0101 Battalion 3 reported “we found him, he’s all right.”

Second and Third Rescues

As the EMS personnel began to treat the captain, who was barely conscious, he gasped that there 

were more firefighters inside and he thought they were dead. Several firefighters returned to the side 

of the house where they encountered two firefighters from Engine 19 who had just crawled through 

the same window.

The crew from Engine 19 had been stopped at the front door unable to advance for several minutes 

due to the heavy heat and smoke in the front hallway. It appears that the heat and smoke conditions 

at that time were caused by the breach in the stairs, where the captain had fallen through to the 

basement. The captain and one of the firefighters depleted their air supplies and returned to their 

apparatus to change air cylinders, leaving one firefighter on the porch with the hoseline.
10 U.S. Fire Administration/Technical Report Series

While the captain and firefighter were at the apparatus changing cylinders, the driver of Engine 19 

donned an SCBA and proceeded to the front door, where he encountered the other firefighter from 

Engine 19. By this time the interior heat and smoke conditions were significantly reduced, possibly 

because the hoseline had ruptured directly over the opening in the stairway. The driver entered the 

house, following Engine 17’s hoseline, made the turn down the stairs, and fell into the same hole 

where the captain from Truck 17 had fallen through the stairs.

The firefighter followed the driver and also fell through the hole in the stairway. They assisted each 

other back up the stairs to the family room, then walked across the room toward a light that was 

shining through the broken window. They were assisted from the window by the firefighters outside 

and turned over to the EMS personnel in the back yard for treatment.

There was a period of confusion after the two additional firefighters were removed from the window. The first report of additional missing firefighters was transmitted on the EMS radio channel at 

0106 hours. At 0107 there was a transmission reporting that, “17 Engine Captain reports three men 

in; three men out.” This was followed two minutes later by a report of, “three firefighters down and 

one still missing”, also on the EMS channel.

The EMS supervisor and the acting deputy fire chief, both of whom had just arrived, went to the rear 

yard and confirmed that three personnel had been rescued from the house and were being treated. 

The acting deputy chief then requested a third alarm, because several of the firefighters on the scene 

were now assisting in treatment of the three rescued personnel. The third alarm was dispatched at 

0110 hours.

The acting deputy chief returned to the front of the dwelling where he met the acting battalion chief 

and assumed command of the incident. The two command officers believed that all of the missing 

firefighters were out of the house. At 0116 hours the EMS supervisor reported on the EMS radio 

channel that all firefighters had been accounted for.

By this time the fire had extended into the attic and was breaking out in the third floor bedrooms. 

The second and third alarm companies were assigned to fire control efforts, while the three injured 

firefighters were transported to hospitals in two ambulances.

Missing Firefighter Located

Engine 7, a second alarm company, advanced a 1 3/4 inch line to the rear porch and attacked the fire 

that had broken out in the kitchen, while Engine 18’s line was advanced into the basement. The fire 

had extended into the cabinets under the kitchen counter tops and weakened the floor joists, causing 

the kitchen floor to sag at the center of the room. It took a considerable amount of time for Engine 

7 to gain control of the situation in the kitchen and then advance the line into the family room. By 

his time the interior smoke condition had been relieved and visibility had improved.

Advancing into the family room, the crew from Engine 7 found the three unconscious personnel 

from Engine 17. (See diagram on the following page.) At 0139 hours the Incident Commander was 

informed that three additional firefighters had been found and were being removed from the building. Additional personnel responded to the urgent requests for assistance and the three firefighters 

were removed to the rear yard.

The EMS personnel determined that all three were in cardiac arrest and initiated resuscitation 

efforts.
USFA-TR-078/February 1995 11

The assistant fire chief, who had responded on the third alarm and was in the process of assuming 

command of the incident, requested two additional alarms to provide personnel for fire suppression, 

since most of the personnel on the scene were involved in the efforts to rescue and revive the three 

firefighters. The three crew members from Engine 17 were all dead on arrival at hospitals.

The fire was controlled without further incidents. The chronology for the incident is detailed on the 

following below.

CHRONOLOGY

00:22:00 Call to 9-1-1 from 8366 Bricelyn Street reporting structure fire.

00:22:53 First Alarm Dispatch, Zone 3-15: E17, E18, E19, T17, 4042.

00:27:42 Engine 17 on scene, reports “smoke from 1st floor.”

00:28:09 Battalion Chief 3 (4043) responding in place of Battalion Chief 2 (4042).

00:28:09 Truck 17 on scene.

00:32:27 Engine 18 on scene.

00:32:48 Engine 19 on scene.

00:37:04 Battalion Chief 3 on scene.

00:38:38 Battalion Chief 3 reports, “3 story...heavy smoke from 2nd and 1st floor.”

00:41:50 Medic 11 (5111 on scene. (EMS Channel).

00:46:20 Battalion Chief 3 requests 2nd alarm to respond to the rear.

00:46:55 2nd alarm dispatched: E15, E7, T8, DC4, 4539.

00:49:49 Rescue 1 (5101) on scene.

00:54:30 Engine 15 on scene.

00:54:42 Truck 8 on scene.

00:55:36 MAC2 (Air Unit) on scene.

00:56:54 Engine 7 on scene at Exley Way.

00:58:27 Battalion Chief 3 reports “Fireman down inside, trying to get him out”.

00:59:40 Deputy Chief (404) on scene.

01:00:54 EMS supervisor (502) on scene.

01:01:19 Battalion Chief 3 reports “We found him. He’s all right.”

01:05:08 Unit 4539 on scene.

01:05:58 Medic 11 reports “We have more firemen in the building.” (EMS Channel)

01:07:58 Medic 11 reports “Fireman out of the building.” (EMS Channel).
12 U.S. Fire Administration/Technical Report Series
USFA-TR-078/February 1995 13

01:09:45 Dispatcher asks Incident Commander: “Is there a report of a fireman missing and two 

others down?”

01:09:50 Deputy chief reports “The medics are back here. We got them all.”

01:10:06 3rd alarm dispatched: E11, E8

01:11:53 Battalion Chief 3 asks deputy chief “Do we have everybody we started with?”

01:14:04 Deputy Chief reports he is going out front.

01:15:29 Engine 11 on scene.

01:15:48 EMS Supervisor reports “All firefighters are accounted-for.” (EMS Channel)

01:20:35 Engine 8 on scene.

01:27:01 EMS Supervisor reports “All three injured firefighters transported.” (EMS Channel).

01:39:43 Battalion Chief 3 reports “Three firemen down. They are trying to get them out of the 

side.”

01:41:48 Assistant Fire Chief (41) on the scene.

01:43:24 EMS Supervisor reports “Three firefighters in cardiac arrest.” (EMS Channel).

01:46:57 Deputy Chief requests 4th alarm.

01:51:21 Assistant Fire Chief assumes command.

02:04:36 EMS Supervisor reports “Three firefighters have been removed from side 3.” (EMS 

Channel).

02:09:54 Assistant Fire Chief requests 5th alarm.

02:43:34 Assistant Fire Chief declare fire under control.

ANALYSIS

This incident demonstrates how easily firefighter fatalities can occur when simple and basic operational problems occur together in the worst possible sequence. There was no indication that this 

incident was more than a “routine” dwelling fire and many veteran members of the Pittsburgh Fire 

Bureau expressed disbelief that three firefighters could have been “lost” for more than an hour or 

could have died in a small room that had two windows to the exterior, within six feet of the ground 

level.

The combination of circumstances that resulted in these three deaths illustrates that every fire situation presents inherent dangers. There is no single problem event or circumstance that can be blamed 

for what happened. Several contributing factors can be identified that combined to turn a seemingly 

routine fire into a tragedy of immense proportions. The detailed analysis of the incident points 

out several areas where changes should be made, particularly in the areas of training and incident 

management. 
14 U.S. Fire Administration/Technical Report Series

Known and Unknown Factors

All three firefighters died from asphyxiation, which involved both carbon monoxide inhalation and 

oxygen deficiency. This occurred as a direct result of exhausting their air supplies and being unable 

to find an exit from the family room. It is assumed, but it cannot be confirmed, that all three were 

using their SCBAs, with facepieces in place, for the entire time they were inside the house until their 

air supplies were depleted.

It is known that the three crew members from Engine 17 exhausted their air supplies and that their 

vision was fully obscured by heavy smoke, at least during the period when they were running out of 

air. The fire did not involve the room where they were found; after the fire there was only moderate 

heat damage at the upper levels of the room and their protective clothing and equipment showed no 

signs of damage or deterioration caused by exposure to the fire.

It is not known if the deceased firefighters knew immediately that the fire was in the basement, 

which was two levels below their point of entry, or if they spent some time looking for the fire on 

the first or second floors. There was no indication that they had attempted to advance the hoseline 

down into the basement or into the kitchen.

It is not known if the hoseline that was operated through the rear window into the basement caused 

an opposing hoseline situation that may have pushed additional smoke and heat toward the three 

deceased firefighters as they tried to advance down the basement stairs.

Their return path back up the stairs was blocked by the fire coming up through the collapsed section. 

Their hoseline, which was suspended over the collapses stair section, eventually burned through and 

ruptured. The hoseline was found with the nozzle open at the bottom of the stairs, which suggest 

that they were trying to control the fire that was coming up through the opening when the hose 

ruptured. It appears that the firefighters could have escaped through the kitchen or through the 

windows in the family room. With the door to the basement stairs in the open position their path 

into the kitchen would have been blocked and the smoke and heat coming up the stairs would have 

presented an additional obstacle. If they had closed the door at the top of the stairs they might have 

been able to walk or crawl out through the kitchen, if they had known about the kitchen door and 

windows.

The trapped firefighters did not appear to have located either of the two windows in the family room. 

The insides of the windows were covered by the plastic panels, which left a smooth interior surface 

that would have made them somewhat more difficult to locate than regular windows. There is no 

indication that they were searching for windows by feeling their way along the walls and no indication that any attempt had been made to break either of the windows from the inside. There was at 

least one axe in the room, which could have been used to break out a window.

The exact sequence of events inside the family room remains a mystery and will probably never be 

known. The following analysis examines several different issues that relate to the three victims and 

their equipment, in an attempt to better understand what appears to have happened to them. It also 

examines the overall management of the incident and how that is related to the outcome.
USFA-TR-078/February 1995 15

SAFETY EQUIPMENT

Self-Contained Breathing Apparatus

The SCBA units worn by the three fatally injured firefighters and the unit worn by the surviving 

captain were impounded at the scene for examination and testing. The SCBAs used by the deceased 

members were found with the air supplies fully exhausted, while the SCBA worn by the survivor still 

had 300 psi of air pressure remaining in the storage cylinder.

Autopsy Results – All three firefighters died from asphyxiation. Two of the three victims had high 

carboxyhemoglobin levels, in the 40 to 50 percent range, which indicates that they died primarily 

from smoke inhalation. The third deceased firefighter had a relatively low carboxyhemoglobin level, 

approximately 10 percent, and appears to have died primarily from hypoxia (oxygen deficiency). 

The captain from Truck 17 also had a carboxyhemoglobin level in the 40 to 50 percent range, which 

was incapacitating and potentially fatal.

Observations – Two of the three deceased firefighters were reported to have been found with their 

facepieces in place and their SCBAs in normal operating configuration. It could not be confirmed if 

the third firefighter’s facepiece was in place and secure when he was found, or if the breathing tube 

had been disconnected from the regulator. Only one of the deceased firefighters was confirmed to 

have the facepiece still tightly in place when found.

It is not known if all three victims used their SCBAs for the entire time they were inside the dwelling 

and exposed to the products of combustion. All three entered the dwelling with their SCBAs on their 

backs, but it is not known if their facepieces were in place at the time they entered. It is possible that 

one or more of the individuals may have delayed using their SCBA and inhaled significant quantities 

of carbon monoxide before realizing that respiratory protection was needed.

The crew of Engine 17 may have spent some time looking for the fire on the first floor level, thinking they were in the basement, before they located the basement stairs and realized that the fire was 

below them. They may have suddenly encountered a heavy concentration of smoke and heat when 

they opened the door at the top of the stairs and only donned their facepieces at that time.

Test Results – The four SCBAs were examined and tested by the Division of Safety Research of the 

National Institutes of Occupational Safety and Health (NIOSH) at their facilities in Morgantown, 

West Virginia. Three series of tests were performed on the four units by NIOSH.

In the first series of tests, each of the four units was found to be deficient in one or more of the 

performance tests that are required by NIOSH for certification of an SCBA. The tests indicated that 

three units failed to meet the required 200 liter per minute air flow rate, two failed to meet the 30 

minute service duration requirement, and two failed to maintain positive pressure throughout the 

respiration cycle. The low pressure alarms on all four units were set to activate below the required 

level and one low pressure alarm intermittently failed to operate.

The breathing resistance test could only be performed on two units and one of those units exceeded 

the static pressure limit of 1.5 inches of water column inside the facepiece. One facepiece could not 

be tested because of the contaminants inside the facepiece and the exhalation valve. Another facepiece could not be properly tested because the exhalation valve spring was dislodged and the valve 

would not seal in the closed position. 
16 U.S. Fire Administration/Technical Report Series

While problems were noted with each of the four units, all four were found to be functional and 

capable of delivering air to the users. Although three of the four units failed to meet the 200 liter per 

minute flow rate, they should have been able to deliver an adequate flow to meet the user’s demand 

rates, unless the users were engaged in extremely strenuous activities. It was also determined that all 

four SCBAs could maintain a positive pressure while in use, except for some potential inward leakage 

during inhalation on two of the units. The leakage tended to let air escape from the facepieces more 

than allowing outside air to enter, which is the objective of positive pressure. The low pressure alarm 

settings were only slightly below the specified levels.

A second set of tests was conducted by NIOSH to evaluate the amount of inward leakage that could 

have occurred with the four SCBAs. These tests indicated that there may have been some inward leakage in two of the units, caused by a combination of an inadequate air flow rate into the facepiece and 

leakage through the exhalation valves or around the facepiece seals. The rate of inward leakage was 

measured for each unit and the amount of carbon monoxide exposure to the users was estimated, 

using calculations that were based on the concentration of carbon monoxide that can be anticipated 

inside a burning dwelling and the time the users would have been exposed.

These tests indicated that the leakage would not account for the high carboxyhemoglobin levels that 

were found in three of the victims. The victim who had a low carboxyhemoglobin level was using 

one of the units that was found to be leaking and the estimated rate of CO leakage with this unit 

came closer to being consistent with the autopsy findings. Even in this case, however, the calculations 

based on the measured leakage rate did not fully account for the carboxyhemoglobin levels that were 

reported in the autopsy results.

A third series of tests was conducted to determine the cause or causes of the performance deficiencies 

that had been observed in the first series of tests. The regulators were examined and initial pressure 

and flow reading were taken. Standard maintenance and calibration procedures were then performed 

to bring them into compliance with the manufacturer’s specifications. It was determined that all four 

regulators could be brought into compliance through the performance of the routine maintenance 

and calibration procedures on the regulators and low pressure alarms. When retested all four units 

met or exceeded the NIOSH performance requirements and the manufacturer’s standards.

These findings underline the need for regular inspection and maintenance programs for all SCBA 

units, with the work performed by properly trained technicians, following the manufacturer’s recommended procedures. Some of the problems that were found may have resulted from untrained 

members attempting to perform maintenance procedures on their SCBAs. The problems with exhalation valves and facepiece seals should have been detectable by the users through daily user checks or 

by testing for a tight seal when donning the facepiece.

When the initial reading were taken for the third test series, the restricted air flow problems that 

had been observed in the first series did not reoccur. This suggests that the initial problems may have 

been attributable to moisture or debris which got into the facepieces and regulators at the scene of 

the fire and then evaporated or were released with time and repeated testing. It is not known if all of 

the performance deficiencies that were observed in the initial tests were consistent with the condition of the units when they were used at the Bricelyn Street fire.

The four units had been removed from the house and were outside in sub-freezing weather when 

they were impounded for the investigation. They were stored in a secure location, but were not closely 

inspected until several days after the fire and the regulators were not opened until two months after 
USFA-TR-078/February 1995 17

the incident. It is possible that a combination of moisture and foreign matter may have gotten into 

the regulators before they were impounded. 

Relationship to Autopsy Results – Based on the test results and autopsy findings, it does not appear that 

the performance deficiencies that were found in the SCBAs were the primary causal factors in the 

deaths of the three firefighters. The fact that the three victims exhausted their air supplies appears to 

be the primary causal factor.

The high level carboxyhemoglobin levels, which are consistent with unconsciousness, coma or 

death, depending on the individual and the length of exposure, suggest that three of the four individuals were exposed to the fire atmosphere for some time without the protection of their breathing 

apparatus. It cannot be determined if this occurred after their air supplies were exhausted, during 

attempts to “buddy breathe” or during periods when the firefighters may have been working without the protection of their SCBAs

It is not uncommon for firefighters to remove or loosen their facepieces after running out of air 

and the reported autopsy results are similar to the findings from previous situations where this has 

occurred. High level exposure to carbon monoxide is known to quickly cause disorientation and 

compromise motor skills, which would have made it more difficult for the firefighters to find a 

means of escape from the dwelling. The elevated temperatures inside the house may have also contributed to their rapid incapacitation and disorientation.

At least one of the victims may have removed or loosened his facepiece and one or two of the others 

may have attempted to “buddy breathe” with him. Experience with other cases of attempted buddy 

breathing indicates that both individuals may be very quickly exposed to high concentrations of CO 

or other contaminants, unless the SCBAs are equipped with special fittings to allow air to be shared. 

This may quickly result in two individuals in distress, instead of one being capable of helping to 

rescue the other.

The most likely explanation for the low carboxyhemoglobin level found in the third deceased firefighter is the leakage through the exhalation valve or around the facepiece seal. This victim was 

found with the facepiece still tightly in place. This amount of exposure to carbon monoxide would 

be likely to cause a headache and minor impairment to the firefighter, but it is not likely to result in 

disorientation or significant impairment of motor skills.

PASS Devices

All four of the SCBAs had personal alert safety system (PASS) devices attached to the harness traps 

and all four were found in the off position. This indicates that the firefighters did not turn on their 

PASS devices before entering the building and did not manually activate them when they found 

themselves in trouble. If the PASS devices had been operating there is a high probability that they 

would have been heard by other firefighters who were in the room or at the window and a reasonable expectation that the victims could have been successfully rescued.

The PASS units were tested and found to be operational, however, the alarm signal sound outputs for 

all four units were below the levels specified in the 1988 edition of the NFPA Standard 1982, which 

was in effect when they were purchased. Even with the reduced sound output levels, it appears likely 

that they would have been heard, especially with four units operating in a small room.
18 U.S. Fire Administration/Technical Report Series

Portable Radios

Two of the victims had portable radios; however, both radios were found in turnout coat pockets 

and there was no indication that the victims had attempted to use them to call for assistance. No 

transmissions were received from either radio during the time that the firefighters are believed to 

have been in distress. The only radio transmission that was recorded from either radio was the initial 

report given by the captain of Engine 17 before entering the structure.

The firefighter’s radio was operational when it was tested later than night. The captain’s radio, which 

had been used to transmit the initial report, had a dead battery and a blown fuse when it was tested, 

but functioned properly when these items were replaced. Both of these problems may have resulted 

from exposure of the radio to water, which may have occurred before or after the victims were 

removed from the house.

It was not determined if the radios were set on the proper channel for the incident.

INCIDENT MANAGEMENT

The Pittsburgh Fire Bureau has adopted the Incident Command System as a standard operating procedure. However, the degree of application of the system depends on the Incident Commander.

The Incident Command System and the Pittsburgh Bureau’s SOP #6 stress the importance of an early 

assumption of command so that all operations, from the outset, are directed by one individual and 

based on a single attack plan. The procedures call for an early arriving company officer to assume 

command of the incident if there is no chief officer at the scene. The early assumption of command 

and development of a strategic plan are particularly important considerations to ensure that operations are conducted safely.

None of the company officers assumed command of this incident and there is no indication that 

anyone was attempting to direct or coordinate the actions of the first alarm companies, except for 

the request to have the next arriving engine company provide a supply line for Engine 17. All of the 

first alarm companies committed themselves to various operations based on their own initiatives. 

The first officer to officially assume command of the incident was the acting battalion chief, who 

arrived 10 minutes after the first companies.

The acting battalion chief announced that he was establishing command and positioned himself 

at the front of the dwelling. He did not receive any initial information on interior conditions or 

activities and did not receive any progress reports from the operating companies over the radio. His 

knowledge of the situation was limited to the operations he could observe from the front of the 

dwelling.

The acting battalion chief was placed at a significant disadvantage due to his late arrival at the fire 

scene and the complicated arrangement of the dwelling’s interior. He did not know that there was 

an intermediate level between the front entrance and the basement. He had no information on the 

specific location and actions of Engine 17 or the fire conditions they were encountering. From the 

front he had very limited view of the structure to make an exterior size-up.

The acting battalion chief did not give any directions or assignments to the first alarm companies 

over the radio. The only specific instructions that were recorded on the radio tape were to direct the 

second alarm companies to come in from the rear. Face-to-face communications would not have 

been recorded.
USFA-TR-078/February 1995 19

The acting deputy chief arrived while the first rescues were being made. He initially went to the 

rear yard to size-up the fire situation, where he encountered the EMS personnel treating injured 

firefighters. After spending several minutes dealing with that situation, he completed the exterior 

size-up and went to the front where he assumed command of the incident from the acting battalion 

chief. He did not have information on interior fire conditions or on the locations, assignments and 

accountability for the interior crews when command was transferred.

The acting deputy chief had an initial concern about accounting for all personnel at the scene, but he 

received information that all personnel had been accounted for. This relieved his concern and caused 

him to focus on fire suppression efforts until he was informed that the three personnel from Engine 

17 had been found unconscious inside the dwelling.

EMS Coordination

The EMS units that respond to fires are not under the direction of the Fire Bureau Incident Commander. 

The EMS units communicate with each other and with their dispatcher on an EMS radio channel, 

but they have to coordinate face-to-face with Fire Bureau units or go through their dispatcher who 

is located in the same Communications Center as the fire dispatcher. An EMS supervisor responds on 

the second alarm to establish a liaison at the command post.

The two EMS rescue units in Pittsburgh carry protective clothing and breathing apparatus so that the 

crews can enter building to assist with rescue operations and the removal of injured patients, however, they are not integrated into the Fire Bureau’s incident management structure. The separate radio 

channels make it difficult to coordinate operations between fire and EMS units that may be working 

side by side. The lack of a unified command system and accountability for all personnel in the fire 

area can create potentially dangerous situations.

At this incident there was a parallel flow of communications on the fire and EMS radio channels. 

Significant information relating to the identities of the individuals who had been rescued was not 

effectively communicated back to the Incident Commander. The rescued firefighters were being 

treated by EMS personnel and at one point the EMS radio channel quoted “17 Engine captain reports 

three men in – three men out.” (This apparently came from an EMS employee who recognized the 

captain who was being treated and associated him with his previous assignment at Engine 17). A 

later report over the EMS radio advised that all personnel had been accounted for. These messages 

added to the confusion over who had been rescued and who was missing.

The EMS supervisor, who responded on the second alarm, initially went to the rear yard where the 

firefighters were being treated. After the patients had been transported, he went to the front of the 

house and established the EMS liaison at the Command Post. The identities of the individuals who 

had been transported were not provided to the Incident Commander.

SAFETY AND ACCOUNTABILITY

Many fire departments that routinely use command and control systems to keep track of the locations and assignments of companies have added accountability systems to keep track of the individuals assigned to each company. This information is used during the course of operations to account 

for all personnel at regular intervals and verify that they are safe.

An accountability check involves communicating with each company officer to ensure that they can 

personally account for each assigned individual. Accountability checks are required at regular inter-
20 U.S. Fire Administration/Technical Report Series

vals, usually every 15 to 20 minutes. A significant event, such as a report that firefighters are injured 

or missing, or a change in the strategic plan, calls for a special accountability check.

The Pittsburgh Fire Bureau had a written procedure for a safety identification system to be established on multiple alarm incidents; however, its implementation was at the discretion of the Incident 

Commander and it did not require regular accountability checks. Name tags are issued to all personnel and deposited on the apparatus when the individual is assigned to that crew. When the system is 

implemented, all of the tags are picked up and assembled on a control board which is used to track 

the location, status, and assignment of each company at the incident. This system provides a crew 

roster for the operating companies at the command post.

On all multiple alarms Engine Company 39 is placed out of service and the crew responds with Unit 

4539 to perform safety-related functions. The company officer becomes the Incident Safety Officer 

and two for the crew members are responsible for setting up the control board at the command post. 

The remaining crew member is assigned to refill SCBA cylinders.

Unit 4539 arrived with the second alarm companies and the personnel assumed their pre-assigned 

roles. The control board was set up, but the name tag system was not implemented. Without the 

personnel identification system there was no roster to verify the assignments of the personnel who 

had been rescued and ensure that no one else was missing.

If an accountability check had been required 20 minutes after arrival, the time would have coincided 

with the period when it appears that the crew of Engine 17 was running out of air and realizing they 

were in trouble. A rescue operation initiated at that time might have found and rescued them before 

they were fatally overcome. An accountability check after the first three members had been rescued 

also would have revealed the crew of Engine 17 was missing.

Crew Integrity

One of the important considerations in all incident management systems and accountability systems 

is crew integrity. All members of a company should function as a team, taking their direction from 

the company officer. The company officer is expected to be accountable for the position, function, 

and safety of all members of the company at all times. Accountability systems require company 

officers to verify at regular intervals that they can account for all company members.

There are situations where it is appropriate to split a crew into smaller teams. However, each team 

that is operating in a fire area should have a minimum of two members and at least one of those 

members should have a portable radio to maintain contact with the company officer or with the 

appropriate supervisor in the incident command system.

Three of the four companies on the first alarm failed to maintain crew integrity. The three members 

from Engine 17 were the only crew that stayed together. The three individuals who were rescued 

were not in contact with their company officers and their company officers did not recognize that 

members of their crews were missing until after the three personnel from Engine 17 had been found. 

The confusion over the identities of the individuals who had been rescued contributed significantly 

to the failure to recognize that Engine 17’s crew was missing.

TEMPORARY ASSIGNMENTS

The fact that 12 out of 17 personnel on the first alarm were in out-of-class assignments or filling 

positions for other individuals added to the confusion at this incident. The officers and crew mem-
USFA-TR-078/February 1995 21

bers were not used to working together and their helmet markings did not indicate their temporary 

assignments. This reinforces the need for an accountability system, including a means to visually 

indicate temporary assignments.

Several individuals were working in higher level positions because regularly assigned officers were 

absent or “moved up” that night. The initial incident commander was an action battalion chief who 

normally functions as a company officer and was not used to managing incidents at this level. One 

of the individuals who was rescued was a captain from an engine company, who was working an 

extra shift in a firefighter’s position on a ladder company, reporting to an acting lieutenant. Some of 

these individuals may have been unsure of their responsibilities or had difficulties with reporting 

relationships.

EMERGENCY SURVIVAL ACTIONS

While the exact sequence of events will never be known, it is evident that the three crew members 

from Engine 17, at some point in time, realized they were in trouble. Assuming that they entered the 

structure with full air cylinders and consumed the air at a normal rate, they probably would have 

been running short of air between 0045 and 0050 hours, which is close to the time the captain from 

Truck 17 encountered them.

The captain later reported that none of the crew members from Engine 17 seemed to be in distress at 

the time he first encountered them, but they began to have critical problems within a short time after 

he arrived in the family room. He described a sequence of events under zero visibility conditions in 

which low pressure alarms were sounding and attempts were being made to share the remaining air 

supply by “buddy breathing.”

The actions of the victims may have been impaired by the combined effects of carbon monoxide 

inhalation and heat stress, which are likely to cause confusion and interfere with motor skills. It is 

not known what efforts they were making to find a way out of the house; however there is no evidence that they located the windows or the doorway leading to the kitchen.

It is not known why the trapped personnel did not use their portable radios to call for assistance 

when they realized they were in trouble or manually activate their PASS devices to sound an audible 

alarm. The analysis of several incidents involving firefighters in critical situations also suggests that 

firefighters are often reluctant to admit they are in trouble until it is too late to effectively call for 

assistance.

Firefighter training should include standard survival actions that should be followed in emergency 

situations. This type of training, which is required by NFPA Standard 1500, should include an 

emphasis on early recognition of being in trouble and calling for assistance without delay. A standard 

procedure, such as a ‘MAYDAY” over the radio, should trigger a priority response to locate and assist 

the personnel who are in trouble.

As noted in the section on breathing apparatus, experience from similar incidents also suggests 

that “buddy breathing” should be discouraged, unless the breathing apparatus has been provided 

with special connections to interconnect units. In most situations it appears to be more effective 

for members who still have air in their cylinders to use it to rescue those in trouble or to summon 

assistance than to attempt to share the limited available supply. All members should be well trained in 

the procedures that should be followed if an SCBA malfunctions or the air supply is depleted.
22 U.S. Fire Administration/Technical Report Series

Training should emphasize the need to identify alternate exists in all situations. Company officers 

should always be aware of the environment where their companies are working, keeping an eye on 

conditions, looking for alternative exits, and thinking about how to react if conditions change suddenly. This requires company officers to resist the temptation to become too involved in performing 

manual tasks to fulfill the responsibilities of a supervisor.

RAPID INTERVENTION TEAMS

The 1992 edition of NFPA 1500 also requires the assignment of designated “rapid intervention 

teams” at working incidents. The mission of a rapid intervention team is to be ready to take immediate action to rescue or provide back-up for firefighters in trouble or to search for companies that 

fail to respond to a request for an accountability check. This is recommended to be a specifically 

designated crew or company, assigned to stand-by, wearing full protective clothing with SCBA ready 

for use.

LESSONS LEARNED AND REINFORCED

1. Incident Command procedures should be utilized at all multi-company incidents. The early establishment of 

incident command is essential to initiate operations in an organized and coordinated manner. All 

personnel should be trained in the basic concepts of the incident command system and fully capable 

of performing their normal functions, as well as any other functions they could be assigned to perform. Command and staff personnel must be assigned to create and operate an organization that is 

in proportion to the incident. All units that operate in the fire area, including EMS units, should be 

integrated into the incident command system.

2. A qualified Incident Safety Officer should be assigned to all working incidents to ensure that all safety concerns 

are fully addressed.

3. Accountability procedures should be implemented at all working incidents. A standard approach to accountability is needed to routinely verify that all personnel are safe at regular intervals and to specifically 

account for all personnel when there is a change in strategy or when an unusual event occurs at an 

incident.

4. A Rapid Intervention Team should be assigned to stand-by at all working incidents to provide assistance to companies or individual personnel who are in danger.

5. Crew integrity should be maintained. Companies should work together as teams, under the direct 

supervision of their company officers. The company officer should be in contact with all assigned 

personnel at all times. If companies are split into teams, each team should have a separate identity 

and a portable radio and should be tracked as a separate unit in the accountability system.

6 Emergency survival procedures should be a standard component of firefighting training. All personnel should be 

well trained in the actions that should be taken in emergency situations, such as becoming lost and 

disoriented or running out of air in a hazardous area. This training should include when and how to 

request assistance and a standard approach to be implemented when a report of personnel missing 

or in distress is received.
USFA-TR-078/February 1995 23

7. A Self-Contained Breathing Apparatus maintenance program is essential. All SCBA units should be inspected 

and function tested at every shift change and after each use. Any units with defects should be immediately taken out of service for inspection, evaluation, and repair by qualified technicians. Untrained 

personnel should not be permitted to perform any procedures that involve disassembly of the SCBA 

regulator.

All SCBA units should be regularly inspected and should have preventive maintenance procedures, 

including calibration and testing, performed by qualified technicians following the manufacturer’s 

documented recommendations.

8. Personal Alert Safety Systems should be utilized at all incidents where firefighters operate in hazardous areas. 

Every SCBA should be equipped with a functioning PASS device. Members should be trained to 

always turn on the PASS when working in a potentially hazardous area and should manually activate 

the PASS alarm if they are in danger. The PASS devices should be function tested daily and regularly 

inspected and maintained by trained personnel. Technological advances in PASS devices should be 

researched to determine if more advanced and reliable units can be obtained.

9. Hillside structures require special attention. Fires in hillside structures should focus special attention 

on identifying the different levels and which levels have exterior access from different sides. It is 

particularly important to avoid placing companies over a fire when they are not aware that the fire 

is below them.
24 U.S. Fire Administration/Technical Report Series

APPENDIX A

Bureau Initiatives

Following the completion and presentation of a report on this incident by an internal Board of 

Inquiry, the following actions were implemented by the Pittsburgh Fire Bureau.

Additional changes were being considered at the time this report was completed.
USFA-TR-078/February 1995 25

BUREAU INITIATIVES

October 5, 1995

Operations

C Dispatch transmit to Command a time announcement every 15 minutes (elapsed time of fire)

C 2nd battalion chief respond as safety officer to all structure fires

C Safety unit/command board (Engine 39) respond to all structure fires

C Standby company (Go-Team) dispatched 2 alarm structure fires or greater

C Establishment of Hazard Zones at emergency incidents

C Established a first alarm water supply policy (forward lay)

C Expanded requirement of first arriving company officer radio status report

C Expanded requirement of first arriving company officer radio status report

C Established trigger word to immediately clear fireground channel for emergency traffic.

C Established policy of mandatory activation of PASS Device in a hazard zone.

C Reinforce use of existing Incident Command and accountability systems

C EMS Bureau units reassigned to fireground channel during structure fires

C Established policy that company officers will not operate nozzles on fire attack lines

Equipment

P Upgrading existing PASS Devices

P Relocate fireground channel(s) positions on portable radios

P Upgrade SCBA apparatus to state of the art

C Revised and expanded S.O.P. on SCBA concerning inspection/use/care

C Increased maintenance/inspection cycle on SCBA

Training

CAll chief officers attend ICS/Tactics and Strategy training course

PCompany officers attend ICS/Tactics and Strategy training course

PProvide in-service SCBA training program

PProvide in-service training on firefighter survival techniques

C = Completed P = Planned next two quarters
26 U.S. Fire Administration/Technical Report Series

APPENDIX B

Photographs of Fire Scene

1. Front view of 8361 Bricelyn Street.
USFA-TR-078/February 1995 27

2. Rear view of 8361 Bricelyn Street.
28 U.S. Fire Administration/Technical Report Series

3. Side yard showing retaining wall and window where firefighters were rescued 

(above lawn chair).
USFA-TR-078/February 1995 29

4. Window in corner of family room showing plastic panel which has partially melted and 

bent-over due to heat.
30 U.S. Fire Administration/Technical Report Series

5. Inside view of window where firefighters were rescued.
USFA-TR-078/February 1995 31

6. View from family room looking toward kitchen. Partially open door is at the top of the 

basement stairs.
32 U.S. Fire Administration/Technical Report Series

7. View of corner of the family room at top of basement stairs.