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Executive Summary 

On July 23, 2018, a 34-year-old 

male career firefighter died due 

to prolonged exposure to high 

temperatures and thermal injuries 

after falling into the crawlspace 

at a large residential structure 

fire. The residential structure was 

a custom designed 8,400 square 

feet single-family home. At 

approximately 0120 hours a 

lightning strike ignited a fire in

the home. At 0151 hours, the 

homeowner called 9-1-1 to report 

a lightning strike, the odor of 

smoke in the home, but no visible 

fire in the home. The county’s 

communication center dispatched 

a local box alarm (Box 5-62) for 

a single-family structure at 0152 

hours for a lightning strike and 

smoke in the building. Engine 51 

(E51), Engine 101 (E101), Tower 

10 (TWR10), Battalion Chief 1 

(BC1), and Paramedic 56 (P56) 

were dispatched. At 0157 hours, the homeowner called back and stated, “We have fire in our house due to 

lightning.” He then repeated his address, and said, “I don’t see a flame but our whole house is filled with 

smoke.” E51 arrived on-scene at 0200 hours. The officer of E51 (E51A) reported they had a two-story, 

single-family dwelling with smoke showing. E51A requested a full first alarm box assignment for Box 5-62. 

After initially positioning on Side Alpha, E51 re-positioned to Side Charlie to access the swimming pool as 

a water source. Tower 10 arrived at 0202 hours and positioned on Side Alpha. BC1 arrived on-scene at 0204 

hours and confirmed the initial report. BC1 assumed Command and declared an offensive strategy. At 0208 

hours, E51 entered the structure through the laundry room door near the garage on Side Charlie. Command 

Crews operating in a defensive strategy working to knock 

down the fire in 8,400 square foot single-family home. 

(Photo courtesy of the Fire and Rescue Department) 

F2018-13 • November 29, 2022
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Firefighter Dies after Falling Through a Floor at a Large Area Residential 

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Report # F2018-13

did not receive a complete report of conditions and operations on Side Charlie. Due to lack of smoke in the 

laundry room, E51 repositioned their hoseline to the lower basement entrance (Side Charlie/Side Delta) 

based on the size-up by the BC1 aide, stating there was floor to ceiling smoke in the basement. When E51 

entered the basement on lower Side Charlie, they did not advise Command of the change in grade. At 0213 

hours, after being informed by the BC1 aide, Command advised all units “We do have an all clear from the 

occupants, occupied times three, all clear of the house. We do have an all clear.” At 0216 hours, E101

officer (E101A) advised Command, “We have heavy fire on floor number one, Side Charlie” but did not 

have an exact location of the fire. Command was not advised that the crew from E101 pulled a preconnected hose line from E51 and went back to the 1st floor laundry room. Tower 10A transmitted, “Tower 

10 to Command, “It’s gonna be Quadrant Two, 101 and Engine 51 are making entry right now. We have 

made access to the basement, still smoke from floor to ceiling. We’ve closed the door back up. Only crews 

you should have in are on the first level entering side Charlie.” E101B (deceased firefighter) entered the

laundry room door advancing a 13⁄4-inch hoseline through the laundry room and into the kitchen/breakfast 

area with E101A trailing a significant distance behind. At approximately 0220 hours, E101B fell through 

the 1st floor into a basement level crawlspace with heavy fire conditions. Two Mayday emergency 

transmissions were made. The first Mayday was by E101A on Bravo 1 (the tactical channel used for this 

incident). The second by E101B on Bravo 2 (an unmonitored radio channel). Command deployed a rapid 

intervention crew (RIC) which had been staged on Side Alpha at 0218 hours, to enter the basement at 

approximately 0227 hours. The rescue group located E101B, who was removed from the structure at 0244 

hours. Once outside the structure, E101B received advance life support care and was moved to Medic 105 

(M105) to be transported to a local trauma hospital. E101B was pronounced deceased at 0312 hours.

Contributing Factors

• Lack of crew integrity

• Lack of complete scene size-up

• Below-grade fire

• Large area residential structure

• Lack of a defined incident action plan 

• Inadequate fireground communications

• Missed critical incident benchmarks

• Member operating on the wrong radio channel

• Task saturation of the incident commander

• Lack of personnel accountability

• Wind/weather

Key Recommendations

• Fire departments should ensure that crew integrity is properly maintained by visual (eye-to-eye), 

direct (touch), or verbal (voice or radio) contact at all times when operating in an immediately 

dangerous to life and health (IDLH) atmosphere. The intent is to prevent firefighters from becoming 

lost or missing

• Fire departments should ensure incident commanders conduct a detailed scene size-up and risk 

assessment during initial fireground operations and throughout the incident including Side Charlie 
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Report # F2018-13

• Fire departments should develop and implement a standard operating procedure/guideline 

(SOP/SOG) to identify below-grade fires and ensure that appropriate tactical operations are 

implemented

• Fire departments should ensure that a deployment strategy for low frequency/high risk incidents is 

developed and implemented for large area residential structures with unique architectural features 

• Fire departments should ensure that incident commanders develop an incident action plan (IAP) 

that matches conditions encountered during initial operations and throughout the incident

• Fire departments should ensure that critical incident benchmarks and fire conditions are 

communicated to incident commanders throughout the incident. This is accomplished with effective 

fireground communications

• Fire departments should have a procedure to ensure all members operating in the hazard zone have 

their radios on the designated radio channel

• Fire departments should ensure all members and dispatchers are trained on the safety features of 

their portable radio, particularly the features useful during a Mayday 

• Fire departments should develop a process to prevent task saturation of incident commanders 

during multi-alarm incidents

• Fire departments should ensure that the member assigned to the resource status and situation status 

function is not given other duties during an incident

• Fire departments should develop a formal training program that defines the job duties and functions 

for staff aides, incident command technicians, or staff assistants

• Fire departments should ensure incident commanders maintain control of situation status, resources 

status, and communications to ensure the completion of tactical objectives 

• Fire departments should incorporate the principles of Command Safety into the incident

management system during the initial assumption of command. This ensures that strategic-level 

safety responsibilities are being incorporated into the command functions throughout the incident

• Fire departments should review and/or develop SOG/SOPs to ensure that water supply is 

established during initial fireground operations, particularly in areas with limited or no hydrants 

• Fire departments should ensure adequate staffing and deployment of resources based on the 

community’s risk assessment

• Fire department should periodically review and, if necessary, revise their SOP/SOG on the 

deployment of rapid intervention crews (RICs)

• Fire departments should use resources from the National Institute of Standards and Technology 

(NIST), Underwriter’s Laboratories (UL) Fire Fighter Safety Research Institute (FSRI), and the 

International Society of Fire Service Instructors (ISFSI) to develop and revise operational 

procedures on fireground tactics and provide training in fire dynamics in structures for all 

firefighting staff

• Fire departments should consider having all members carry a wire cutting tool
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• Fire departments should ensure that all members engaged in emergency operations receive annual 

proficiency training and evaluation on fireground operations, including live fire training. This 

training should be conducted with automatic aid and mutual aid fire departments 

• Fire departments should ensure adequate incident scene rehabilitation is established in accordance 

with NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency 

Operations and Training Exercises 

• Fire departments should consider a radio protocol that identifies the unit they are calling first 

(receiver), then identifies themselves (sender). 

 

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine 

deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these 

incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations 

are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any 

other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to 

develop a description ofthe conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH 

summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and 

recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Firefighter Dies after Falling Through a Floor at a Large Area 

Residential Structure Fire – Maryland 

Page 1

F2018-13 • November 29, 2022

Introduction

On July 23, 2018, a 34-year-old male career firefighter died due to prolonged exposure to high 

temperatures and thermal injuries after falling into a crawlspace at a large area residential structure 

fire. On July 23, 2018, the United States Fire Administration notified the National Institute for 

Occupational Safety and Health (NIOSH) of this incident. On August 7, 2018, a safety and 

occupational health specialist, a general engineer, and a medical officer from the NIOSH Fire Fighter 

Fatality Investigation and Prevention Program traveled to Maryland to investigate this incident. 

An opening meeting was held with the fire chief, executive staff of the fire department, and a member 

of the International Association of Fire Fighters (IAFF) local. Subsequently, NIOSH investigators met 

with the fire department arson investigator, the physician who conducted the autopsy for the Maryland 

Office of the State Medical Examiner, members of the department’s internal safety review board 

investigating this incident, dispatchers with the county’s Communication Center, the assistant chief of 

the bureau of education and training, the assistant chief of the safety bureau, the supervisor of the 

county’s maintenance shop, and the department’s self-contained breathing apparatus (SCBA) 

maintenance staff. The NIOSH investigators reviewed the fire department’s standard operating 

procedures (SOPs); training records for Engine 101B, Engine 101A, and Battalion 1; witness 

narratives from the incident report; and dispatch and tactical channel radio transmissions. 

The NIOSH investigators visited and photographed the fire scene. Interviews were conducted with the 

firefighters, fire officers, and deputy chiefs who responded to the incident. NIOSH investigators also 

met with agents from the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) investigating 

this incident and members of the Underwriters Laboratories, Firefighter Safety Research Institute. 

The NIOSH investigators inspected and photographed the deceased firefighter’s personal protective 

gear and SCBA. The Fire and Rescue department requested NIOSH evaluate E101B’s SCBA. The 

NIOSH investigators transported the SCBA to the NIOSH National Personal Protective Technology 

Laboratory (NPPTL) in Morgantown, West Virginia on August 18, 2018. On September 11, 2018, 

representatives of the Fire and Rescue department, arson investigators, county police officers, ATF 

special agents, and technicians from the SCBA manufacturer traveled to Morgantown, West Virginia 

to observe the evaluation and testing of Engine 101B’s SCBA. During the NIOSH evaluation, the 

SCBA’s data log information was successfully downloaded. After the evaluation was complete, the 

SCBA and other equipment were returned to the Fire and Rescue department.
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Report # F2018-13 

NIOSH investigators returned to the Fire and Rescue department on October 24 - 28, 2018 and January 

2, 2019, to complete interviews with Fire and Rescue department personnel and members of the 

county’s communication center. 

Fire and Rescue Department 

The county where this incident occurred is a charter government with its own legislative and executive 

branch. With no incorporated towns or cities within the county, the county government provides all 

local government services to its residents. This includes public safety provided by the county police 

and the Fire and Rescue department. This combination fire and rescue department provides fire 

suppression, prevention, training, and investigation, as well as rescue services and emergency medical 

services to 321,113 residents in a 253 square-mile area that includes urban, suburban, and rural 

communities. The department also provides and receives automatic aid to and from surrounding 

communities. The department operates 13 stations staffed with 491 career firefighters and supported by 

474 volunteer firefighters. Six stations are staffed by career firefighters. The other seven stations are 

operated by independent fire companies, some of which own the fire stations and have an 

administrative and operational staff that supports the career department. These seven fire stations are 

staffed by a combination of career firefighters and volunteer firefighters. The Fire and Rescue 

department operates three shifts, working 24-hours on, 48-hours off. 

Every fire station has at least one engine and one paramedic unit assigned. Many stations also house 

apparatus such as ladder or truck company, a heavy rescue unit, brush trucks, foam and dry chemical 

units, and water tenders. The number and type of responding units are determined by the department’s 

deployment model (Fire and Rescue Department’s General Order 100.17 - Standard of Coverage). The 

department has developed an SOP for alarm assignments used by the county’s communications center. 

A local alarm assignment for smoke in a building includes the dispatch of two engine companies, one 

truck company, an emergency medical services (EMS) transport unit, and a battalion chief and staff 

aide. A full box alarm adds the following to the assignment: 2 additional engines, 2 additional trucks or 

squads, an additional EMS transport unit, an EMS supervisor, and the safety officer. Minimum staffing 

for engines includes one officer and two firefighters. Minimum staffing for trucks is one officer and 

three firefighters. Minimum staffing for a medic unit is two members. The riding position correlates 

with the assigned portable radio, SCBA, and personnel accountability system. (See Figure 1). 

Figure 1: Riding positions and radio designations by type of apparatus. 

(Figure courtesy of the Fire and Rescue Department.)
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Most of the fire apparatus and vehicles are serviced and maintained by the county’s fleet maintenance 

division. All apparatus were serviced and tested according to the requirements of the National Fire 

Protection Association (NFPA) 1901, Standard for Automotive Fire Apparatus [NFPA 2016b], and 

NFPA 1911, Standard for the Inspection, Maintenance, Testing, and Retirement of In-Service 

Emergency Vehicles [NFPA 2017].

Divisions

Emergency Services Bureau

The Fire and Rescue department’s General Order 100.17 – Standard of Coverage establishes the 

minimum staffing levels for fire and non-fire emergencies. Under General Order 100.17 – Standard of 

Coverage, the regular staffing by apparatus is:

• Special Services includes aerial apparatus, squads: four members

• Extrication Unit includes aerial apparatus with extrication equipment, squads, and

rescues: four members

• Engines - three or four members

• Tankers - apparatus carrying 1,500 gallons or more of water: two members

• EMS Transport Units: two members

• Battalion Chiefs – battalion chief and aide: two members

• Chief Officers and Staff Personnel: one member.

Additionally, under the order, the staffing levels sent to a residential structure incident are

separated into two categories: rural and metro. The specific list of equipment and personnel that respond 

to each category are detailed in Table 1.

A “Working Fire Task Force” for a single-family structure in a metro (hydranted) area brings two 

engines, one special service, one ambulance, and one BC (if they have not already responded), totaling 

13-16 personnel. In addition, several on-call personnel are alerted and given discretion as to their 

physical response: one on-call BC, one on-call Assistant Chief, one Fire Communications Liaison, one 

Public Information Officer, and one Fire Investigator. If responding to a rural (non-hydranted) area, three 

additional tankers are alerted for response. 

A “2nd Alarm” for a single-family structure in a metro (hydranted) area brings two engines, one special 

service, one ambulance, one additional Field Safety Officer, and one Battalion Chief (on-call) which 

totals 13-16 personnel. Additionally, all on-call personnel are obligated to respond (as opposed to using 

discretion). An air unit, the fire department chaplain, the department bus, and a canteen unit are also 

alerted. If the response is to a rural (non-hydranted) area, one tanker is also alerted for response.

A “3rd Alarm” for a single-family structure in a metro (hydranted) area brings three (3) additional 

engines. If to a rural (non-hydranted) area, one (1) tanker is also alerted for response.

In 2018, the Fire and Rescue department responded to 38,709 alarms of which 352 were structure fires. 

See Appendix One for the complete list of the department’s runs in 2018. 
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UNIT TYPE UNIT 

STAFFING

LOCAL ALARM

SINGLE FAMILY 

(METRO)

FIRST ALARM 

(BOX)

SINGLE FAMILY 

(METRO)

LOCAL 

ALARM 

SINGLE 

FAMILY 

(RURAL)

FIRST ALARM 

(BOX) SINGLE 

FAMILY

(RURAL)

Engine 3 to 4 2 Engines

6-8 personnel

4 Engines

12-16 personnel

2 Engines

6-8 personnel

5 Engines

15-20 personnel

Tower/Truck 4 1 Truck/Tower

4 personnel

3 Truck/Tower

12 personnel

1 Truck/Tower

4 personnel

3 Truck/Tower

12 personnel

EMS Transport 

Unit 2 1 Medic Unit

2 personnel

2 Medic Units

4 personnel 1 Medic Unit

2 personnel

2 Medic Units

4 personnel

Squad 4 (0) (*) (0) (*)

Tanker 1 (0) (0) 1 Tanker 

1 personnel

2 Tankers 2 

personnel

Battalion Chief 2 

1 BC with staff 

aide

2 personnel

1 BC with staff 

aide

2 personnel

1 BC with staff 

aide

2 personnel

1 BC with staff 

aide

2 personnel

Field Safety 

Officer 1 (0) 1 FSO (0) 1 FSO

Medical Duty 

Officer 1 (0) 1 EMS Supervisor (0) (1) 1 personnel

TOTAL 

PERSONNEL - 14-16 personnel 32-36 personnel** 15-17 personnel 37-42 personnel**

Table 1: The Fire and Rescue department’s deployment model for urban/suburban response 

and rural response in July 2018. 

(Figure courtesy of the Fire and Rescue Department.) 

*Squads are optional if closer, but are somewhat interchangeable with Towers/Trucks, so staffing 

is included with the Towers/Trucks. 

**A second on-duty BC is alerted for the Local Alarm and for the 1st Alarm Box assignments. The 

second BC is given discretion as to their physical response. Note: In this incident, the second onduty BC responded within two minutes of the initial arriving unit’s scene size-up and request for a 

1st Alarm Box assignment increasing the staffing by two members.
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Bureau of Education and Training

The level of performance demonstrated by a fire department is usually a good indication of the type, 

frequency, and quality of the training provided. The Fire and Rescue department has a state-of-the-art 

training center and a full-time training staff. The department not only provides daily in-service training 

conducted by company officers, but also provides scheduled training for officer development and 

specialty training for drivers, apparatus operators and specialty teams.

The minimum goal of any fire department training program should be to teach each person in the 

department to operate at acceptable and safe performance levels for his or her rank and assignment. 

Although national and state consensus standards for firefighter training are certainly considered, the 

specific requisite training for a firefighter is determined by their authority having jurisdiction (AHJ). 

In addition to the NFPA standards, Maryland Occupational Safety and Health (MOSH) established the 

Maryland Fire Service Health and Safety Consensus Standards for fire departments within the state. 

Under the MOSH Consensus Standards, agencies with a duty to respond to an emergency incident, “must 

provide training and resources to responders commensurate with the duties required at those incidents” 

[Maryland OSHA, 2002].

The MOSH Consensus Standard also addresses minimum qualifications and training to ensure an 

individual is qualified to perform a certain function. Under the standard, a pre-emergency responder’s 

training is to be “determined by the AHJ, based on the level of anticipated response” [Maryland 

Department of Labor, Licensing and Regulation, 2002]. However, for personnel classified as emergency 

medical responder, emergency medical technician (EMT), cardiac rescue technician and paramedic, the 

individual must obtain the appropriate license or certification from the Maryland Institute for Emergency 

Medical Services System (MIEMSS). Because both NFPA and MOSH standards are voluntary.

Maryland fire departments are provided the flexibility of establishing their own training standards and 

programs.

The department’s recruit training is a 26-week, formal program that largely corresponds directly with 

the national and state industry consensus training standards. It includes the following:

• Maryland Emergency Medical Technician Basic (EMT/B) 

• Emergency Vehicle Operators Course (ProBoard certified) 

• NFPA 1001, Standard for Fire Fighter Professional Qualifications [NFPA 2013a], Firefighter I 

and II, Hazardous Materials, Awareness and Operations (ProBoard certified)

• Technical Rescue training courses (e.g., auto extrication, machinery extrication, etc.)

• Firefighter survival and rescue training

• Incident Command System (ICS)

• Safety training.

Incumbent personnel receive formal and informal training through a variety of sources including

in-station, multi-company, quarterly officer training, regional, and conference and/or seminar attendance 

opportunities. Additionally, the department conducts battalion level training as needed, such as rapid 

intervention and Mayday management. 
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In 2018, rapid intervention and Mayday management training focused on integrating the incident 

command system (ICS) at the battalion and company level for a Mayday firefighter rescue during a highrise operation. Additionally, training in modern fire dynamics focused on the complexity of the modern 

fire environment (e.g., faster fire propagation, unanticipated events, and more rapidly occurring dynamic 

fire situations) based on recent changes in construction materials and design. 

In the Fire and Rescue department there are three broad categories of fire rescue service responders. 

Each of the following groups have different minimum training requirements: 

• career members

• county volunteer members (assigned to career staffed stations by the Assistant Chief of 

the Emergency Services Bureau)

• corporate volunteer members (members of corporate volunteer fire departments that

operate in coordination with Fire Administration).

Bureau of Occupational Safety and Health 

The department’s Bureau of Occupational Safety and Health (BOSH) has developed programs 

addressing members’ safety, health, wellness, risk management, and exposure support. The department 

offers and encourages an annual fitness assessment and requires an annual medical evaluation with 

medical fitness for duty requirements consistent with NFPA 1582, Standard on Comprehension 

Occupational Medical Program for Fire Departments, for both career and volunteer operational 

firefighters [NFPA 2018a]. The BOSH’s wellness program includes an anti-tobacco policy. As a 

condition of employment, persons selected for all future training classes shall not use tobacco products 

in any form throughout the term of their employment whether on-duty or off-duty. Any use of tobacco 

products during the term of employment shall constitute grounds for disciplinary action and/or 

termination. 

Staffing for the BOSH consists of: 

• One assistant chief: Program Manager

• One battalion chief: Accident & Injury Investigation & Review 

• One captain: Health Maintenance Coordinator (NFPA 1582 compliant) 

• One lieutenant: Fire Fighter Peer Support (Behavioral Health) and Physical Fitness

• One administrative assistant: Statistical data and data analysis

• Each shift safety officer is assigned to an operational battalion chief (three shifts)

• One civilian Risk Management Analyst and Programs Administrator (Senior Analyst). 

The Fire and Rescue department has an Occupational Safety and Health Committee which is involved 

with the development and revision of policy and procedures. 

Training and Experience

The hiring process for the Fire and Rescue department is administered by the county’s human 

resources department. Minimum qualifications for applicants include being at least 18 years of age, a 

Class “C” driver's license, a high school diploma or GED, and documentation of eligibility to legally 

work in the United States. Those meeting the application requirements are invited to take the written 
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civil service examination. The written examination consists of multiple-choice questions in the 

following areas: video-based human relations, animated mechanical aptitude, reading, and math. The 

exam must be completed within two hours and twenty minutes. Applicants passing the civil service 

examination are placed on the hiring list.

Those passing the written examination must then pass a candidate physical ability test offered at the 

county’s public safety training center. The next step in the hiring process is an interview by members 

of the fire department and personnel from the Human Resources department. Selected applicants are 

offered conditional employment, based upon:

• Passing a background check

• Meeting the medical requirements in accordance with NFPA 1582, Standard on 

Comprehension Occupational Medical Program for Fire Departments [NFPA 2018a].

• Passing a drug screen

• Passing a psychological evaluation

• Completing the 26-week fire training academy. 

The candidate then becomes a probationary firefighter and is assigned to the Emergency Services 

Bureau. The probationary period lasts 12 months. 

The state of Maryland requires training for volunteer firefighters that meets or exceeds the 

requirements of NFPA 1001, Standard for Fire Fighter Professional Qualifications [NFPA 2013a]. 

These requirements include Fire Fighter I, Hazardous Materials Awareness, Hazardous Materials 

Operations, and First Responder. The process requires annual recertification. In the state of Maryland, 

the training hour requirements are: 

• Firefighter I: 108 hours

• Firefighter II: 60 hours

• First Responder: 45 hours

• Hazardous Materials Awareness: 12 hours

• Hazardous Materials Operations: 24 hours 

The department’s fire academy, operated by the Bureau of Training and Education, runs for 26 weeks 

and consists of NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter I, Fire 

Fighter II, Hazardous Materials Awareness, Hazardous Materials Operations, EMT Basic, Firefighter 

Safety and Survival, Vehicle Rescue Technician, Confined Space Rescue Technician, Swiftwater

Rescue, Trench Rescue, Structural Rescue Awareness, Weapons of Mass Destruction (WMD)

awareness, and Emergency Vehicle Operator. 

The recruit class topics cover EMT-Basic, Fire Fighter I, Fire Fighter II, Hazmat Operations, Vehicle 

Operator, self-contained breathing apparatus (SCBA) training, personal protective equipment (PPE) 

training, ladder training, interior firefighting, and other subjects. The Bureau of Education and 

Training is certified by ProBoard and the Commission on Accreditation of Allied Health Education 

Program – ALS/Paramedic Program Accreditation. This allows recruits to receive ProBoard 

certification for Fire Fighter I, Fire Fighter II, Hazmat Awareness and Hazmat Operations.
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The firefighter from Engine 101 (E101B) was hired by the Fire and Rescue department in 2005. He 

had 13 years of fire experience and was promoted to lieutenant posthumously. The firefighter was 

certified as NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I & II, 

NFPA 1031, Standard for Professional Qualifications for Fire Inspector and Plan Examiner, Fire 

Inspector I, II, & III, NFPA 472, Standard for Competence of Responders to Hazardous 

Materials/Weapons of Mass Destruction Incidents, Hazardous Materials Awareness, Hazardous 

Materials Operations, Hazardous Materials Technician, and NFPA 1006, Standard for Technical 

Rescue Personnel Professional Qualifications, including Confined Space Rescue Technician, Rope 

Technical I and II, Trench Technical Rescuer I and II, and Vehicle and Machinery Rescue Technician.

Department training records show E101B had completed 85 classes totaling over 1000 classroom and 

practical training hours during his 13-year career.

The lieutenant (E101A) was hired by the Fire and Rescue department in 1999, had 20 years of 

experience, and was promoted to lieutenant in 2006. The lieutenant was certified to NFPA 1001, 

Standard for Fire Fighter Professional Qualifications, Fire Fighter I & II; certified Maryland 

Emergency Medical Technician Paramedic; NFPA 1031, Standard for Professional Qualifications for 

Fire Inspector and Plan Examiner, Fire Inspector I, NFPA 472, Standard for Competence of 

Responders to Hazardous Materials/Weapons of Mass Destruction Incidents, Hazardous Materials 

Awareness and Hazardous Materials Operations; NFPA 1021, Standard for Fire Officer Professional 

Qualifications, Fire Officer I & II, NFPA 1041, Standard for Fire and Emergency Services Instructor 

Professional Qualifications, Fire Instructor I & II; NFPA 1006, Standard for Technical Rescue 

Personnel Professional Qualifications, Vehicle and Machinery Rescue Technician I & II; and National 

Fire Academy’s Health and Safety Officer. E101A was also currently certified by Blue Card as a 

Hazard Zone Incident Commander. During the officer’s 20-year career, department training records 

show158 classes totaling over 3600 classroom and practical training hours were completed.

The incident commander was hired by the Fire and Rescue department in 1985 and had 33 years of fire 

experience. He was promoted to battalion chief in 2007. Training records indicate the following 

training: certified to NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I,

II, and III; NFPA 1031, Standard for Professional Qualifications for Fire Inspector and Plan 

Examiner, Fire Inspector I, II, and III; NFPA 472, Standard for Competence of Responders to 

Hazardous Materials/Weapons of Mass Destruction Incidents, Hazardous Materials Awareness, 

Hazardous Materials Operations, and Hazardous Materials Technician; NFPA 1021, Standard for Fire 

Officer Professional Qualifications, Fire Officer I & II, NFPA 1041, Standard for Fire and Emergency 

Services Instructor Professional Qualifications, Fire Instructor I, II, and III; and NFPA 1006, Standard 

for Technical Rescue Personnel Professional Qualifications, and Vehicle and Machinery Rescue 

Technician I & II. The Incident Commander (IC) was also certified by Blue Card as a Hazard Zone 

Incident Commander.

Apparatus, Staffing, and Communications

The Fire and Rescue department’s General Order 410.01, Communications, applies to all Fire and 

Rescue department operations, as well as the county’s department of police, information technology 

bureau, and communications division (communications center) that administers all 9-1-1 call-taking 

and fire dispatch services in the county. The county’s communications center coordinates all county 
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radio communications including facilitation of police, fire, and emergency medical calls. The 

communications center is operated by the county’s department of police, with a uniformed Fire 

Captain and Fire Lieutenant serving as Fire Communication Liaisons from fire and rescue services to 

support fire operations. The liaisons are on an administrative work schedule and do not have any 

official management function in the command center. 

The county’s communication center is staffed with 80 personnel, which are assigned to four shifts. 

Dispatcher tours are 0700 – 1900 hours and 1900 – 0700 hours. The work schedule is 2-day tours, 2-

night tours, and then four days off. 

All county agencies use the 800-megahertz (MHz) radio system. There are numerous tactical radio 

channels available during an incident. 

All fire apparatus and vehicles are equipped with automatic vehicle locators, which is a system that 

dispatches the closest company or unit to an incident and is tied to the computer-aided dispatch (CAD) 

system. 

Training for dispatchers consists of the following: 

• New telecommunicators attend a 6-week classroom training program 

• One week of fire department training 

• All telecommunicators are trained and certified as emergency medical dispatchers and trained 

and certified in cardiopulmonary resuscitation (CPR) using the International Academies of 

Emergency Dispatch for training

• One year of training with field training officer

o Two tracks: Law enforcement or Fire

o Must spend two years in a discipline before moving to the other track. 

Building Construction

The single-family home was located on a three-acre lot in a suburban neighborhood. The structure was 

large and uniquely shaped. The Maryland State Department of Assessment and Taxation listed the 

structure size as 7,313 square feet of above grade living area and 1,100 square feet of finished 

basement. The basement did not cover the entire structure (See Photo 1).
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For the purposes of this report, the western side (main entrance) of the structure was the front, or Side 

Alpha. The left (northern) side of the structure was Side Bravo; the rear (eastern/southeastern) side of 

the structure was Side Charlie; and the right (southern) side of the structure was Side Delta (See Photo 

2). 

The general shape was two rectangles with an offset of approximately 30 degrees at the approximate 

center of the structure. There was a bump-out portion at the approximate center of Side Charlie, 

terminating with an octagonal turret-type feature. The overall centerline length of the structure (Side 

Bravo to Side Delta) was approximately 145 feet, accounting for a 30-degree offset. The depth of the 

structure varied. The northern (toward Side Bravo) rectangular portion was approximately 40 feet wide

(Side Alpha to Side Charlie). The southern rectangular portion was approximately 50 feet wide. The 

width of the structure at the location of the bump-out portion increased to approximately 85 feet, from 

the nearest Side Alpha wall.

The structure was wood frame construction with a brick veneer. The roof had multiple pitches 

consisting of wood sheathing covered with asphalt shingles. The structural components were a 

combination of nominal dimensional lumber, open web trusses, and engineered wooden I-beams.

Photo 1. The 8,413 square foot custom-built home showing Side Alpha. 

(Photo courtesy of the Fire and Rescue Department.)
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Side Alpha had two exterior entrances: an arched main entranceway that led into the foyer and a 

smaller side door that led into the 1st floor kitchen (See Diagram 1). 

Side Bravo had two floors above grade and no basement. The 1st floor had a 3-car garage while the 

2nd floor was bedrooms. To the left of the garage was an exterior door leading into the 

laundry/mudroom. The laundry/mud room had a doorway with a pocket door, which connected to an 

open area with a two-section stairway to the 2nd floor. At the stairway to the left was a step-down 

family room. The family room had a stairway down to the finished basement. At the stairway straight 

ahead was the kitchen and to the left a breakfast area (See Diagram 1).

Photo 2. An aerial view of the home showing the sides of the house 

as defined by the Fire and Rescue department.

(Photo courtesy of the Fire and Rescue Department.)
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Diagram 1. Diagram of the 1st floor.

(Diagram courtesy of the Fire and Rescue Department.)
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From the exterior, upper Side Charlie transitioned to lower Side Charlie with a change in grade and 

about a 30-degree change of direction to the south. On lower Side Charlie there was an open-air deck 

on 1st floor. Below the deck were double glass doors providing access to a finished basement. The 

finished basement extended beneath approximately half of the structure from Side Delta to the center 

of the home ending at a crawlspace. The crawlspace was essentially below the 1st floor kitchen, 

breakfast area, and the family room (See Diagram 2). The crawlspace was only accessible from the 

basement utility room by a short set of stairs at the utility room’s Side Alpha/Side Bravo corner. 

Access to the crawlspace was hidden from view with little or no indication of its existence. Tongueand-groove hardwood floors covered the entire first floor except for the breakfast area which had 

marble tile. The kitchen, breakfast area, and the family/TV room were directly above the crawlspace 

(See Diagrams 1 and 2). The underside of the floor system for 1st floor, which is the crawlspace 

ceiling, consisted of unprotected dimensional lumber supported by solid lumber joists. Height of the 

crawlspace varied due to differing floor levels of the areas above, with an estimated average height of 

approximately four to five feet. 

The crawlspace was divided into two confined sections: a “finished” section (on the northern side) and 

an “unfinished” section (on the southern side) (See Diagram 2 - dotted line). Various household items 

were stored in both sections, which created a cluttered and confined area in both sections. The flooring 

of the finished (northern) crawlspace consisted of platform-type floor assembly of plywood and 

linoleum on top of a moisture barrier. The unfinished (southern) section had earth covered by moisture 

barrier and plywood panels. The walls of both sections were concrete masonry units (e.g., cinder 

block). 
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Report # F2018-13 

Diagram 2. Sketch of the basement. The red “X” marks the approximate location 

where E101B was found. 

(Diagram courtesy of the Fire and Rescue Department.) 
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Timeline 

The following timeline is a summary of events that occurred as the incident evolved. Not all incident 

events are included in this timeline. The times are approximate and were obtained by examining the 

dispatch records, audio recordings, witness statements, and other available information. This timeline 

also lists the changing fire behavior indicators and conditions reported, as well as fire department 

response and fireground operations. All times are approximate and rounded to the closest minute. The 

timeline is not intended, nor should it be used, as a formal record of events. 

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Lighting struck a tree in the rear (Side 

Charlie) of the affected residence. 

Note: for the sequence of events for the 

lighting strike go to the Fire Cause 

Section.

1:52:14 

Hours 

The county’s communication center 

dispatched Local Box 5-62: 

“Paramedic 56, Paramedic E101, 

Engine 51, Tower 10, and Battalion 1 

respond for visible smoke from a 

lightning strike.” 

01:52:14 

Hours 

“Tower 10 with 4.” The 

communication center acknowledges. 

01:54:16 

Hours

“Engine 51 with 5.”

Note: No staffing level transmission 

given from E101, M56, P56, and BC1.

01:54:19 

Hours

Communication center, “Engine 51, 

Tower 10, Engine 101, Paramedic 56, 

Battalion Chief 1, you are responding to 

Box 5-62 for a lightning strike.”

01:54:23

Hours

E51 to communication center, “We 

have a single-family, two-story house 

with smoke showing, go ahead and 

start a full box.” 

2:00:29

Hours

02:00:44

Hours

E51 to TWR10: “Tower 10 take the 

front of the building.” 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:01:23

Hours

E51 advanced a 13⁄4-inch hoseline to Side 

Alpha of the structure. 

“Battalion 1 to Engine 51, the map shows 

a pool in the back. If you can, position E51 

to use your hydraulic pump.” 

Communication center, “Upgrading Box 

Alarm 5-62. Dispatching Tower 7, 

Paramedic Engine 71, Paramedic Tower 

3, Engine 111, Paramedic 105, EMS 1, 

and Safety 1 to upgrade Box 5-62 to a 

building fire and operating on Bravo 1.”

02:01:56 

Hours

02:02:14 

Hours

TWR10 advised they were on location, 

position Side Alpha. 

02:02:24 

Hours

E101 advised they had arrived on 

scene, second engine. 

02:03:07 

Hours

Paramedic105 advised they were 

enroute. 

02:03:11 

Hours

E71 advised they were enroute, PAR 4. 

02:03:32 

Hours

51A to BC1, “We pulled around back 

to use the pool and we’re going to 

make entry from the back. The owner 

advised E51A, that most of the heavy 

smoke was in the basement.” 

BC1 to communications center, 

“Battalion 1 is on scene and 

confirming a large two-story singlefamily dwelling with smoke showing. 

We are committing to an offensive 

strategy; Battalion 1 is assuming 

Command.” 

02:03:55 

Hours

BC1 acknowledged E51A. 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:04:31 

Hours

Command to E51,” I am assigning you 

Fire Attack Group Supervisor. You’re 

going to have yourself and Tower 10.” 

Command to E51, “Is your operator 

going to access the swimming pool for 

water supply?” 

02:04:54 

Hours

E51A to Command, “That’s correct. We 

are on Side Charlie, making an attack from 

Side Charlie. I suggest other units come in 

from Alpha.” 

02:05:07 

Hours

Command to E51A, “Give me a visible 

report on Side Charlie from the 

basement as soon as you can.” 

02:06:05 

Hours

BC1 Aide to Command, “I’ve got twostory Side Charlie, smoke in the 

basement with glass slider access on 

Side Delta and Side Charlie, a finished 

basement, and I do have smoke 

conditions.” 

02:07:43 

Hours

E101 to Command, “We are two out, 

Side Charlie.”

02:07:51 

Hours

E51 entered the structure through the 

laundry room door near the garage on 

Side Charlie.

02:08:01 

Hours

Command to E101A, “101 you’re 

advising that you’re on Side Charlie 

and you’re with 51? Is that correct? “ 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:08:12

Hours

E101A to Command, “We are outside 

the building, but we are (with E51), 

second line pulled, two-out.” 

Note: E101B pulled a 300-foot 13⁄4-inch 

hoseline off E51 and pulled the 

hoseline to the doorway of the laundry 

room. 

02:08:46 

Hours

E51A to Command, “We are going to 

reexamine if we have access to the 

basement. We’re going to come in 

through the basement slider.”

02:09:34 

Hours

E71A to Command, “I am getting close 

to the incident now. Do you need me to 

come to the scene or grab secondary 

water supply?”

02:09:42 

Hours

Command to E71A, “No, you are going 

to have to bring water. I believe E101 

has laid in from our street. If you can, 

lay in from the main road to E101’s 

supply line. I’m not even sure what 

we’ve got on the remainder of the 

assignment, but somebody got to get 

that hydrant on the main road at the 

next street up.” 

02:10:19 

Hours

Command to E71A, “Go ahead and 

forward lay from the hydrant to E101’s 

supply line.” 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:10:55 

Hours

TWR10A to Command, “Yeah, I was 

just telling the Lieutenant on 51 to 

redeploy their line to the basement. 

We’re currently exterior right now, 

Side Charlie, getting ready to make 

entry.” 

Note: E101B has pulled a 300-foot 13⁄4 

-inch hoseline of E51 to the basement

entrance. E51’s 200-foot hoseline is

too short and won’t reach the basement

entrance.

Note: No water supply has been 

established 10 minutes into the 

fireground incident and 20 minutes 

have elapsed since the original 9-1-1 

call. 

02:11:41 

Hours

TWR10C to Command: “Electric in the 

garage is secured.” 

Command acknowledged. 

02:12:12 

Hours

Command to P56, “56, IRIC on Side 

Alpha.” 

02:12:41

Hours

Command to all units, “We do have an 

ALL CLEAR from the occupants, 

occupied times three, ALL CLEAR of 

the house. We do have an ALL 

CLEAR.”

Battalion 2 (BC2) reported on scene. 

County communications 

acknowledged Truck 7 (TR7) and 

BC2 on scene. 

02:12:53

Hours
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:13:01 

Hours

Command to BC2: “I am going to have 

you assume Charlie Division when you 

can get here and get around there.” 

02:14:00 

Hours

E111 on the scene. E111 is the 4th due 

Engine. E11 picked up E71’s supply 

line at the hydrant. 

02:14:56 

Hours

Command to E51A: “Fire Attack, 

Engine 51, CAN Report.” 

02:15:09 

Hours

E51B to E51D: “Engine 51 charge the 

300-foot line.”

02:15:30 

Hours

Fire Attack to Command, “Go ahead 

and have somebody place positive 

pressure at the front door. We have 

smoke in the basement and can’t find 

the fire at this time.”

02:15:48 

Hours

E101 to Command, “We have heavy 

fire on floor Number One, on the 

Charlie Side.”

02:16:17 

Hours

E101A to Command, “We need to 

redeploy our line back up to the initial 

entrance.”

E101B was ordered to back out of the 

basement by E101A. E101B and 

E101A abandoned their attack line (300-

foot) and pulled another 200-foot 13⁄4-inch 

hoseline from E51 to the laundry room.

02:16:25 

Hours

Command to E101A: “When you are 

talking about the initial entrance, 

you’re talking the Alpha Side, is that 

correct?”
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:16:33 

Hours

E101A to Command: “Yes, Side 

Charlie.”

Command acknowledged, “No, you 

mean the initial entrance on Side 

Charlie?”

02:17:43 

Hours

TWR10A to Command, “It’s going to 

be quadrant two, E101 and E51, are 

making entry right now. We have made 

access to the basement, still have 

smoke from floor to ceiling, I closed 

the door back up. Only crews you 

should have interior are on the 1st level 

entering Side Charlie.” 

02:18:07

Hours

Command to TWR10A, “Very well. 

Command to E71 and T7, hold do not 

make that attack.”

02:18:29

Hours

Command to T7A: “Truck 7, I want 

you to assume RIT, Truck 7, I want 

you to assume RIT. From that position 

where you’re located. You’ve got E51, 

E101, and Tower 10, they’ve entered 

from Charlie Side.” 

T7 acknowledged. 

Command acknowledged the 

communication center, that the 

incident was at the 15-minute mark. 

Command to communications center, 

“Go ahead and give me the Task 

Force.” 

Communication center acknowledged. 

02:19:10 

Hours
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:19:45

Hours

E101B: Open Mic. 

Note: E101B was operating on Bravo 2, 

an unmonitored talk group. E101B’s key 

up was not heard on fireground or the 

communications center.

“Communication center is upgrading box 

alarm to the Task Force for Box 5-62.” 

“Dispatching Engine 61, Engine 91, 

Squad 1, HR, PIO, on call center 

supervisor, on call Fire Investigator, on 

call Battalion Chief, on call Safety

Officer, due to respond Bravo 6, Bravo 

6.”

02:20:22 

Hours

02:20:11 

Hours

E101A: “Mayday, Mayday, Mayday. 

E101B is in the basement to the left.” 

Note: E101B had fallen through the 1st

floor into a crawlspace, which was 

used as a storage area. The crawlspace 

contained active fire and high heat 

conditions.

02:20:31 

Hours

E101A to Command, “101 is in the 

basement now, I believe he’s in the 

basement now.” 

02:20:47 

Hours

Command to E101A, "E101A, I’ve got 

you on the MAYDAY. 

T7 RIT deploy from the Charlie Side, 

you’ve got a Mayday from E101, all 

units hold the air. 

E101 go ahead with your MAYDAY.” 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:21:05

Hours

E101A to Command (Bravo 1), “He’s 

in the basement, hoseline trying to pull 

him up, go through the basement.” 

Note: E101B to Command (Bravo 2), 

transmitted a clear Who, What, Where 

consistent with MAYDAY training. 

E101B was operating on Bravo 2. 

A simultaneous transmission on Bravo 1 

prevented radios operating on scan mode 

from hearing any transmissions outside of 

Bravo 1 talk group. Communications 

center did not hear the transmission on 

Bravo 2.

02:21:44 

Hours

Command to E51A, “Very well, 51, 

you’re trying to find her.” 

Command to E101A, “E101A, I 

understand that you’ve fallen into the 

basement?”

Command to communications 

center, “Give me a 2nd Alarm and 

keep them on Bravo 6.” 

02:22:05 

Hours

Communications center is upgrading 

Box Alarm 5-62 to 2nd Alarm. 

“Dispatching Paramedic Engine 22, 

Paramedic Engine (pause for 

correction) Automatic Aid Engine 

849, Automatic Aid Truck 29, Air 

Unit 17, MAB 13, Chaplain, 

Command 17, and Canteen 6 

respond on a 2nd Alarm for Box 5-

62. It is going to be for a house fire

now with a Mayday. You’re going to

operate on Bravo 6, Bravo 6.”

02:22:56 

Hours
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:22:27 

Hours

E71 to Command, “We are redeploying 

the hoseline around Side Delta, to Side 

Charlie. I’ll team up with Truck 7.” 

02:23:19 

Hours

TWR10A to Command, “I have 101’s 

officer.”

Command acknowledged: “Tower 10, 

you’ve got 101’s officer, are you out of 

the structure?”

02:23:42 

Hours

TWR10A to Command, “Correction, 

Engine 51’s officer.” 

02:24:00 

Hours

Charlie Division to Command, “We’ve 

got E101 Officer out. we are still 

looking for E101B.” 

Note: The was the first reference that 

E101B was the Mayday emergency.

02:25:15 

Hours

Division Charlie to Command, “E101B 

fell through the floor. He is on the 

hoseline. He went down with the 

hoseline and could not get pulled up. 

Units are inside, right now, uh, 

searching for him.” 

02:25:53

Hours

Division Charlie to Command, “E101B 

is one floor below the grade level at the 

front door. The only area, that has 

exposed at the grade level, is the Delta 

Side, as well as the lower part of the 

Charlie Side.”
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:26:15 

Hours

Command to Division Charlie, “Charlie 

can you confirm a PAR for E51’s crew 

and Tower 10’s crew?”

Division Charlie acknowledged E101A 

was accounted for at this time. The 

only person that was unaccounted for 

was E101B. 

02:26:38 

Hours

Command to Division Charlie, “E101B 

is from E101and you have E101 

Officer? You have her out and we have 

contact with E51A and Tower 10A?”, 

02:27:44 Command to E51D, “What about the 

third member of E51’s crew?” 

E51D acknowledged, “Engine 51C has 

not been located, as of yet.” 

02:28:00 

Hours

E101B’s PASS manually activated.

2:28:55 

Hours

Command to T7D, “Okay, Engine 51C 

has come out under his own power and 

he is sitting on the back deck. 

Command to E51C, “I want you to 

return to Engine 51, to your crew.” 

02:29:12 Division Charlie to Command, “E51C 

is direct on that. One priority addition, 

we have Engine 51E who is 

unaccounted for. So, we have E101B 

and E51E still unaccounted for. Engine 

51C is safe outside.” 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:29:33 

Hours

E51 to Command, “E51E is with me 

and E51B is with me. It is unknown 

where E51C is at this time? 

Correction, he is now with me. Also, be 

advised, the laundry room doorway that 

we initially went in, is about to flash.”

02:30:45 

Hours

Command to Division Charlie, “Charlie 

Division, the initial Fire Attack Group 

was E51, E101, and Tower 10. Then 

RIT came around, it was Truck 7, E71 

and now I’m sending you Tower 3.” 

Division Charlie Supervisor 

acknowledged. 

02:31:33

Hours

E51D to Command: “Be advised, we 

are at less than a 1⁄4 tank of water. We 

are out of water.”

Note: A continuous water supply still 

had not been established. 

“Engine 111A to Engine 71D, 111 to 71, 

water is on the way, 71 Operator?”

Communications center to Command: 

“Getting the emergency identifier 

from E101B portable.” 

Note: The emergency identifier on 

Bravo 2 was likely activated by the 

man down feature. The 

communication center did not report 

E101B’s identifier from the portable 

radio.

2:33:12
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:37:35 

Hours

E51D to Command: “Hydraulic pump 

is deployed and activated. I have a 

water source.”

Command acknowledged. 

02:39:39 

Hours

Command to E61, “Alright Squad 6, 

form up with Engine 91 and Engine 22. 

You’re going to go to the rear. Squad 6, 

you’re going to have the second RIT. 

Truck 6, correction Squad 6, you are 

now assuming RIT number two.” 

E61 acknowledged, “Okay, that’s E61, 

E91, and 22. We are going to be the 

second RIT.”

02:42:06 

Hours

RIT to Command, “We’ve got E101B. 

Need EMS to the Charlie side 

basement door.” 

Command acknowledged: “Alright 

RIT, you have E101B and you’re on 

the Charlie side basement door. EMS 1 

are you direct? Division Charlie are 

you direct?” 

02:42:34 

Hours

Command to communications center, 

“Go ahead and give me the evacuation 

tone. Charlie Division, I want all units 

pulled out, with E101B found. All units 

pulled out and give me a PAR as soon 

as you can.” 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:43:39 

Hours

“Division Charlie to Command, 

“E101B is out of the building.” 

Command acknowledged: “Division 

Charlie, I’m direct, E101B is out of the 

building. We are evacuating, and I need 

PARs on everything that went in.” 

Note: The rapid intervention group 

located and extricated E101B 15 minutes 

and 5 seconds after entry. E101B was 

extricated from structure, 22 minutes and 

11 seconds after the Mayday was initially 

declared (Appendix 3).

02:46:36 

Hours

Command to all units on the 

fireground, “All units on the 

fireground, units are PAR. We are 

going to commit to a defensive 

strategy, defensive strategy.” 

Medic105 was enroute to the local 

hospital. E101B was unconscious with 

CPR in progress. 

02:54:48 

Hours

E101B pronounced deceased at the 

local trauma hospital 

0312 

Hours

Command to communications center, 

“Place the fire at Box 5-62 under 

control.” 

1008 

Hours

Command to communications center, 

“Place the fire for Box 5-62 out.” 

1158 

Hours
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Report # F2018-13 

Personal Protective Equipment

At the time of the incident, the E101B was wearing a turnout coat and pants, a helmet, a protective 

hood, boots, and gloves that met the current requirements of NFPA 1971, Standard on Protective 

Ensembles for Structural Fire Fighting and Proximity Fire Fighting [NFPA 2018b]. The selfcontained breathing apparatus (SCBA) and the personal alert safety system (PASS) that E1010B was 

wearing were certified to the 2013 edition of NFPA 1981, Standard on Open Circuit Self-Contained 

Breathing Apparatus (SCBA) for Emergency Services [NFPA 2013b]. 

At the police department’s evidence room, the NIOSH investigators inspected E101B’s helmet, 

protective hood, turnout coat, turnout pants, left glove, and boots. The helmet showed significant 

thermal degradation. The protective hood had some minor discoloration. The turnout coat had charring 

on the outer shell, left side, back, and right side. The turnout coat moisture barrier was charred on the 

left shoulder and the thermal barrier showed thermal damage. The turnout pants had charring on the 

front of the right leg of the outer shell. The turnout coat and turnout pants had been cut off the E101B 

firefighter to provide emergency medical care. The glove and boots had some thermal damage. 

In addition to the NIOSH visual inspection, the fire department hired a subject matter expert (SME) to 

examine the PPE worn by E101B. The SME’s report stated, “The examined items were subjected to a 

rigorous visual inspection on all surfaces of the clothing items to assess how the specific areas of 

damage might be related to the protective qualities of the respective items. The protective garments 

(coat and pants) were further examined for their compliance with the purchase specification for the fire 

department.” “No defects or issues were found with the quality of the examined clothing items that 

could be considered as contributing to the adverse injuries sustained by E101B. All clothing items 

were found to meet the relevant edition of NFPA 1971, Standard on Protective Ensembles for 

Structural Fire Fighting and Proximity Fire Fighting at the time of their manufacture except for the 

protective hood, for which the product label was missing.” “Certain portions of the clothing reached 

temperatures well over 500°F with some of these areas being at high temperatures for extended periods 

of time.” “Complete degradation of trim material on the garments and helmet indicated temperatures in 

excess of 600 to 700°F.” 

A summary of the NIOSH SCBA evaluation is included as Appendix Two. The full evaluation report 

is available upon request from NIOSH NPPTL or available from the NIOSH NPPTL PPE website. 

Appendix Three shows a diagram of the data log from the SCBA worn by E101B. The diagram 

includes breathing air rate, the PASS alarm activation, and temperature alarm activation. 

The breathing air in the cylinder of the SCBA was tested and certified to the 2013 edition of NFPA 

1989, Standard on Breathing Air Quality for Emergency Services Respiratory Protection [NFPA 

2013c]. (See Appendix Four). 

The personal protective equipment was not considered a contributing factor in the fatality in this 

incident. NIOSH investigators conducted no further evaluation or testing of the personal protective 

equipment. 
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Report # F2018-13 

Weather 

During the early morning of July 23, 2018, the area was experiencing light rain with thunderstorms. At 

01:51 hours, the temperature was 73 degrees Fahrenheit (73o F), relative humidity was 100%, winds 

were from the east southeast (ESE) at 14 miles per hour (mph) with wind gusts to 24 mph. The 

barometric pressure was 29.71 inches [Weather Underground 2018]. 

Investigation

On July 23, 2018, at 01:51:03 hours, the county’s communication center received a 9-1-1 call from a 

homeowner reporting an odor of smoke in his home. The caller stated that “we’re not sure what is on 

fire, we just smell smoke, and everyone is out of the house.” The 9-1-1 dispatcher verified that the 

resident did not see fire. He only smelled the odor of smoke. The caller also indicated that there was a 

recent lightning strike in the area. Note: Information obtained during the investigation of this incident 

indicated that the lightning strike occurred at approximately 0120 hours, but the neither the county 

communication center nor the responding units were aware of the time of the lightning strike.

The communications center dispatched a local box for a single-family structure in a Metro (hydranted) 

area at 01:52:14 hours on Dispatch Channel Alpha 1. The dispatcher stated that there was “visible 

smoke from a lightning strike.” The dispatcher assigned local Box 5-62 to operate on tactical channel

Bravo 1. Companies dispatched for Box 5-62 were: Engine 51 (PAR 5), Engine 101 (PAR 3), Tower 

10 (PAR 4), Paramedic 56 (P56) (PAR 2), and Battalion 1 (PAR 2). Note: This residence was in a 

suburban area with limited fire hydrants. The closest fire hydrant was approximately 1260 feet from 

the residence and was ultimately used in the incident. The communication center did not dispatch a 

rural local alarm assignment for Box 5-62 per department SOP based on a hydrant within 2000 feet of 

the structure.

E51 arrived on scene at 02:00:29 hours and saw low lying smoke, like a fog across the front lawn on 

Side Alpha. Also, smoke was showing from both floors of the residence. Note: The structure involved 

is located on a three-acre lot in a suburban neighborhood. This structure was a large, uniquely 

shaped, mansion-type, single-family dwelling. The structure size was 7,313 square feet of above grade 

living area and 1,100 square feet of finished basement. 

Upon arrival, E51A advised the communications center that they had a two-story single-family 

dwelling with smoke showing. E51A requested this incident be upgraded to a full box. The 

communications center dispatched a first alarm single-family structure fire box (Metro hydranted area) 

at 02:01:56 hours. Companies dispatched were Truck 7 (PAR4), Paramedic Engine 71 (PAR 4), 

Paramedic Truck 3 (PAR 5), Engine 111 (PAR 3), Paramedic 105 (PAR 2), EMS 1 (PAR 1), and 

Safety 1 (PAR 1). Battalion 2 (PAR 2) self-dispatched, which was a standard practice for the Fire and 

Rescue department on full box alarms. 

While enroute, BC1 referenced a fire department map on the vehicle’s mobile data terminal (MDT). 

The map showed no hydrants on the street and BC1 advised E51A that there was a swimming pool on 

Side Charlie. At 02:01:23 hours, BC1 ordered E51 to reposition to Side Charlie and use the swimming 

pool as a water supply. Prior to these orders, E51 stretched a 200-foot 13⁄4-inch pre-connect hoseline to 
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a door near the Side Alpha/Side Bravo corner. Prior to operating the hoseline, E51A ordered E51 to 

move to Side Charlie near the swimming pool. The crew from E51 carried the deployed 13⁄4-inch 

hoseline to Side Charlie as the apparatus was moved. 

E101, as the second arriving engine, backed into the driveway in preparation to reverse lay

from E51 to the street. However, E51 repositioned to Side Charlie of the structure before E101 began 

the reverse lay operation from E51. Pulling out of the driveway, E101 then repositioned and laid a 

supply line from the driveway entrance toward Side Alpha of the structure. After repositioning to Side 

Charlie, E51A spoke to the homeowner. The homeowner reported most of the heavy smoke was in the 

basement. At 02:03:32 hours, E51A radioed BC1 with this information. At 02:03:55 hours, BC1 

advised the communications center that BC1 was on scene of a large two-story single-family dwelling 

with smoke showing, BC1 was assuming Command, and an offensive strategy was announced. 

At 02:04:31 hours, Command assigned E51 and TWR10 to the Fire Attack Group, with E51A as the 

Fire Attack Group supervisor. Command also asked if E51 was using the swimming pool as a water 

source. At 02:04:54 hours, E51A advised that they were establishing a water supply using the 

swimming pool. Also, they were making an attack from Side Charlie. E51A said that other crews 

should make an attack from Side Alpha. At 02:05:07, Command asked E51A for a status of conditions 

in the basement as soon as possible. 

At approximately 0205 hours, Command ordered his aide to conduct a 360-degree walkaround of the 

structure. At 02:06:05 hours, the BC1 aide reported to Command that there was smoke in the finished 

basement with double glass doors on Side Charlie and Side Delta. Note: Both Side Charlie and Side 

Delta had upper and lower (below grade) levels. Both lower levels had sets of double glass doors. 

At 02:07:51 hours, with a charged hose line, noting smoke conditions but no visible flames, E51 and 

TWR10 entered the house through the laundry room door on the 1st floor. They advanced the 13⁄4-inch 

hoseline about 8 feet into the laundry room. The initial floor of entry into the laundry room and 

conditions observed in the structure were not reported to Command. E51B had the nozzle and penciled 

the ceiling, and water came back. The thermal imager from his SCBA showed some heat at the ceiling 

and floor, but no fire. TWR10A and E51E also had thermal imagers that indicated the same conditions 

plus they observed indications of fire below them and all crews exited the structure. These conditions 

were not transmitted to Command. E101 pulled a second 13⁄4-inch hoseline to the laundry room door as 

a backup hoseline. E101 did not make entry into the structure at this time.

At 02:08:46 hours, crews were out of the laundry room. E51A advised Command that the Fire Attack 

Group (which now included E101) was going to try and access the basement through the glass doors 

on Side Charlie. Moving to the lower level of Side Charlie, E101B advanced a 300-foot 13⁄4-inch 

hoseline and E51 moved their 200-foot 13⁄4-inch hoseline. However, E51’s 200-foot hoseline did not 

reach the basement entrance of the structure. E101B entered the basement on the lower level of Side 

Charlie with the 300-foot charged hoseline with crews from E51 and TWR10. 

At 02:09:07 hours, Engine 71 radioed Command inquiring whether they needed to secure secondary 

water supply. Command, recognizing that the first two engine companies had not secured a continuous 
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water supply, confirmed that E71 would need to secure water. Command instructed E71 to connect 

“that hydrant on the next street up” to the supply line E101 laid at the entrance to the driveway. As 

determined during the NIOSH interviews, the water supply issues temporarily distracted Command 

from managing fireground operations. 

At 02:10:55 hours, TWR10A called Command and advised that E51 was going to redeploy their 200-

foot 13⁄4-inch hoseline to the basement. E51, E101, and TWR10 were getting ready to make entry into 

the basement through the glass door on Side Charlie. Command confirmed with TWR10A that TWR10 

and E101 are making entry with E51, from that same location, on Charlie Side, which TWR10A 

acknowledged. Note: A continuous water supply was not established 10 minutes into fireground 

operations. 

At 02:11:23 hours, TWR10C advised Command that the power to the house had been secured (deenergized) at the electrical panel in the garage. At 02:12:01 hours, Command called P56 to confirm 

they were functioning as the initial rapid intervention crew (IRIC). P56D acknowledged and stated 

they were on Side Alpha. 

At 0212 hours, BC2 and T7 arrived on scene. Command assigned BC2 as Division Charlie at 0213 

hours. 

At 02:15:30 hours, the Fire Attack Group supervisor (E51A) called Command, and requested positive 

pressure be established at the front door stating, “We have smoke in the basement and can’t find the 

fire at this time.” As crews entered the basement, E101A called Command. E101A advised heavy fire 

on the 1st floor on Side Charlie. E101A requested that their hoseline be redeployed to the initial

entrance. Note: At this time, a portion of the 1st floor family/TV Room was beginning to fail or had 

already collapsed. When the companies opened the basement door, this completed a flow path through 

the basement, into the crawl space, and then out the open laundry room door. This was the fire that 

E101A and TWR10D witnessed through the 1st floor double glass doors of the entrance to the TV 

Room on Side Charlie. The fire would flare up every time someone opened the basement door. Once 

the basement door was closed, the fire would lessen (See Photo 3). Winds were blowing 14 mph and 

gusting to 24 mph could have contributed to the fire flaring up every time the basement door was 

opened. NIOSH investigators came to this conclusion based on multiple interviews with fire officers, 

firefighters, investigators, and the review of photographs.

Command was initially confused by the location and asked E101A if they were going back to Side 

Alpha. At 0217 hours, E101A clarified that the entrance was on Side Charlie. TWR10A advised 

Command that they, along with E51 and E101B, had made basement entry and found smoke, floor to 

ceiling. However, due to the report of fire showing on the first floor from E101A, the crews exited the 

basement and closed the basement door. The only crews inside at this point were on the 1st floor, Side 

Charlie going in the laundry room. Upon the report of fire on the first floor, E101B dropped the 300-

foot hoseline at the basement door and went to E51 and pulled a 200-foot 13⁄4-inch hoseline to the 1st

floor laundry room door. 
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Once E71 completed the water supply, Command assigned E71 and T7 to Side Alpha. A firefighter 

from P56 working with the engine and truck forced the front door. The firefighter described the 

conditions on the 1st floor as deteriorating. Smoke was sucking in and out and was brown in color. At 

02:18:07 hours, Command stopped E71 and T7 from entering the structure based upon TWR10A’s 

size-up of the conditions in the basement. Command assigned T7 as a RIC and put E71 “On Deck” on 

Side Alpha. Note: “On Deck” is a forward staging position located just outside the immediate hazard 

zone, safely distanced from the entrance of a tactical position or division. Once a crew is assigned to 

an On Deck position, they are first and foremost a rapid intervention crew until they are given an 

assignment into the hazard zone. 

The communications center transmitted the 15-minute mark to Incident Command at 02:19:09 and the 

IC requested a Task Force assignment at 02:19:10 hours. Note: At 02:20:22 hours, the communications 

center dispatched a Task Force comprised of Engine 61, Engine 91, Squad 1, HR, PIO, on call center 

Photo 3. The double doors on the left were where E101A reported seeing 

heavy fire. The doorway with the heavy smoke showing is the entrance to the 

laundry room. The time is approximately 0215 hours.

(Photo courtesy of the Fire and Rescue Department.)
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supervisor, on call Fire Investigator, on call Battalion Chief, and on call Safety Officer on Bravo 6.

Note: The 15-minute mark was based on BC1 assuming Command rather than the arrival of the 1st due 

apparatus E51, which was at 0200 hours. Also, this was almost 30 minutes since the 9-1-1 call and 60 

minutes since the lightning strike that occurred at approximately 0120 hours. 

At 02:17:43 hours, E101B entered the 1st floor laundry room. E101A was several feet behind him 

when E101B made entry. E51 was moving their hoseline to the entrance of the laundry room. At 

approximately 02:19:45 hours, the floor of the 1st floor breakfast area was beginning to fail or had 

already collapsed into the crawl space. E101B fell into the hole and into the basement’s crawlspace

with the hoseline (See Diagram 3). Whether the floor had collapsed prior to his entry into the room or 

whether his weight contributed to the collapse is unknown. 

Conditions in the crawlspace were fire and high heat conditions. At 02:20:11 hours, E101A called a 

Mayday: “Mayday, Mayday, Mayday, E101B is in the basement to the left” on Bravo 1. E101A’s

Mayday transmission was immediately acknowledged by Command, but Command was unclear who 

was experiencing the Mayday. 

At 02:21:05 E101A transmitted on Bravo 1 “E101B is in the basement, trying to pull him up, go 

through the basement.” Simultaneously, E101B transmitted a clear Who-What-Where statement on 

Bravo 2. Any radio on scan would not have heard E101B’s transmission due to the concurrent 

transmission on Bravo 1. Because Bravo 2 was unmonitored by the communications center, and the 

fireground was operating on Bravo 1, E101B’s transmission was not heard by either Command or the 

communications center.

E51 and TWR10 were operating in the zero-visibility laundry room trying to find E101A and E101B. 

E51B advanced towards the breakfast area on the 1st floor and found E101A reaching into the hole 

hoping to reach/pull E101B out. According to NIOSH interviews, E51B began flowing water into the 

hole. After getting E101A away from the edge, E51B also reached into the hole hoping E101B could 

grab his arm/hand. Due to deteriorating fire and structural conditions, E51B, E101A, and TWR10 had 

to exit the laundry room. 

P56 established the initial rapid interview crews (IRIC) at 0212 hours. At 0218 hours, T7 and E71 

were positioned on Side Alpha and Command assigned T7 as RIC with E71 “on-deck.” At 0222 hours, 

E71 and a member of P56 joined T7 on the RIC. E71 took their 300-foot 13⁄4-inch hoseline from Side 

Alpha to Side Charlie via Side Delta. Both E71A and T7A were doing a quick 360-degree walkaround 

on the structure. The crew from T7 was gathering tools for the RIC operation. 

At 0227 hours, Command tried to conduct a PAR for E51. E51A and E51B were located at E51 in the 

driveway. Command requested a PAR for E51C, who was unaccounted for at this time. At 02:28:02 

hours, T7D, the driver/operator of T7, radioed Command that E51C was with T7 at the basement door. 

At 02:28:55 hours, Command advised E51C to return to his crew at E51. 
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At 02:29:12 hours, the Division Charlie supervisor advised Command that E51E and E101B were 

missing. At 02:29:33 hours, E51A called Command and advised that E51E was with the crew at E51. 

At approximately 0228 hours, E71, T7, and P56D entered the basement through the Side Charlie glass 

doors to rescue E101B. E71A and T7A were the first members of the rapid intervention group to enter 

the basement. They reported “cold smoke” conditions creating poor visibility for the members entering 

the basement. E71A took a few seconds to map the layout of the basement with the use of their thermal 

imager. A right-handed search was initiated by the members of the RIC. E71B was on the nozzle of the 

300-foot 13⁄4-inch hose line that was initially deployed from E101 on Side Alpha. E71C was positioned

on the hose line with E71B. T7B, T7C, T7A, and P56D made entry to begin the search. T7D initially

remained on the exterior to prepare the RIC bag for additional air supply if needed.

Diagram 3. The placement of hoselines and supply lines at the time of the 

Mayday. The time was 0219 hours. 

(Diagram courtesy of the Fire and Rescue Department.)
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As crews were moving forward into the basement, they encountered furniture in their path, smoke 

conditions that were described as having a black-oily residue consistency, and a slippery floor 

potentially from the residue in the air. T7C and P56D located the second set of steps that led up to the 

crawlspace where E101B was located. They could hear the fire in the same direction. T7C wiped his 

SCBA face-piece and could see a glow. They notified E71B that the fire was in that direction. They 

continued through the door and ascended the steps into the crawlspace where E101B was located.

Members of the rapid intervention group stated that as they got to the top of the steps, visibility was 

low, the heat increased and they heard E101B’s PASS alarm. Fire was observed on both sides of them. 

E71A encountered wires hanging from the ceiling level, which were pushing against his chest. He 

removed his wire cutters and began to cut the wires. The wires and the various storage items 

continuously impeded the rescue attempt. 

E71C was the first member of the RIC to find E101B by following the sound of the activated PASS 

alarm. He felt his hand come across E101B’s gear and felt around to see how he was positioned. E71C 

stated that when he found him, E101B was very stiff, lying face down and slightly on his left side. 

They stated that there was no visible fire in that area, only smoke conditions. As E71C began to pull 

E101B toward the steps, E71A made it to their location to assist (See Diagram 4). E71A believed they 

dragged E101B approximately 25–30 feet to the steps in the utility room. T7C arrived at their location 

to assist with the removal of E101B. 

At this point in the operation, members from TWR10, T3, and E22 were inside the basement 

completing searches and standing by to provide additional assistance. T7B moved E101B down the 

steps to the main level of the basement. Members of the rapid intervention group noticed some of their 

low-air alarms on their SCBA were activated at this point. As E101B was removed from the basement, 

crews had to move the furniture to make a straight path to the exterior. Other members in the basement 

assisted by removing E101B the rest of the way to the exterior. E101B was transferred to EMS 

personnel at the basement level for treatment and transport. At 02:43:39 hours, the Charlie Division 

supervisor advised Command that E101B was out of the house. E101B was extricated from the 

structure in 22 minutes and 11 seconds after the Mayday initially declared. The rapid intervention 

group located and extricated E101B in 15 minutes and 5 seconds after entry. 
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Diagram 4. The blue dotted line shows the path that the rapid intervention group 

took to locate E101B and exit the structure. 

(Diagram courtesy of the Fire and Rescue Department.)
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The rapid intervention group consisted of E71, T7, P56D, T3, E22, E61 and TWR10. 

At 02:46:36 hours, Command made an announcement on Bravo 1 that all companies were to evacuate 

the building and operations were changed to a defensive strategy. A personnel accountability report 

was conducted, and all members were accounted for at the incident scene. 

Medical care was initiated on E101B once he was out of the house on Side Charlie. He was moved to a 

stretcher and taken to P105 for transportation to a local hospital. P105 was enroute to the hospital at 

0254 hours. E101B was pronounced deceased at 0312 hours. 

The fire was declared under control at 1008 hours. The fire for Box 5-62 was declared out by 

Command at 1158 hours. 

Fire Origin and Cause

The origin of the fire for Box 5-62, as determined by the Fire and Rescue department’s Office of the 

Fire Marshal, was the unfinished crawlspace below the 1st floor family room and breakfast area. 

Investigators identified the ignition sequence of the fire to be a lightning strike which induced the 

failure of the flexible corrugated stainless-steel tubing (CSST) system used to distribute propane gas 

throughout the building. This caused the ignition of fugitive gas escaping from the hole formed by the 

arcing process which then ignited the wood floor assembly. The classification of the fire cause was 

determined to be natural. Natural fire causes involve fires started without direct human intervention or 

action, such as fires resulting from lightning, earthquake, wind, and flood. 

Contributing Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key 

events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH 

investigators identified the following items as key contributing factors in this incident that ultimately 

led to the fatalities:

• Lack of crew integrity

• Lack of complete scene size-up

• Below-grade fire

• Large area residential structure

• Lack of a defined incident action plan

• Inadequate fireground communications

• Missed critical incident benchmarks

• Member operating on the wrong radio channel

• Task saturation of the incident commander

• Lack of personnel accountability

• Wind/weather
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Cause of Death

According to the post-mortem examination by Maryland Office of the Chief Medical Examiner, the 

cause of death was due to prolonged exposure to high temperatures and thermal injuries. Toxicologic 

analysis showed a normal carboxyhemoglobin saturation strongly suggesting the firefighter did not 

experience carbon monoxide poisoning from the combustion products of the fire. 

Recommendations 

Recommendation #1: Fire departments should ensure that crew integrity is properly maintained by 

visual (eye-to-eye), direct (touch), or verbal (voice or radio) contact at all times when operating in an 

immediately dangerous to life and health (IDLH) atmosphere. The intent is to prevent firefighters 

from becoming lost or missing.

Discussion: When a company is assigned to operate in an IDLH environment, all members should enter, 

work, and exit together to reduce the risk of firefighters becoming lost or missing. Crew integrity means 

firefighters stay together as a team of two or more. Crew integrity starts with the company officer 

ensuring that all members of the company understand their riding assignment and have the proper 

personal protective equipment, proper tools, and proper equipment. Upon arrival at the incident, when 

a company is given a task to perform by Command, the company officer is responsible for clear 

communication to ensure the crew understands the assignment and the means and methods that will be 

used. Companies working at the task level have the greatest risk as they work within IDLH 

atmospheres which is inside the hazard zone. Therefore, all firefighters need to strictly follow the 

established personnel accountability system. 

The task level is where the work is performed by assigned companies. The strategic and tactical levels 

are in place to support the task level. Task level activities are supervised by company officers working 

with company members directly in the hazard zone. The task level is critical because it addresses the 

incident’s problems while taking place in the hazard zone which can kill or injure firefighters. All 

activities outside the hazard zone are in place to support units working on the task level. 

Task level responsibilities include: 

• Following all staging procedures

• Being properly assigned into the hazard zone

• Properly using the personnel accountability system

• Staying together as a company

• Attaching all members to a hoseline

• Maintaining an adequate air supply to safely exit the hazard zone

• Recognizing maximum depth into a structure is 175 feet and based on air supply

• Avoiding freelancing [Blue Card 2018; NFPA 2021a].

Company officers should give an accountability report upon exiting the hazard zone to either 

Command or their assigned division or group supervisor. 
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It is every firefighter’s responsibility to stay connected with crew members. The officer has the 

ultimate responsibility for crew integrity by ensuring no members are separated or lost. The officer

should maintain constant contact with their assigned members by sight, touch, voice, or radio contact 

when operating in the hazard zone, and ensure members stay together as a company or crew. If any of 

these elements are not adhered to, crew integrity is lost, and firefighters are placed at great risk. 

Accepted crew communication practice has always been to be within sight, sound, or touch to maintain 

crew integrity. Background noise from other crews moving throughout the structure, saws operating on 

the roof, water flowing from hoselines, and apparatus noise from outside the structure can make it 

extremely difficult for crews to effectively communicate. When company officers call out to crew 

members for their locations and receive a non-specific response such as “over here,” the officer has 

limited information and is unable to maintain crew integrity. A firefighter stating, they are “near a door 

or window” is a specific response that enables the officer and crew to form mental pictures and 

develop a virtual map while entering the structure. These mental pictures and virtual maps may be 

utilized in a rescue situation. 

If a member becomes disoriented, the member should move toward the officer’s voice to assist with 

their reorientation. Company communication methods should be determined by the company officer 

while establishing company operating procedures. Members should report to their officer, which 

ensures personnel accountability and firefighter safety [Fire and Rescue Departments of Northern 

Virginia 2013a]. A company officer can keep track of their personnel in zero visibility conditions by 

calling out to their crew members. This is also necessary when conducting a personnel accountability 

report (PAR). A best practice is to use the member’s last name because crew members may have the 

same first name. 

If a firefighter becomes separated and cannot re-connect with their crew immediately, the firefighter

should attempt to communicate via portable radio with the company officer. If reconnection is not 

accomplished after three radio attempts, or reconnection does not take place within one minute, a 

Mayday should be declared. If conditions are rapidly deteriorating, the Mayday should be declared 

immediately. In addition to declaring a Mayday, the firefighter should activate the radio's emergency 

alert button (if available), followed by manually turning on their PASS alarm [NIOSH 2022b]. 

Similarly, if the company officer or the firefighter's partner recognizes they have a separated member, 

they should immediately attempt to locate the member by radio or by voice. If contact is not 

established after three attempts or within one minute, a Mayday should be declared immediately [IAFC 

2012]. 

Crew integrity is also essential to fireground accountability. All firefighting operations should be 

conducted under the department’s accountability system. A personnel accountability system should 

have the capability of always identifying who is operating in the hazard zone, their assignment, and 

their location. Whatever accountability system a fire department uses, the system needs to be able to 

identify the location of assigned crews within a small geographic area of an incident scene. When a 

firefighter becomes lost or missing, the personnel accountability system needs to be able to identify 

that firefighter. Personnel accountability should be managed at the point of entry to maintain continual 

awareness of firefighters in the hazard zone. Tags or passports collected only at the command post 

can’t maintain awareness of whether firefighters are in or out of a building [IAFC 2012].
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At this incident crew integrity was not maintained. 

Recommendation #2: Fire departments should ensure incident commanders conduct a detailed 

scene size-up and risk assessment during initial fireground operations and throughout the incident, 

including Side Charlie. 

Discussion: The strategy and incident action plan (IAP) (tactics) of an incident are dictated by the sizeup, initial risk assessment, and situational report by the first arriving officer. One priority is to get fire 

department resources to Side Charlie as quickly as possible. However, unless an obvious life safety 

issue exists (e.g., visible victims requiring immediate assistance), interior firefighting operations 

should not commence until an observation or report from Side Charlie is received. If physical barriers 

make the 360-degree size-up impractical for the first arriving officer, the size-up of Side Bravo, Side 

Charlie, and Side Delta may be delegated to another engine company or other resource on the 1st

Alarm. Even if a 360-degree size-up is conducted, resources should be assigned to Side Charlie. 

Ideally, Side Charlie resources would include an engine with a hoseline, but any unit engine, truck, 

medic unit, or chief could be assigned. [Fire and Rescue Departments of Northern Virginia 2013b]. 

The 360-degree size-up is an ongoing task that should be assigned to the safety officer. 

At any incident, life safety is always the 1st priority, followed by incident stabilization (2nd priority) 

and then property conservation (3rd priority). The ability to ensure the safety of firefighters is a 

continuous process throughout the incident. A sound risk management plan ensures that the risks are 

evaluated and matched with the actions and conditions. Incident commanders should use the following 

risk management principles: 

• Activities that present a significant risk to the safety of firefighters shall be limited to situations

that have the potential to save endangered lives.

• Activities that are routinely employed to protect property shall be recognized as inherent risks

to the safety of firefighters, and the actions shall be taken to reduce or avoid these risks.

• No risk to the safety of firefighters shall be acceptable where there is no possibility to save

lives or property [Brunacini 2002].

A radio report of conditions, including those on Side Charlie, should be transmitted over the assigned 

tactical channel to the incident commander (IC) and the dispatch center. The transmission should 

include the following: 

• Smoke and fire conditions, with an emphasis on identifying the seat of the fire. The initial

radio report from the first arriving unit for a structural fire should include the signal for a

working fire, number of stories, type of occupancy, and location of fire. This lays the

foundation for additional reports and serves as notification to responding units as to the type of

SOP to implement

• If there are critical building description information available through the critical incident

dispatch system (CIDS) for the response address, then this information would aid in

implementing or adjusting SOPs. The CIDS could contain information that would necessitate

alternative actions to fulfill identified operational goals
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• Building features: e.g., number of stories (particularly if there is a difference between Side

Alpha and Side Charlie)

• Basement access and type

• Any other life or safety hazards [FDNY 2011].

Any change to operational priorities or responsibilities based on the above size-up shall be clearly 

communicated to Command, all responding units, and the dispatch center via the assigned tactical 

radio channel [TSFRS 2014]. Command is then obligated to re-broadcast and receive 

acknowledgement from all operating companies. 

The International Association of Fire Chiefs (IAFC) has developed a set of Rules of Engagement for 

Structural Firefighting that will improve risk assessment and safety for firefighters [IAFC 2012]. The 

Rules of Engagement serve as a best-practice model procedure for fire departments to adopt in their 

own SOPs. The Rules of Engagement are also an excellent training document. The Rules of 

Engagement integrate several nationally recognized safety-related programs and principles. They 

include risk-assessment principles from NFPA 1500 and 1561. The Rules of Engagement align with 

the concepts in the IAFF's Fire Ground Survival Program and lessons learned from numerous 

firefighter fatality investigations conducted by NIOSH’s Fire Fighter Fatality Investigation and 

Prevention Program [IAFF 2010; NIOSH 2022a]. The IAFC Rules of Engagement recognize that those 

at most risk are the firefighters and company officers operating in the hazard zone and integrate them 

into the risk-assessment and decision-making process. These rules allow firefighters to say no to 

unsafe conditions or practices and report such situations, without penalty, through a structured process. 

The Rules of Engagement has been formally adopted by an increasing number of fire departments and 

fire service organizations. They are considered to be the standard of practice for the fire service [IAFC 

2021]. 

Rules of Engagement for Fire Fighter Survival 

1. Size-up your tactical area of operation.

2. Determine the occupant survival profile.

3. DO NOT risk your life for lives or property that cannot be saved.

4. Extend LIMITED risk to protect SAVABLE property.

5. Extend VIGILANT and MEASURED risk to protect and rescue SAVABLE lives.

6. Go in together, stay together, and come out together.

7. Maintain continuous awareness of your air supply, situation, location, and fire conditions.

8. Constantly monitor fireground communications for critical radio reports.

9. Report unsafe practices or conditions that can harm you. Stop, evaluate and decide.

10. You are required to abandon your position and retreat before deteriorating conditions can harm

you.

11. Declare a Mayday as soon as you THINK you are in danger.

The Incident Commander’s Rules of Engagement for Fire Fighter Safety 

1. Rapidly conduct, or obtain, a 360-degree situational size-up of the incident.

2. Determine the occupant survival profile.

3. Conduct an initial risk assessment and implement a SAFE ACTION PLAN.

4. If you do not have the resources to safely support and protect firefighters, seriously consider a
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 defensive strategy.

5. DO NOT risk firefighter lives for lives or property that cannot be saved. Seriously consider a

defensive strategy.

6. Extend LIMITED risk to protect SAVABLE property.

7. Extend VIGILANT and MEASURED risk to protect and rescue SAVABLE lives.

8. Act upon reported unsafe practices and conditions that can harm firefighters. Stop, evaluate and

decide.

9. Maintain frequent two-way communications, and keep interior crews informed of changing

conditions.

10. Obtain frequent progress reports and revise the action plan.

11. Ensure accurate accountability of every firefighter’s location and status.

12. If after completing the primary search, little or no progress toward fire control has been achieved,

seriously consider a defensive strategy.

13. Always have a rapid intervention team in place at all working fires.

14. Always have firefighter rehab services in place at all working fire [IAFC 2012].

Many fire departments have adopted the acronym SLICE-RS by the International Society of Fire 

Service Instructors [ISFSI 2013]. This process has been specifically designed to help 1st arriving 

company officers apply recent research on modern fuels and fire dynamics to their early strategic and 

tactical decisions on the fireground: 

• Size-up all scenes

• Locate the fire

• Identify and control the flow path

• Cool the heated space from a safe location

• Extinguish the fire

• Rescue and Salvage (are actions of opportunity that must be considered not only at the

initiation of operations but throughout the incident) [NFPA 2014].

The acronym SLICE-RS is not designed to replace the well-known RECEO-VS method that was 

developed by Chief Lloyd Laymen and has been widely adopted by the fire service over the years. 

SLICE-RS is to be used by the first arriving company officer as well as RECEO-VS [NFPA 2014]. 

In his book Fire Fighting Tactics, Chief Lloyd Layman used S-RECEO-VS. The “S” is for size-up. 

The first arriving officer or fire department resource should size-up or provide an estimate of the 

situation upon arrival. Chief Layman promoted the importance of size-up just as SLICE-RS supports 

this process today [Layman 1953]. This information is important to the fire service when discussing 

fireground tactics (See Diagram 5). 

S-RECEO-VS is:

• Size-up or estimate of the situation

• Rescue

• Exposures

• Confinement

• Extinguishment
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• Overhaul 

• Ventilation

• Salvage [Layman 1953]. 

Based on a risk-benefit analysis, the first-arriving engine company officer should initiate development 

of the appropriate organizational structure to manage the incident. If there is a need to initiate interior 

offensive operations, they should be initiated as quickly as possible. 

While enroute to the fire, the first-arriving engine officer needs to begin to set up for water supply 

operations. With the appropriate area preplan, the officer can designate fill sites, dump sites, or relay 

positions that will allow in-coming units to take their pre-determined positions. This should be done 

before or in conjunction with committing crews to interior operations [Fire and Rescue Departments of 

Northern Virginia 2013a].

Procedures developed for fireground operations should be flexible enough to allow the change due to: 

• Life hazard (first priority)

• Problems with water supply and water application 

• Volume and extent of fire, requiring large caliber streams 

• Location of the fire, inaccessible for hoseline operations 

• Materials involved in the fire and explosion potential compounding the problem 

• Exposure problems where further fire spread would be a major concern 

• Stability of the structure, which would be dependent on the condition of the structural 

components of the building and the intensity and duration of the fire [Brunacini 2002; IFSFI 

2013].

The initial scene size-up, risk assessment, and IAP are essential for any structure fire, but this is 

especially true for large structures due to a variety of complexities. An incident of this magnitude 

Diagram 5. Lloyd Layman’s “Basic Division of Firefighting Tactics”
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necessitates a complete scene size-up and risk assessment as part of the decision-making process. In 

addition, the scene size-up for large occupancies require more time versus a 2,000 to 3,000 square foot 

residential structure. The limited size-up at this incident hampered the response. 

Recommendation #3: Fire departments should develop and implement a standard operating 

procedure/guideline (SOP/SOG) to identify below-grade fires and ensure that appropriate tactical 

operations are implemented. 

Discussion: Below-grade fires, particularly those in private dwellings, are one of the most dangerous 

and most difficult fire locations for firefighters to identify and fight. Recognizing a below-grade fire is 

essential to developing proper strategy and tactical objectives. These types of fires are low 

frequency/high risk events for several reasons. Below-grade fires may be difficult to initially detect; 

may be difficult to access; require additional staffing for hoseline placement, operation, and 

ventilation; and firefighters may be working over the fire [NIOSH 2018]. There is increased risk to 

firefighters is due to: 

• Limited entry and egress into a basement 

• Unusual and/or unanticipated void spaces

• Working above the fire 

• Weakened floor joists and flooring materials 

• Being caught in the fire’s exhaust portion of the flow path 

• Unknown and frequently excessive fire loading 

• Restricted ventilation options 

• Utility panels and meters plus connections

• Otherwise, separate areas connected by non-fire stopped utility penetrations

• Hanging wires and ductwork

• Furniture and appliances - often disorganized distribution of the contents. 

During below-grade fire operations, every firefighter should remember access and ventilation. Access 

includes how easily a firefighter can get water in and how they can make an attack via a window or 

door. Ventilation may not exist in a below-grade areas; however, wind can pressurize the structure and 

contribute to erratic fire behavior. For structures with no exterior access to basement or below-grade 

area, the main way for air and smoke to move through the home will be from the basement, up the 

stairs toward an open door or windows above grade. 

If the fire has not penetrated the structure, a bi-directional flow will occur at the doorway. The air 

supply to the fire is inefficient and limited, therefore the potential of flashover is reduced when no 

exterior ventilation access to the basement is present. 

Potential ventilation via windows or doors connected to the below-grade compartments enables rapid 

changes in fire growth. Uni-directional exhaust flows in the stairwell(s) may result in an increased 

burning rate of contents and any wood floor assembly, increasing the potential for floor collapse and 

reducing safe operating time on the floor above. Ventilation of below-grade space was a key factor in 

firefighter line of duty deaths including the Pang Fire (Seattle, WA); the Cherry Road Fire 
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(Washington, DC); the Squirrelsnest Lane Fire, Colerain, OH; the Berkley Way Fire, San Francisco, 

CA; and the Pater Road Fire, Hamilton, OH. [Madrzykowski and Weinschenk 2018]. 

Key factors in recognizing a below-grade fire include: 

• fire or smoke venting from a cellar window, smoke pushing from the chimney (especially 

during warmer weather)

• evenly distributed smoke with no visible fire on the 1st floor

• floorboards may not be hot. Look for smoke around the edges of the baseboard or HVAC duct 

penetrations

• smoke from eaves, attic windows or louvered attic vents especially in older homes with balloon 

frame construction [Kerber et al. 2012; Madrzykowski and Kent 2011].

Below-grade fires in dwellings with balloon construction will likely extend to the attic via hidden 

voids. Units operating above the basement need to stretch enough hoseline to reach the upper floors. 

Intermediate floors need to be checked for fire before a hoseline is committed to the top floor. Floor 

and wall voids in balloon frame construction are all interconnected and can spread fire throughout the 

building in unexpected ways. Flooring systems and floor coverings are good insulators and may not 

transfer a significant amount of heat from a basement fire. Laboratory experiments, field-testing, and 

modeling have shown that in post-flashover basement fires with platform construction and engineered 

lumber sub-floors, even after the floor supports start to lose the structural integrity:

• high heat conditions may not be generated on the floor above

• thermal imagers may not provide clear information on the level of hazard

• floor supports that hold up to a strike from a tool during sounding may not be able to carry the 

weight of a firefighter or firefighters [Kerber et al. 2012; Madrzykowski and Kent 2011].

SOPs/SOGs need to consider numerous factors that affect fire-fighting operations. This will ensure 

essential strategic-, tactical-, and task-level functions are performed by the IC, division/group 

supervisors, company officers, and firefighters. Additionally, this process compliments the defined 

knowledge, skills, abilities, competencies, and fireground experience to assist: 

• ICs to plan and implement an effective strategy and IAP

• division/group supervisors to formulate and follow tactics 

• company officers to successfully carry out assigned tasks

• firefighters to effectively perform their duties and functions [FDNY 2013].

A fire department’s SOP/SOG for below-grade fires needs to include the following topics:

• community risk assessment

• scene size-up

• building construction

• strategy and tactics

• use of a thermal imager

• ventilation considerations

• proper size and adequate hoselines.

Below-grade fires are one of the most challenging situations for firefighters. As with all fires, a risk 

assessment and an occupant survivability profile should be conducted to evaluate the risks for lives and
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property. Fire departments should conduct a post-incident analysis for significant incidents, especially 

below-grade fires. Fire departments should periodically update their community risk assessment 

program and SOPs/SOGs based on recommendations from post-incident analysis reports. 

If the size-up indicates there is a fire in the basement (e.g., floor to ceiling smoke and not lifting 

significantly once the basement walk-out door was opened) then the basement needs to be investigated 

and cleared before crews can safely operate above. Opening a door is ventilation and will increase the 

size of a ventilation-limited fire. Basement fires also need to be considered ventilation limited until 

proven otherwise so if the fire location is not known then ventilation should be limited until sufficient 

water can be applied to what is burning.

Recommendation #4: Fire departments should ensure that a deployment strategy for low 

frequency/high risk incidents is developed and implemented for large area residential structures 

with unique architectural features. 

Discussion: The challenges of conducting operations at single family dwellings that have large square 

footage ranging from 6,000 to 10,000 square feet, require an advanced understanding of building 

construction, engineering, and fire dynamics. They also necessitate an integration of adaptive fire 

management principles that require distinctively unique firefighting methodologies, practices, and 

tactical deployment. These occupancies are not your typical single-family dwellings and cannot be 

managed with conventional strategies, tactics, and standard deployment. From an incident management 

standpoint, these incidents require a more rigorous level of command resiliency, tactical patience, and 

disciple. 

Since no two fire departments are alike, there is no standard scale to measure and evaluate frequency 

and severity of risk. Some fire departments will have a greater or lesser degree of tolerance for risk 

than others. The intent of the risk management process is for a fire department to develop a standard 

level of safety. This standard level of safety defines the parameters of the acceptable degree of risk 

under which members perform their job functions. 

When assuming command of a large area residential fire, fire officers may resort to what they did at a 

similar incident, or what they’ve seen and heard most frequently. These individuals use memory recall 

to try and find a match in terms of training, experience, and competencies for developing effective 

strategy and tactics. If there is nothing to draw from, the individuals will resort to actions that they are 

familiar with or comfortable with relating the incident. The process is methodical and needs to start 

from the beginning of the incident with the arrival of the 1st Alarm companies. If steps are skipped or 

missed, it becomes very difficult to change the outcome as the incident progresses. There is very little 

room for deviation at large single-family dwellings on the tactical level and task level. The tactics for 

firefighting operations at a large area residential fire should occur based upon departmental procedures 

or guidelines. 

Frequency is how often something occurs, and severity (risk) is a measure of the consequences if an 

undesirable event occurs (See Figure 2). Each risk has its own set of factors that will dictate how the 
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fire department determines the severity of the consequences. Priority of the risk is in direct relation to 

inherent risks that have had a harmful effect on the fire department and its members [NFA 2009]. 

Fires at single family dwellings with large square footage and unique architectural features are low 

frequency/high risk events. A fire department should have a deployment strategy in place to effectively 

manage these types of incidents. The deployment strategy should address staffing, incident 

management, appropriate tactics, adequate water supply, and other resource/logistical management 

issues. 

A good indication of a low frequency/high risk incident is the description of the structure size as it 

relates to areas of the structure that can be covered by a 200-foot hoseline. This includes the maximum 

depths into the structure at which safe operations can take place (See Figure 3). Using this structure 

description method will provide a more consistent classification of structure size, basing it on a core 

operational task – hoseline deployment for interior firefighting operations. 

Figure 2. Risk versus Frequency.

 The frequency is inversely proportional to inherent risks potentially harmful to 

firefighters.

(Courtesy of Graham Research Consultants.) 
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At this incident, fireground operations became overwhelmed due to the size and complexity of the 

structure and the difficulty in locating the fire. Command was at a disadvantage due to the multiple 

tactical changes on Side Charlie. The contour of the structure created issues for officers trying to 

identify and describe their location to Command. Also, the lack of available water supply created 

issues that affected the incident. Agencies that utilize pre-connected hose lines should be aware of the 

limitations of the hose length when accessing large area residential structures. This was an issue when 

E51 had to move from Side Alpha to Side Charlie and then two different access points on Side Charlie. 

The hoseline length was too short to enter the structure at the basement level. 

Recommendation #5: Fire departments should ensure that incident commanders develop an 

incident action plan (IAP) that matches conditions encountered during initial operations and 

throughout the incident.

Discussion: Fireground operations are very dynamic and fast-paced. An IC needs to determine a 

strategy then develop an IAP to ensure implementation of actions are taken to control the incident. ICs

should follow the decision-making model that includes: 

• identifying incident critical factors (through a situational evaluation or “size-up”) 

• consider the standard risk management plan 

• declare the strategy (offensive or defensive) 

• set tactical objectives.

This model will lead to the development of the IAP, which serves as the tactical road map to 

effectively manage the incident. The IAP defines where and when resources will be assigned 

throughout the incident, along with tasks and objectives [NFPA 2014].

To ensure a standard outcome of each incident, ICs should match the standard conditions to standard 

actions. This is the core of the ICS and the basis for all operations. Standard actions would include 

identifying the incident’s critical factors before taking any action, and regular updating of the 

Figure 3. This figure shows the coverage of a 200-foot hoseline based 

upon the size of the structure. 

(Diagram courtesy of the Fire and Rescue Department.)
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incident’s critical factors and size-up to determine if the strategy and/or IAP needs to be modified. 

These actions require current, accurate, and relevant information. The overall goal of this systematic 

evaluation process continually produces standard, safe, well-managed incident outcomes [Blue Card

2018]. 

The defined strategy established by ICs describe the overall approach to incident operations and drives 

the IAP. The IAP provides the tactical assignments required to achieve the offensive/defensive 

objective. The order of occurrence is key—the strategic goals are developed first and followed by the 

development of tactical objectives that can be assigned to responding companies. At each incident, ICs 

should start with a standard placement-oriented operational plan that develops a strong, dependable 

beginning for command and control of the incident. [Brunacini 2002; Fire and Rescue Departments of 

Northern Virginia 2013a].

The initial IC, most often, is a company officer who arrives on-scene prior to a command officer. The 

company officer should conduct a detailed size-up and communicate the size-up to all responding 

resources, including the dispatch center. The company officer then assumes command and defines the 

strategy and IAP. The company officer may not have the ability or time to record the IAP on paper and 

provide documentation when transferring command. In this case, a verbal IAP is appropriate. As with 

this or any incident, events can occur very quickly before a detailed tactical worksheet or written IAP 

is developed [Brunacini 2002; Harms, 2010].

The initial IAP can be as simple as a verbal transmission to all units assigned to an incident. Once an 

officer assumes command, the overall strategy – either offensive or defensive is communicated. 

Command can make specific assignments to arriving companies along with tactical objectives such as 

search, rescue, fire attack, ventilation, utility control, and exposure protection. The responding 

command officer should be monitoring radio communications and documenting tactical objectives on a 

tactical worksheet, if possible. When the chief officer arrives on-scene, an update from the initial IC

can occur (face-to-face or by radio). The command officer will then assume command at a stationary 

location. By following this process, the initial and subsequent incident commanders will be in a 

stronger position to manage an incident should an emergency event occur [NFPA 2014].

NFPA 1561 defines an IAP as a verbal plan, tactical worksheet, written plan, or combinations thereof

developed by an IC that reflects the overall incident strategy, tactics, risk management, with member 

safety at the forefront. NFPA 1561, Standard on Emergency Services Incident Management System 

and Command Safety [NFPA 2014] requires the following:

• 5.3.12.1 The incident commander shall be responsible for developing and/or approving an IAP

• 5.3.12.2 This IAP shall be communicated to all staged and assigned members at an incident

• 5.3.20 The incident commander shall be responsible for reviewing, evaluating, and revising the 

IAP and overall strategy of the incident (See Diagram 6).

Offensive Incident Action Planning 

When an incident’s critical factors and the risk management plan indicate an offensive strategy, 

Command will define the tactical objectives which typically require entering the structure (hazard 
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zone) to control the incident hazards. An offensive IAP is based on the standard offensive tactical 

priorities.

Offensive strategy tactical priorities and their corresponding completion benchmarks are: 

• Water on the fire

• Life Safety: Primary and Secondary “All Clear” 

• Fire Control: “Under Control”

• Property Conservation: “Loss Stopped” 

• Customer Stabilization: Short term. 

The offensive tactical priorities establish the major operational activities required for a complete, 

integrated effort, and they identify the three major functions needed to establish the overall incident 

response [Blue Card 2018].

Diagram 6. A guide for developing an incident action plan at Type V and Type IV 

incidents. For these types of incidents, the incident action plan is most often 

communicated verbally. 

(Courtesy of FireFighterCloseCalls.com.)
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Defensive Incident Action Planning 

A defensive situation occurs when the incident has evolved to the point that lives and property are no 

longer savable and offensive tactics are no longer effective or safe. The defensive strategy is based on 

protecting firefighters and property (exposures). 

Firefighter safety is the number 1 defensive priority. 

Defensive strategy tactical priorities and their corresponding completion benchmarks: 

• Define the hazard zone and keep firefighters out of the potential collapse zone(s)

• Establish cut-offs—Forward progress stopped

• Search exposures—Primary and Secondary “All Clear” 

• Protect exposures— “Fire Control”—Loss Stopped.

Defensive operations represent a standard organizational response to situations that cannot be 

controlled with offensive tactics. When conditions go beyond the safety systems required for interior 

operations, Command needs to conduct defensive operations from outside the hazard area. Command 

needs to write off lost property and decide where the cut-off will take place. If defensive operations are

conducted from the onset of the incident, a primary search will not be completed for the involved 

structure(s). During defensive operations, Command will coordinate the rotation of crews for rest and 

rehydration.

A basic defensive IAP includes the following tasks:

• Complete scene size-up

• Identify critical fireground factors 

• Determine the need for additional resources 

• Evaluate fire spread/write-off lost property

• Determine collapse zones and ensures no entry

• Search exposures

• Protect exposures 

• Prioritize master streams; provide big, well-placed streams 

• Surround and drown [Blue Card 2018]. 

As an incident progresses, Command needs to continually review and update the IAP. This should 

occur when benchmarks are met, conditions change, or benchmarks have not been achieved. The 

following list serves as a guide for Command to consider:

• Firefighter safety

• Consider changing operational modes – go defensive

• Matching the current strategy with the current conditions

• Location of fire attack 

• Effect of the fire attack

• All affected areas searched (“All clear”)

• Timing and support

• Adequate back-up

• Adequate staffing and resources

• Develop “Plan B”
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• Corrective actions to the current conditions (Fire Control, All Clear, Loss Stopped) [Blue Card

2018].

The IC in this incident established an IAP as based on the situation initially encountered. The 

configuration of the structure created issues for officers trying to describe to the various sides of the 

structure to Command. Additionally, the incident escalated, and Command became involved with other 

tasks. Departments need to consider requesting additional chief officers on each alarm from automatic 

aid or mutual aid departments to ensure for command safety. 

Recommendation #6: Fire departments should ensure that critical incident benchmarks and fire 

conditions are communicated to incident commanders throughout the incident. This is 

accomplished with effective fireground communications. 

Discussion: Fireground benchmarks are essential for a successful and safe outcome. To ensure that the 

proper benchmarks are communicated at fireground incidents, fire departments should develop and 

maintain an SOP/SOG that specifies a consistent process for communicating critical benchmarks. This 

would include effective hands-on classroom and practical training programs with annual live fire 

training, a defined department deployment model, an effective incident management system, adequate 

radio equipment (mobile and portable radios), and adequate radio channels (dispatch, tactical, and 

command) [NIOSH 2013a, NIOSH 2013b, NIOSH 2014].

Effective incident communications provide the connection between the strategic, tactical, and task 

levels of management. This connection allows the team to commit resources and coordinate actions. 

To be effective, ICs need to coordinate the ongoing communication between and within the three 

operational levels (i.e., strategic, tactical, task) despite each level having its own special set of needs, 

capabilities, and challenges. These differences create logistical challenges for the entire team. They 

require a strong, well-practiced, procedures-based communications plan and positive function-based 

relationships among the participants [Blue Card 2018]. 

Radio communications allow the tactical and task levels to connect with the IC working on the 

strategic level. While radio communication does not put water on the fire, the overall outcome of the 

incident can be traced back to the quality of the radio communications among the participants [Blue 

Card 2018]. Since the IC is located at the command post (outside the hazard zone), interior conditions 

need to be communicated by interior crews as soon as possible to the IC. This allows the IC to modify 

their strategy, if needed. Subsequent updates, as well as when benchmarks are completed (e.g., 

“primary search complete is all clear” and “the fire has been knocked down”), are especially important 

to the IC. 

A fire department’s communications SOP/SOG should include communications necessary to gather 

and analyze information to plan, issue orders, and manage operations. For example: 

• additional resources required 

• status of searches

• is there water on the fire

• assignment completed
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• unable to complete an assignment or task 

• special information

• ensure all companies and resources are operating on the designated radio channel 

• emergency traffic or Mayday FIRESCOPE [2017]. 

Critical incident factors and their possible consequences offer the basis for a standard incident 

management approach. A standard information approach is the launching pad for effective incident 

decision making and successful operational performance. ICs should use the critical factors, in their 

order of importance, to make tactical assignments for the IAP. The IC should develop a standard 

information system and use effective techniques to keep informed at the incident. ICs should not 

assume the action-oriented responder engaged in operational activities will stop what they are doing to 

notify the IC with a continuous supply of top-grade, objective information. It is the IC’s responsibility 

to do whatever is required to stay effectively informed [NIOSH 2010].

Radio discipline is essential for all members operating at an incident scene. Members should be trained 

on and use the thought process of "is my transmission necessary." Radio transmissions should be 

reserved for relevant messages such as benchmarks, personnel accountability reports, safety issues or 

concerns, needed resources, changing conditions, and emergency traffic and Mayday. Non-relevant 

transmissions can distract the IC and add little, if anything, to the IAP. 

The following are considerations of critical incident benchmarks that should be completed during 

fireground operations: 

• First-due company officer should assume Command

• A complete size-up and risk assessment should be completed by the first-due company officer 

• The first due companies should advise Command if they did not lay a supply line 

• Once operations were initiated on Side Charlie, the company officer should provide a 

description of company locations and entry locations 

• When companies change locations, the division supervisor should provide a complete 

description of the tactical operations including a description of the basement and its dimensions 

• When Command assigns a division supervisor, this should be communicated to the companies 

assigned to this division to ensure personnel accountability within the division 

• Once the 1st Alarm companies are on-scene, a company or companies should be assigned as the 

Rapid Intervention Crew (RIC). 

• Companies or units assigned to RIC should operate, or be located, together 

• Once officers communicate critical information about smoke or fire in a structure, Command 

should revise the IAP and communicate any tactical changes 

• Company officers should conduct radio checks to ensure all company members are on the 

correct radio channel. Radios should not be on the “scan” function

• The fire agency should evaluate and simplify the selection of radio frequencies to reduce the 

possibility of mistakes upon dispatch. 

• Command should be advised when a company assigned water supply and is having trouble 

establishing the water supply. 
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Fire departments should consider an incident management system training and a certification program 

for company officers and chief officers. The program would benefit officers who serve in the role of IC 

plus supervise and manage emergency and hazard zone operations for every day, local National 

Incident Management System, Type V and Type IV incidents [NFPA 2014]. 

Recommendation 7: Fire departments should have a procedure to ensure all members operating in 

the hazard zone have their radios on the designated radio channel. 

Discussion: Effective incident communications provide the connection among the three management 

levels of the organization: strategic, tactical and task levels. Incident communications are the 

information “carrier” that the team uses to connect, commit resources, and create effective, coordinated 

action. Radio communications are the way that the tactical and task levels connect with the IC working 

on the strategic level. In most cases, the overall outcome of the incident is directly connected to the 

quality of the radio communications among the participants [Blue Card 2018]. 

Many hazard zone distractions can cause communications problems. ICs need to understand this when 

communicating with operating companies. Companies also need to understand that their portable 

radios provide the only communications link to the outside world. The command system depends upon 

coherent communications between the IC and the operating units. 

Radio channels should be assigned at the time of dispatch. Changing radio channels in the middle of an 

operation can jeopardize communications [Abbott 2016]. Therefore, radio channels should not be 

changed unless necessary. All hazard zone operations and Mayday operations should remain on the 

same tactical channel when a Mayday has been declared. Connecting all hazard zone companies to the 

Mayday operation helps the IC and division/group supervisors to assist the firefighter who is 

experiencing a Mayday.

Once a tactical radio channel is assigned, the company officer has the responsibility to ensure that all 

members are on the correct tactical channel, including the proper talk group. This is especially 

important before the company enters the hazard zone. In addition, firefighters and fire officers 

operating in the hazard zone should avoid using radios in the scan mode. The problem is that if the 

dispatch channel is scanned every time a dispatcher transmits or receives a message, it interferes with 

the fireground operation, which interrupts radio communications. Critical messages may be missed, 

lost, or delayed. 

Recommendation 8: Fire departments should ensure all members and dispatchers are trained on the 

safety features of their portable radio, particularly the features useful during a Mayday. 

Discussion: Like turnout gear and SCBA, the portable radio assists firefighters operating in the hazard 

zone. Therefore, each firefighter should be equipped with a portable radio and trained on its use and 

safety features. This training process should extend to the fire department’s dispatchers because the 

dispatchers are a critical component of the response and responsible for designating a channel for 

emergency alert button (EAB) transmission [NFPA 2021; NIOSH 2022b]. 
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The design of portable radios changed significantly when NFPA issued 1802, Standard on Two-Way, 

Portable RF Voice Communications Devices for Use by Emergency Services Personnel in the Hazard 

Zone [NFPA 2021]. This standard resulted from the findings and recommendations of a NIOSH line of 

duty death investigation [NIOSH 2012], the safety investigation report from the affected fire 

department, the IAFF, and the IAFC [NFPA 2021]. 

The safety features on portable radios include: 

• emergency alert button (EAB), which is commonly referred to as the “orange” button on top of 

a portable radio or remote speaker microphone 

• the man-down notifier (MDN) 

• the dispatcher’s ability to “alert” a portable radio

In addition, several portable radio manufacturers are developing the ability for a dispatcher or on-scene 

ICs to remotely activate a firefighter’s EAB. 

Emergency Activation Button (EAB) [NIOSH 2022b, NFPA 2021] 

The EAB is preprogrammed to send an emergency transmission on a pre-designated channel or 

talkgroup. A talkgroup is defined as a group of radios addressed as a single entity by the system 

and the functional equivalent to a conventional repeater channel. When operating on a simplex 

channel or in the direct mode, the radio can revert to a channel/talkgroup monitored by the IC

or a dispatch center. The communication system administrator must program the transmission 

channel/talkgroup for the EAB. 

The EAB is activated by pressing it for at least 1 second, but not more than 3 seconds. When 

the EAB is activated, the portable radio identifies the user’s department identification or riding 

position (e.g., Engine 19 Officer). This signal overrides any other communication over the 

selected radio channel for 10 to 30 seconds depending on the programming. Once activated, the 

portable radio operating on a trunked system is given priority access to the talkgroup until the 

EAB is reset. While in the EAB mode, transmissions will be at the device’s highest radio 

frequency (power), and an audible beacon will sound at full volume until the EAB is reset 

[NIOSH 2022b, NFPA 2021]. 

Man-down Notifier (MDN)

The MDN is an alternate way to activate the EAB. The MDN can be activated in two ways: 1) 

a certain radio tilt angle, or 2) a combination of the radio tilt angle and the lack of radio motion. 

The MDN function alerts the firefighter that the EAB is about to activate which, if appropriate, 

allows the firefighter to dismiss the transmission [Motorola 2014; NIOSH 2022b; NFPA 2021]. 

Dispatcher Alert

The third safety feature is the dispatcher’s ability to “alert” a firefighter’s portable radio. This is 

a valuable function when trying to locate a lost, missing, or down firefighter. The “alert” will 

continue to sound until reset but is only as loud as the volume is set on the portable radio. 

For these three safety features to operate properly, the firefighter must take several key actions 

before entering the hazard zone. The portable radio must be on the channel that has been

assigned to the incident and is being monitored by the dispatcher or IC. If the portable radio is 
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on a different channel, dispatch or the IC may not be alerted or notified of the Mayday. Also, 

the scan function on the portable radio needs to be turned off when operating in the hazard 

zone.

At this incident the EAB and the man-down notifier were not activated, and the fallen 

firefighter was on an unmonitored radio channel. The portable radio safety features should be 

detailed in a fire department’s SOP/SOG on fireground communications and Mayday protocols. 

In addition, all firefighters and dispatchers should be properly trained and demonstrate 

competency with portable radio safety features on an annual basis. 

Recommendation #9: Fire departments should develop a process to prevent task saturation of 

incident commanders during multi-alarm incidents.

Discussion: Since the inception of the ICS, the duties and responsibilities of ICs have significantly 

increased. As an incident escalates, it is difficult for one individual to effectively manage a complex 

emergency operation. The IC needs to address issues dealing with situation evaluation, deployment 

management, strategy, the IAP, communications, personnel accountability, firefighter and responder 

safety, the tactical worksheet, RIC, and other essential job tasks. To ask one person to command and 

control a complex incident is unfair to this individual, the firefighters, and the citizens we protect

[Brunacini AV, and Brunacini N 2004]. Front loading the incident with support for the IC is essential, 

especially during the first hour of the incident, which is most often when firefighters are seriously 

injured or killed [Brunacini AV, and Brunacini N 2004]. 

Many fire departments have a process in place to support the initial IC. This is especially important 

when the command officer does not have a staff aide, incident command technician, or chief’s aide. 

This process can include dispatching an additional battalion chief on the working alarm assignment. If 

this battalion chief is going to be assigned to supervise a division or group, then another battalion chief 

should be dispatched. 

The essential element is to ensure that ICs have the necessary support to command and control an 

incident. When an incident starts to escalate, a process is needed to immediately provide resources to 

develop a strong command structure and presence during the first hour of an incident. Additionally, 

this process helps ensure a smooth transition from a small incident to a large incident. An additional 

battalion chief can function as the planning section chief to allow the IC to focus on operational issues. 

Recommendation #10: Fire departments should ensure that the member assigned to the resource 

status and situation status function is not given other duties during an incident. 

Discussion: A personnel accountability system readily identifies both the location and function of all 

members operating at an incident scene [NFPA 2014]. The philosophy of the personnel accountability 

system starts with the same principles of an incident management system—company unity and unity of 

command. Unity can be fulfilled initially and maintained throughout the incident by documenting the 

situation status and resource status on a tactical worksheet. 
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An integral part of the accountability system is to ensure that the firefighters who are assigned and 

operating in the hazard zone are accounted for during initial operations and continues through the 

entire incident. Also, a process should be in place to periodically check that all members operating in 

the hazard zone are accounted for by this system.

One of the most important functions of command safety is for the IC to initiate a personnel 

accountability system that includes the functional and geographical assignments at the beginning of 

operations and continues until the termination of the incident. NFPA 1561, 8.12.4, states “The incident 

commander and members who are assigned a supervisory responsibility that involves three or more 

companies or crews under their command shall have an additional member(s) (e.g., staff aide) assigned 

to facilitate the tracking and accountability of the assigned companies or crews” [NFPA 2014].

A functional personnel accountability system requires the following: 

• Development and implementation of a departmental SOP/SOG 

• Necessary components and hardware, such as an accountability board, individual name tags, 

and company name tags

• Training for all members on the operation of the system

• Strict enforcement during emergency incidents.

A functional personnel accountability system should be able to identify:

• All members operating in the hazard zone (who)

• Where all members are in the hazard zone (where)

• The conditions in the hazard zone (conditions)

• What actions are being taken in the hazard zone (actions)

• Paths of access and egress in and out of the hazard zone (exits)

• Rapid intervention crew(s) (RIC) and assign them.

There are many different methods and tools for resource accountability. Some examples are: 

• Tactical worksheets

• Command boards 

• Apparatus riding lists 

• Company responding boards 

• Electronic bar-coding systems 

• Accountability tags or keys (e.g., PASSPORT System) [NFPA 2014].

Resource accountability should be assigned to personnel who are responsible for maintaining the 

location and status of all assigned resources at an incident. As an incident escalates, resource status 

would be placed under the Planning Section. This function is separate from the role of the IC. The IC

is responsible for the overall command and control of the incident. Due to the importance of responder 

safety, resource status should be assigned to a dedicated member as the size and complexity of the 

incident dictates. Several positions could function in this role including a staff aide, incident command 

technician, staff assistant, chief officer, or other designated member. As the incident escalates and 

tactical-level management components (e.g., divisions or groups) are assigned, the resource status 

officer (accountability officer) works with the division or group supervisors to maintain an on-going 
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tracking and accountability of members [FIRESCOPE 2017]. A properly initiated and enforced 

personnel accountability system enhances firefighter safety and survival. It is vital that resources can 

be identified and located in a timely manner. 

An important aspect of a personnel accountability system is the personnel accountability report (PAR). 

A PAR is an on scene roll call in which each supervisor reports the status of their crew when requested 

by the IC [NFPA 2014]. The PAR should be conducted every 15–20 minutes or when benchmarks are 

met. 

The personnel accountability system should include an SOP/SOG that defines each function’s 

responsibility and the necessary hardware to ensure its success on the fireground. Classroom and 

practical training should be conducted to ensure its proper function during emergency incidents. 

Recommendation #11: Fire departments should develop a formal training program that defines the 

job duties and functions for staff aides, incident command technicians, or staff assistants.

Discussion: The staff aide (e.g., chief’s aide, emergency incident technician, incident command 

technician, field incident technician, or staff assistant) is an essential component of the incident 

management system [Brunacini 2002]. Functions of the staff aide can include any of the following: 

maintaining the tactical worksheet; maintaining personnel accountability of all members operating at 

the incident (resource status and situation status); monitoring radio communications on the dispatch, 

command, and fireground channels; controlling information flow by computer, fax, or telephone; and 

accessing reference material and pre-incident plans [Brunacini AV and Brunacini 2004; LAFD 2011; 

NFPA 2014]. NFPA 1561, 8.6, states, “the incident commander and members who are assigned a 

supervisory responsibility that involves three or more companies or crews under their command shall 

have an additional person (staff aide) assigned to facilitate the tracking and accountability of the 

assigned companies or crews” [NFPA 2014]. 

Some fire departments use firefighters as staff aides and other fire departments use fire officers to 

serve as a staff aide for ICs. Regardless of the rank of the staff aide, the assigned personnel should be 

trained in the duties and responsibilities to proficiently function and meet the expectations of ICs. The 

staff aide, in support of the IC, has three primary responsibilities: 

• resource status

• situation status 

• command post communications [Fire and Rescue Departments of Northern Virginia 2013a]. 

Tasks that may be required to fulfill these functions include: 

• Determine and track status of resources 

• Track units and members 

• Anticipate the need for additional resources based upon assignments being made 

• Manage command channel communications 

• Provide progress reports 

• Monitor secondary tactical channels if utilized in the operation 

• Anticipate and recommend logistical needs to support the operation 
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• Brief incoming chief officers as necessary. 

In some cases, the staff aide will be in a separate vehicle than the chief. When the staff aide arrives 

prior to the chief, the staff aide should report to Command and assists the IC with the three primary 

responsibilities described above [Fire and Rescue Departments of Northern Virginia 2013a]. 

After conferring with the IC, the staff aide’s primary effort should be to set up the command post, 

while the IC maintains focus on the command and control of the incident. The IC will determine 

whether to operate from the front of the vehicle or to move to the rear. 

Once the command post is set up and ready to support communications, resource and situation 

tracking, both the IC and the staff aide may operate from the rear of the vehicle using the command 

board(s) and radio headsets for incident management. A single staff aide may not be able to solely 

manage all three of the primary responsibilities. It is the responsibility of ICs to ensure these three 

responsibilities are completed and assign additional aides as necessary.

The staff aide should set up and manage the personnel accountability system. Proper collection and 

movement of accountability tags and/or passports is a major responsibility of the staff aide. The staff 

aide is responsible for tracking members and units who are operating in the hazard zone as well as 

those in staging. This includes accounting for companies: 

• assigned individually as a single resource 

• assigned to groups, divisions, or branches 

• assigned to staging and at base 

• still be enroute. 

It is a function of the staff aide to advise Command as companies become engaged, as resources are 

depleted, and of the remaining resources in staging. 

The primary activity for situation status is tracking critical tasks that need to be assigned, are 

underway, or already completed. The staff aide should be very familiar with the various command 

boards used in managing an incident. 

The staff aide documents the activities taking place at the incident. This documentation should include 

sketching the building outline or footprint and showing the location of apparatus. 

Progress reports are also a part of situation status and provide a verbal update of the progress of the 

actions underway. They also provide a mental picture for other units and officers who are on-scene or 

in staging. These reports are recorded and allow for recovery of the information for evaluation 

purposes after the incident. 

The staff aide requests, sets up, and communicates on the Command channel. The role of the staff aide

is to support Command, not to run the incident or make strategic or tactical decisions. The staff aide is 

the voice of Command and transmits additional alarms, directions to companies, and progress reports. 

The staff aide should be proficient in the use of the radio system, cell phones, the ICS, and the 

personnel accountability system [Fire and Rescue Departments of Northern Virginia 2013a]. 
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At times, additional assistance at the command post may be required. The staff aide should point out 

the need for such assistance to Command. This assistance may be in the form of a fire company, EMS 

unit, or staff officers. The command post support staff, under the direction of the IC, will be primarily 

concerned with managing additional communications functions, maintaining accountability of 

operational units, and documenting situation status and information [Fire and Rescue Departments of 

Northern Virginia 2013a]. 

Special command units are available from some departments. These units, such as a Field Command or 

Field Communications Unit, also should be considered to support command operations at multiple 

alarm or long-term incidents. 

As the incident expands, an officer could be assigned as a division supervisor or group supervisor. The 

assigned officer will proceed to the division or group, evaluate conditions, and report these conditions 

to the IC. If directed by Command, the assigned officer will assume responsibility for directing 

resources and operations within their assigned area of responsibility. Division/group supervisors 

assigned to operate within the hazard zone needs to be with a second individual, which would be the 

staff aide. The staff aide can assist the division/group supervisor by maintaining accountability of the 

resources assigned to that particular division/group. The division/group supervisor and the staff aide 

should be equipped with the appropriate protective clothing and equipment for their area of 

responsibility [LAFD 2011]. 

During NIOSH interviews with the battalion aides and battalion chiefs involved in this incident, the 

Fire and Rescue department did not seem to have a formal process to train battalion aides on their job 

duties and responsibilities. 

Recommendation #12: Fire departments should ensure incident commanders maintain control of 

the situation status, resource status, and communications to ensure the completion of tactical 

objectives. 

Discussion: Fireground SOPs/SOGs define the strategic goals and tactical objectives for the 

coordinated deployment of departmental resources for specific incidents and occupancies. SOPs/SOGs

are based on factors including department staffing; deployment capabilities; training competencies; 

apparatus, tools, and equipment; community risk assessment and building information, including 

height, area, construction class, and type of occupancy; and potential life hazards. 

The IC develops and communicates a strategy and tactical objectives based on the scene size-up and 

risk assessment. This is a process that must be made in a short period of time during a dynamic 

situation. Most importantly, the strategy and tactics should include an observation and/or report from 

all sides of the structure, especially Side Charlie [Fire and Rescue Departments of Northern Virginia 

2013a]. This will ensure command can develop essential strategic, tactical, and task level functions are 

performed by division/group supervisors, company officers, and firefighters. 
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Strategic Level. This organizational level is designed around the IC and incident advisory team 

operating in the command mode. The strategic level identifies activities required for overall 

operational control. Strategic-level responsibilities include the following: 

• determining the appropriate strategy: offensive or defensive

• establishing a strategic plan for the incident

• setting priorities 

• obtaining and allocating resources

• predicting outcomes and planning

• assigning and communicating specific objectives to tactical-level units.

Tactical Level. The first management “subdivision” of incident scene organization is accomplished by 

assigning division/group responsibilities. Officers at this level are responsible for the tactical 

deployment of assigned resources, evaluation, and communication with the IC. The IC delegates 

responsibilities to them while “supervising” their work directly or by radio transmission. 

When Command appoints division supervisors, one of the most critical functions of Command is to 

ensure the division supervisor is accountable for all resources assigned under their span of control and 

for coordination with Command, the operations section chief, or other supervisory personnel at the 

same level. The division supervisor has the following responsibilities: 

• Implement and manage the division IAP, which matches IC’s IAP

• Implement a risk management plan in the division

• Complete tactical priorities in the division

• Ensure positions always match conditions in the division

• Coordinate with other division supervisors as needed

• Manage the passport accountability system within the division

• Assist with division air management

• Manage work-rest cycles within the division [Blue Card 2018].

Task Level. The task level of the organization is where the work is performed by assigned companies 

and other resources. The strategic and tactical levels are in place to support the task level. Company 

officers routinely supervise task-level activities [NFPA 2014]. This process compliments the defined 

knowledge, skills, abilities, competencies, and fireground experience by assisting: 

• The IC in planning and implementing an effective strategy and IAP

• Division/group supervisors in formulating and following tactics and maintaining accountability 

of assigned resources

• Company officers in successfully carrying out assigned tasks

• Individual members in effectively performing their duties [FDNY 2011; FIRESCOPE 2017]. 

The first arriving resource will communicate the initial on-scene report upon arrival, life safety issues,

initial risk assessment, identification of water supply, deployment of hoselines and back-up hoselines, 

search and rescue, ventilation, identification of initial RIC(s), ground and aerial ladder placement, fire 

attack and extinguishment, and salvage and overhaul. Task level changes to operational priorities or 

responsibilities based on the above size-up should be communicated from the company officer to 

Command, all responding units, and the dispatch center via the assigned tactical radio channel [FDNY 
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2011; TSFRS 2014]. Command is then obligated to re-broadcast and receive acknowledgement from 

all operating companies. 

The procedures developed for fireground operations should be flexible enough to allow for change if 

any of the following issues are present: 

• Life hazard (must be given first priority)

• Problems with water supply and water application

• Volume and extent of fire require large caliber streams

• Location of the fire is inaccessible for hand-line operations

• Materials involved in the fire and explosion that can potentially compound the problem

• Exposure problems where further fire spread would be a major concern 

• Instability of the structure, dependent on the condition of the structural components of the 

building, the intensity, and the duration of the fire [Brunacini 2002; ISFSI 2013]. 

The incident command system (ICS) provides for the systematic development of a complete, incident 

specific, functional command organization to increase the effectiveness of command and firefighter

safety. Functional units handle the most important incident activities. As the incident grows in size 

and/or complexity, functional unit management is assigned to additional individuals to maintain a 

reasonable span of control and efficiency. The system expands and contracts organizationally based 

upon the needs of the incident. Span-of-control recommendations should be followed closely so that 

the organizational structure is not larger than required. In addition, ICs should operate from a vehicle 

away from the hazard zone to effectively manage and control the incident. 

Recommendation #13: Fire departments should incorporate the principles of Command Safety into 

the incident management system during the initial assumption of command. This ensures that the 

strategic-level safety responsibilities are being incorporated into the command functions throughout 

the incident.

Discussion: The purpose of command safety is to provide ICs with the necessary resources to use, 

follow, and incorporate safety into the incident management system. Command safety is used as part 

of the eight functions of command developed by Fire Chief Alan V. Brunacini. The principles of 

command safety describe how ICs should use the regular, everyday command functions to complete 

the strategic-level safety responsibilities during incident operations. Using the command functions 

creates an effective way to ensure a close connection between incident safety and incident command. 

The eight functions of command are: 

• Deployment 

• Assume, confirm, and the positioning of command 

• Situation evaluation

• Strategy/incident action planning 

• Communications 

• Organization

• Review, evaluate, revise 

• Continue, support, and terminate command [Brunacini 2002; NFPA 2014]. 
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A vital command function involves the IC using the initial scene size-up, knowledge of critical factors 

(building type, occupancy, life safety, fire conditions, and available resources), the standard risk 

management plan, the forecast of incident conditions, and a standardized decision-making process to 

select either an offensive or defensive strategy. The choice of strategy (offensive or defensive) is 

independent of location (inside or outside) as it relates to the hazard area or hazard zone. The strategy 

may change over the course of an incident, but only one of the two strategies can be used at one time

[Blue Card 2018]. 

An offensive strategy means that personnel are actively and directly attempting to knock down and 

extinguish a fire. A defensive strategy occurs when the IC decides the best course of action is to 

contain the problem. Examples include firefighters building containment around a leak or spill or only 

putting water on the fire building and threatened exposures outside the hazard zone. Any change of 

strategy needs to be the result of deliberate defendable thought and be communicated. 

The two separate strategies create a clear, understandable plan that describes in basic terms how close 

the emergency responders will handle an incident’s hazards. The IC’s overall strategic decision is 

based on the incident’s critical factors weighed against the risk management plan (See Diagram 7). 

Diagram 7. This model conforms the decision-making process into a standard 

sequence. The incident commander identifies the incident’s significant critical factors 

and develops a risk management plan. The incident commander then bases the 

strategy and incident action plan on the evaluation of those factors. This leads to the 

tactical priorities for the incident. 

(Diagram courtesy of Blue Card.)
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Declaring the incident strategy up front, as part of the initial radio report will:

• Announce to everybody the overall incident strategy

• Eliminate any question on where firefighters will be operating on the incident scene inside the 

structure [Blue Card 2018]. 

Offensive and defensive strategies should not be combined. 

Once the overall incident strategy has been determined and the IAP developed, the IC should manage 

the completion of the tactical priorities for the chosen strategy. Each strategy has a different set of 

tactical priorities to complete. Tactical priorities provide the IC with a simple, short list of major 

categories that are designed to act as a practical guideline during the difficult initial stages of 

fireground planning. The IAP should be short and simple. A complicated IAP tends to break down 

during this critical time. 

Generally, the IC tries to achieve the same basic objectives from one incident to the next. Tactical 

priorities offer a regular set of tools to develop a standard approach to solve incident problems. With 

this standard approach, ICs can manage the basic work sequence at every incident in the same manner.

Recommendation 14: Fire departments should review and/or develop SOG/SOP to ensure that water 

supply is established during initial fireground operations, particularly in areas with limited or no 

hydrants. 

Discussion: The establishment of a water supply at a fireground is a critical operations benchmark. In 

areas with limited or no hydrants, a comprehensive preplanning process is needed. This process may 

include information on map book pages, case notes, or comments on the dispatch to a defined address. 

For non-hydrant areas, this preplan information should be assembled in a water supply preplan book 

and sent (electronically or by hard copy) to applicable engine and tanker/tender companies. In addition, 

this information should be shared with automatic aid and mutual companies [Fire and Rescue 

Departments of Northern Virginia 2019].

While enroute to the fire, the first-arriving engine officer should initiate the incident’s water 

supply plan. Using area preplans, the officer can designate dump sites, fill sites for the shuttle 

operation, or relay positions for in-coming units. Upon arrival, the first-arriving officer’s scene size-up 

and risk assessment should include an estimate on the fire flow requirements on the anticipated water 

supply. This information allows the development of an appropriate IAP and dictates whether an 

offensive operation is appropriate. The first-arriving officer should then communicate the IAP to all 

responding resources and dispatch. 

It is vital that an adequate water supply is maintained throughout the incident. ICs should reassess the 

water supply regardless of whether the incident is served by fire hydrants or requires a rural water 

supply [Fire and Rescue Departments of Northern Virginia 2019]. When water requirements exceed 

the amount available from nearby hydrants or the amount of water carried by the 1st alarm apparatus, a 

water supply group and water supply group supervisor should be designated. All units in the water 

supply group will be under the management of the water supply group supervisor. The water supply 
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group supervisor is the individual responsible for resourcing adequate water supplies required to 

implement the tactics outlined by the IC [FCFCA 2015]. 

At this incident, the county’s Communications Center did not dispatch a Tanker/Tender Task Force for 

Box 5-62, despite the structure being in an area with limited fire hydrants. BC1 recognized there was a 

swimming pool on Side Charlie and while enroute ordered E51 to use the swimming pool as a water 

source during initial fireground operations. As a result, the first two arriving engines did not lay a 

supply line as they arrived on scene. Subsequent efforts by Command to address the water supply issue 

distracted Command from command and control of fireground operations. 

Recommendation #15: Fire departments should ensure adequate staffing and deployment of 

resources based on the community’s risk assessment. 

Discussion: Fire departments should implement deployment strategies to ensure that adequate 

resources are on scene to conduct fire suppression operations for the likely hazards within their 

jurisdiction. These deployment strategies should involve a comprehensive assessment of risk within 

the community and consider factors such as service demands on the department, demographics, 

socioeconomics, building and occupancy types, and other elements that can help to identify the 

likelihood of fire. Fire departments also should consider obstacles that firefighters will encounter 

during firefighting operations, such as, potential life safety issues, fire suppression systems, building 

location (accessibility), and water supply issues. The first arriving resource needs to determine the 

structure size which is considered when implementing a strategy for an incident. This information 

should be transmitted to the dispatch center and all responding resources as part of the preliminary 

size-up report. 

In 1984, results of the Dallas Fire Department Staffing Level Study were published and the 91 various 

simulations that were conducted indicated that inadequate staffing results in the following problems: 

• Delays in the performance of critical tasks

• Increased risk to victims because of the length of delays is increased, the likelihood of survival 

decreases

• Loss of critical functions

• A cumulative effect created by combined delays and the lost functions on the part of each crew 

resulting in an even greater loss of overall effectiveness

• Increased physiological stress on firefighters as they try and compensate for the lower staffing 

level

• Increased risk to the firefighter when aggressive procedures are undertaken without the support 

to complete them safely [McManis Associates et al. 1984] (See Table 2).

Insufficient numbers of emergency response units or inadequate staffing levels on those units exposes 

civilians and firefighters to increased risk. It also drains already limited fire department resources and 

stresses the emergency response system by requiring additional apparatus to respond from further 

distances. Failing to assemble enough resources on the scene of a fire in time to stop the spread and 

extinguish the fire, conduct a search, and rescue any trapped occupants puts responding firefighters and 

occupants in a dangerous environment [Averill JD, et al., 2010; 2013]. 
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If the available staffing and deployment are insufficient for the situation encountered, the risk

assessment should steer the initial strategy toward focusing on primary search and deploying at least a

single hose line to protect the firefighters assigned to a primary search. Prior to having the resources 

for this approach, incident commanders should consider a defensive position until additional resources 

arrive. During this time, the fire will continue to grow and have negative effects on the structural 

integrity of the building, making an offensive attack much less desirable and certainly more dangerous.

NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, 

Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments

requires a minimum full alarm assignment of 14 firefighters and 1 command officer, for a total of 15 

members on the scene of a residential structure fire in a typical 2,000-foot, two-story single-family 

dwelling without a basement and with no exposures within 8 minutes of travel time [NFPA 2016a]. If 

an aerial or platform is in operation, 17 members are required. This staffing allows for one attack line 

to be placed in operation on the 1st floor or 2nd floor, with one back-up line, one search and rescue 

crew (3 firefighters), one ventilation crew (2 firefighters), and a 2-member RIC.

However, best practices suggest that residential structures that exceed these characteristics, but do not 

fit a high-rise or high-hazard occupancy, should receive a minimum full-alarm assignment of 26 

firefighters, one command officer, and one incident command technician, for a total of 28 personnel on 

the scene of a structure fire within 8 minutes of travel time [NFPA 2016a]. This staffing allows for two 

attack hoselines to be stretched to an upper floor, one back-up hoseline, at least two search and rescue 

crews, one interior forcible entry/ventilation crew, one exterior ventilation crew (2-3 firefighters), and 

a four-person RIC.

NFPA 1710 also requires staffing of engine companies and truck companies with a minimum of four 

on-duty personnel. Match resources to service demands and risk, the standard also states that 

companies shall have a minimum of five on-duty members in jurisdictions with high numbers of 

incidents, or six on-duty members in jurisdictions with tactical hazards, high-hazard occupancies, or 

dense urban areas as identified by the authority having jurisdiction (AHJ) [NFPA 2016a].
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Engine Company Ladder/Truck Company

Unit Effectiveness

With a firefighter functioning 

as a pump operator for an 

engine or pumper, only two 

members are available to 

position attack line. 

This is almost impossible if 

the fire is in the rear of a 

building or on an upper floor 

of a building. This is much 

easier with a third firefighter’s

help to stretch the hoseline. 

With a firefighter 

functioning as the aerial 

operator to position the 

aerial, * this leaves only two 

members to preform 

“forcible entry” and form a 

single 2-person search and 

rescue team. 

∗ A tower ladder requires 

two firefighters. One 

firefighter to operate the 

bucket and one firefighter 

to operate the platform.

Flexibility

Depending on the 

circumstances, the 4th

firefighter can hook-up the 

supply line to the hydrant or 

act as forcible entry when the 

engine company arrives on 

scene first.

If all three members enter the 

building that only allows for 

a single “search and rescue 

team” since members cannot 

operate alone. If four 

members enter the building, 

they can form two teams. 

 Assigning a company 

officer as a 

Division/Group 

Supervisor

Using the company officer as 

a division/group supervisor 

either makes the division/ 

group ineffective or leaves the 

engine company with one 

firefighter operating by 

themselves.

The incident commander 

should consider combining 

companies to increase 

company staffing and enhance 

crew integrity and personnel 

accountability. 

Using the company officer as 

a division/group supervisor 

either makes the division/ 

group ineffective or leaves 

the ladder/truck company 

with one firefighter operating 

by themselves. 

The incident commander 

should consider combining 

companies to increase 

company staffing and 

enhance crew integrity and 

personnel accountability. 

Table 2: The impact of decreasing company staffing from 1 officer and 3 firefighters to 1 

officer and 2 firefighters.
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The effectiveness when increasing staffing per company from three firefighters to four firefighters was 

more pronounced when measured for a larger building than the one assumed by NFPA 1710 that was 

used to justify a 15-member response in 8 minutes [NFPA 2016a] (See Diagram 8). The community 

served by the fire department in this investigation was comprised of buildings with basements, close 

exposures, and more than two floors, indicating that the increase in efficiency would be greater than 

that calculated by National Institute for Standards and Technology (NIST) for smaller structures 

[Averill et al. 2010].

At the scene of a structure fire, the driver/operator of the first engine company on the scene must 

remain with the apparatus to operate the pump. This leaves one firefighter to assist the operator in 

securing a water source from a hydrant and two firefighters to deploy a hoseline and stretch it to the 

fire. After assisting the operator, the third firefighter should begin to assist the other two firefighters 

with advancing the hoseline into the building and to the location of the fire. Before initiating 

firefighting operations, the officer of the first arriving engine company conducts a complete 360-

degree walk around of the structure to assess the situation, determines the extent of the fire, requests 

any additional resources, and assumes Command [NFPA 2016a]. The driver/operator of the first 

arriving ladder company must remain with the apparatus to operate and position the aerial device, 

while the other three firefighters perform critical fireground tasks, such as ventilation and search and 

rescue. 

The initial full alarm assignment to a single-family dwelling structure fire in a typical 2000 square 

foot, two-story single-family dwelling without basement and with no exposures shall provide for the

following:

• Establishment of incident command outside of the hazard area for the overall coordination and 

direction of the initial full alarm assignment with a minimum of one member dedicated to this 

task

• Establishment of an uninterrupted water supply of a minimum of 400 gallons per minute 

(GPM) for 30 minutes with supply line(s) maintained by an operator

• Establishment of an effective water flow application rate of 300 gpm from two hoselines, each 

of which has a minimum flow rate of 100 gpm with each hoseline operated by a minimum of 

two members to effectively and safely hoseline maintain the line

• Provision of one support member for each attack and backup line deployed to provide hydrant 

hookup and to assist in laying of hoselines, utility control, and forcible entry

• Provision of at least one victim search and rescue team with each such team consisting of a 

minimum of two members

• Provision of at least one team, consisting of a minimum of two members, to raise ground 

ladders and perform ventilation

• If an aerial device is used in operations, one member to function as an aerial operator to 

maintain primary control of the aerial device at all times

• Establishment of a RIC consisting of a minimum of two properly equipped and trained 

members [NFPA 2016a].
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Diagram 8: Initial full alarm assignment for a 2,000 square-foot, two-story 

single-family dwelling capability deployed within 8 minutes per NFPA 1710. 
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There can be incidents or areas where the response criteria are affected by circumstances such as 

response personnel who are not on duty, unstaffed fire station facilities, natural barriers, traffic 

congestion, insufficient water supply, and density of the population or property. The reduced level of 

service should be documented in the written organizational statement by the percentage of incidents 

and geographical areas for which the total response time criteria are achieved.

The evaluation of the fire department’s provided level of service needs to be measured against the 

authority having jurisdiction’s (AHJ) established service delivery performance objectives. These 

objectives should be based on a jurisdictional risk assessment and established based on a 2000-square 

foot two-story, single-family home without a basement and having no exposures. The AHJ’s response 

objectives should account for numerous factors such as the circumstances affecting response 

personnel, adopted building codes, required fire/life safety-related engineering controls, accepted 

turnout/travel times, complexity of facilities, and occupancy hazards within the jurisdiction [NFPA 

2016a].

NFPA 1710 requires the following:

• 4.1.2.5.1* The fire department shall evaluate its level of service and deployment delivery and 

alarm handling time, turnout time, and travel time objectives on an annual basis.

• A.4.1.2.5.1 The evaluation of a fire department’s provided level of service needs to be 

performed against the AHJ established service delivery performance objectives. These 

objectives should be based on a jurisdictional risk assessment. The objectives established 

within this standard are based on a 2000-square foot (186 m2), two-story, single-family home 

without a basement and having no exposures. The AHJ’s response objectives should be 

established based on numerous factors such as the circumstances affecting response personnel, 

adopted building codes, required fire/life safety-related engineering controls, accepted 

turnout/travel times, complexity of facilities, and occupancy hazards within the jurisdiction.

Note: The Annex material is provided for information purposes and is not a requirement of the 

standard.

• 4.1.2.5.2* The evaluations shall be based on emergency incident data relating to level of 

service, deployment, and the achievement of each time objective in each geographic area within 

the jurisdiction of the fire department.

• A.4.1.2.5.2 The collection of data is required to determine the organization’s ability to meet its 

locally determined objectives and the performance objectives contained in the standard with 

regard to emergency incidences (warning lights and sirens). Organizations respond to numerous 

types of emergency and nonemergency incidents. While the collection and analysis of all of the 

response data is important, attainment of the 90 percent objective is only to be evaluated 

against emergency incident responses. Note: The Annex material is provided for information 

purposes and is not a requirement of the standard.

• 4.1.2.6 The fire department shall provide the AHJ with a written report annually.

• 4.1.2.6.1 The annual report shall define the geographic areas and/or circumstances in which the 

requirements of this standard are not being met.

• 4.1.2.6.2 The annual report shall explain the predictable consequences of these deficiencies and 

address the steps that are necessary to achieve compliance.
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At this incident, the initial dispatch was for two engine companies, one truck company, one medic unit 

and one battalion chief. The total staffing for response to Box 5-62 was 14 members, who were 

responding to an 8,400 square foot structure in an area with limited water supply. Based upon the 

deployment model for a high risk, large area residential occupancy, the minimum response should have 

been four engine companies with a staffing of four, two trucks with a staffing of four, one medic with 

staffing of two, a tanker task force with three tankers with a staffing of two each, and two battalion 

chiefs with a staffing of two each. 

Recommendation #16: Fire departments should periodically review and, if necessary, revise their

SOP/SOG on the deployment of rapid intervention crews (RICs).

Discussion: To ensure compliance with 29 CFR 1910.134 Respiratory Protection [OSHA 1998], fire 

departments must maintain a RIC when members are operating in an immediately dangerous to life 

and health (IDLH) or potentially IDLH atmosphere [NFPA 2018c]. In some organizations, the crew is

known as a rapid intervention team (RIT), or a firefighter assist and search team (FAST).

The RIC function should be incorporated into the department’s incident management system and 

personnel accountability system [NFPA 2014]. The needs of critical fireground operations and staffing 

should be continuously evaluated regarding firefighter safety. Resource assignments should always be 

made with the goal of having the RIC function in place. When ICs need additional resources, the 

consideration of deploying the RIC for an operational assignment without additional resources onscene to function as the RIC should be carefully assessed [NFPA 2014]. 

The following restrictions regarding the use of RIC should be considered by the IC during fireground 

operations: 

• The RIC should not be used for firefighting operations until another company is on-scene to 

operate as the RIC 

• The RIC is dedicated to assist and, if necessary, rescue members who become lost, trapped, 

distressed, or involved in other serious life-threatening situations 

• The RIC should not be used to provide relief for operating companies until the fire/incident has 

been declared “under control” by Command 

• If a RIC unit officer is assigned to other duties by a superior officer, the RIC unit officer should 

remind such officer of RIC designation [Toledo Fire & Rescue Department 2012; TSFRS 

2014]. 

When ICs order the RIC to work, the IC should immediately assign another on-scene company to stand 

by as the RIC. At a minimum, ICs should request an additional alarm and designate a company or 

companies to function as the RIC. The remainder of the companies should report to staging. If no units 

are available, the IC should assign at least two members to act as a RIC while awaiting a special-called 

RIC to arrive. An engine company may be designated as the RIC pending arrival of an additional 

ladder company or rescue company. This ensures compliance with OSHA’s “2 In/2 Out” rule under 29 

CFR 1910.134, Respiratory Protection [OSHA 1998]. 
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Many fire departments have a defined response plan for the dispatch of an additional company (engine, 

truck, squad, rescue, and/or command officer) to respond to an incident and stand by as the RIC. Based 

upon the complexity, magnitude, configuration of the structure or geographical layout of the incident, 

the IC may deploy an additional RIC/FAST by location or function [NFPA 2014]. 

The RIC officer/rescue group supervisor and RIC members/rescue group members will coordinate with 

Command to formulate rescue plan contingencies and continue to monitor the radio and fireground 

conditions. The RIC process is not a passive assignment. This is a process of ongoing information 

gathering and diligent scene monitoring until the unit is released by the IC. The RIC function is a 

critical component for firefighter safety. 

To ensure that firefighters and fire officers are properly trained to conduct RIC operations, they should 

meet the requirements of NFPA 1407, Standard for Training Fire Service Rapid Intervention Crews 

[NFPA 2015a].

Recommendation #17: Fire departments should use resources from the National Institute of 

Standards and Technology (NIST), Underwriter’s Laboratories (UL) Fire Fighter Safety Research 

Institute (FSRI), and the International Society of Fire Service Instructors (ISFSI) to develop and 

revise operational procedures on fireground tactics and provide training in fire dynamics in 

structures for all firefighting staff. 

Discussion: The above organizations have conducted a series of live-burn experiments designed to 

replicate conditions in modern homes and residential structures and to validate previous testing done in 

laboratory settings. The results of these experiments enable firefighters to better predict and react to the 

effects of fire in these occupancies. The fire research experiments were conducted in cooperation with 

the Fire Department of New York; Chicago Fire Department; Spartanburg, South Carolina, Fire and 

Rescue; and other agencies. The live-burn tests are aimed at quantifying emerging theories about how 

fires are different today, largely due to new building construction and the composition of home 

furnishings and products. In the past, these products were mainly composed of natural materials, such 

as wood and cotton, but now contain large quantities of petroleum-based products and synthetic 

materials that burn faster and hotter and generate large volumes of fuel-rich smoke. Where a fire in a 

room once took approximately 20 minutes to “flashover”—igniting all the contents—this can happen 

with today’s furnishings in as little as 4 to 5 minutes [Kerber 2012]. 

Modern living spaces tend to be more open, less compartmentalized and better insulated than homes 

built years ago. As a result, interior residential fires can generate oxygen-depleted, fuel-rich 

environments within minutes. This fire condition of hot, fuel-rich smoke (also known as a ventilationlimited fire) is highly reactive to the introduction of oxygen. Opening a door or venting a window 

introduces massive quantities of oxygen to this environment, which promotes explosive and rapid 

transition to flashover. These same conditions can occur in commercial structures as seen in the fire at 

the Charleston, South Carolina, Sofa Super Store [NIOSH 2009]. 

The NIST and FSRI experiments evaluated individual and combinations of methods for strategically 

ventilating and isolating fires to prevent or delay flashover. In contrast, kicking a door open or 
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breaking a window without knowledge of conditions inside could create a portal for air that can 

literally fan the flames by introducing oxygen into an oxygen-limited fire environment.

A flow path is composed of at least one inlet opening, one exhaust opening, and the connecting volume 

between the openings. The direction of the flow is determined by difference in pressure. Heat and 

smoke in a high-pressure area will flow through openings toward areas of lower pressure. Based on 

varying building designs and the available ventilation openings (doors, windows, etc.), several flow 

paths can exist within a structure. Any operation conducted in the exhaust portion of the flow path will 

place members at significant risk due to the increased flow of fire, heat, and smoke toward their 

position. This risk is true for natural-ventilation cases with or without wind. In cases with the potential 

for wind to affect the heat release rate and the movement of the fire, it is important to keep the wind at 

your back and to attack the fire from the upwind side [FDNY 2013]. 

Firefighters need to be aware and understand that the critical first step in evaluating the potential for a 

wind-impacted fire is recognition of any smoke movement in the flow path, wind speed, smoke being 

forced under doors, and/or pulsing smoke or fire. The IC and company officers must be notified 

immediately when any of these conditions are observed. The communication of this critical 

information to the IC and company officers operating inside the building must be acknowledged. 

Since the widespread use of bunker gear and SCBA, fire suppression operations were sometimes 

conducted from the interior of the structure under the assumption that this would reduce water damage 

and limit fire damage to structures. These operations need to be coordinated with ventilation 

operations. Previous research and examinations of line-of-duty deaths have shown that ventilation 

events occurring with firefighters in the structure prior to suppression have led to tragic results 

[NIOSH 2009, 2012, 2013a, 2013b]. One method of reducing this risk would be the application of 

exterior water. Water is directed into the structure from the exterior to cool the fire gases and reduce 

the heat-release rate of the fire prior to firefighters entering the building. A repeated objection to this 

tactic was based on the belief that harm might occur to people trapped in the structure or the amount of 

water damage to the structure. Structural integrity can be lost in less than 5 minutes once the floor 

assembly becomes involved in fire [Zevotek et al. 2018].

UL has shown that effective suppression operations, either from the interior or exterior, did not 

increase the potential burn injuries to the occupants. However, the delay of suppression operations 

provides the potential for longer occupant exposures to IDLH conditions and increased potential for 

further injury or death [Zevotek et al. 2018].

The challenges and tactical considerations from basement fires have also been studied by NIST, the 

UL Fire Safety Research Institute (FSRI), and the International Society of Fire Service Instructors 

(ISFSI) [Kerber et al. 2012; Madrzykowski 2013; Madrzykowski and Weinschenk 2018]. Many 

firefighters have been injured or killed while trying to extinguish a below-grade fire. Prior research has 

shown below-grade fires present a high risk to firefighters. This risk stems from unexpected floor 

collapse and high heat. Prior research also indicated the tools that firefighters have traditionally used to 
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determine the structural integrity of the floor such as thermal imagers and sounding the floor for 

stability are unreliable and therefore should be combined with other tactics to increase safety.

The key points are:

• Size-up is critical

• Below-grade fires are likely to be ventilation-limited 

• Coordinating ventilation with water application is required to limit the growth of a ventilationlimited fire 

• Water application in the below-grade space is key to smoke cooling

• Effective water application into below-grade space reduces the hazard throughout the structure

• Options exist to make a coordinated and effective attack

• It is best to fight the fire on its own level.

The FSRI and ISFSI study extended earlier research by increasing the size of the basement and 

incorporating three different ventilation and access conditions to the basement [Madrzykowski and 

Weinschenk 2018]. Those access conditions include no exterior access to the basement, limited 

exterior access to the basement, and exterior access to the basement. The results of the experiments 

showed the importance of identifying a basement fire, controlling ventilation, and flowing an effective 

hose stream into the basement from a position of advantage as soon as possible. 

The basement experiments highlighted the importance of identifying a basement fire during size-up 

and subsequently choosing the appropriate tactics to coordinate ventilation with suppression. In all

experiments, the basement fires were ventilation limited. Additional ventilation without suppression

was shown to increase the hazard to any occupants trapped in the structure. Various nozzles and

appliances (Bresnan distributors, piercing nozzles, and cellar nozzles) were used to flow water into the 

basement. Water streams applied through the floor, through a small window remote from the seat of 

the fire, and through a basement level access door controlled the fire and reduced the hazard 

throughout the structure.

Effective water application into the basement cooled the fire gases to prevent flashover, slowed the 

destruction of the structure and the floor assembly, and reduced the hazard from fire. This made it 

possible for a fully protected firefighter to enter the basement. Effective water application also 

supported search operations and reduced the threat from heat and toxic gases for any trapped occupants

[Madrzykowski 2013].

Based upon the NIST, FSRI, and ISFSI research cited above, the following fireground operations 

should be considered for implementation.

• Size-Up

Size-up must occur at every fire. Consideration must be given to the resources available and 

situational conditions, such as weather, fire location, size of the fire and building, and the 

construction features. Ensure a 360-degree size-up is conducted whenever possible. A tactical 

plan for each fire must be developed, communicated, and implemented.
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• Ventilation

Fire departments should manage and control the openings to the structure to limit fire growth 

and spread and to control the flow path of inlet air and fire gases during tactical operations. All 

ventilation must be coordinated with suppression activities. Uncontrolled ventilation allows 

additional oxygen into the structure, which may result in a rapid increase in the fire 

development and increased risk to firefighters due to increased heat-release rates. 

• Firefighting Operations

Given the fuel-rich environment in which the fire service operates, water should be applied to 

the fire as soon as possible. In many cases, water application through an exterior opening into a 

fire compartment may be the best first action, prior to committing fire-fighting resources to the 

interior. Fire departments should cool the interior spaces of a fire building with water from the 

safest location possible, prior to committing personnel into spaces with, or adjacent to, fully 

developed or smoldering (ventilation-limited) fire conditions.

• Rapid Intervention

Fire department rapid intervention procedures should be updated to provide water on the fire as 

soon as possible. During firefighter Mayday incidents, ventilation openings should be 

controlled [ISFSI 2013]. 

This information is presented to educate the fire service and to ensure that fire departments consider a 

change in fireground tactics based upon the research conducted by NIST, FSRI, and ISFSI 

[Madrzykowski 2013; Madrzykowski and Weinschenk 2018]. Much of this research has been directed 

toward developing a better understanding of the characteristics of modern fire behavior and providing 

the fire service with the knowledge needed to modify essential fire-fighting tactics. While firefighting 

will never be without risk, this research represents a vital contribution to overall efforts to reduce risks 

and to save lives. 

Although there is no evidence that the following recommendations (Recommendations 18-21) would 

have prevented this fatality, they are being provided as a reminder of best safety practice for the fire 

service.

Recommendation 18: Fire departments should consider having all members carry a wire cutting 

tool.

Discussion: While there are varying opinions related to the type of wire cutters to use and the location 

to carry them, most will agree that whatever type carried, they should be capable of cutting through 

common types of wires and conduit found in residential and commercial structures. “Cable Cutters” 

are recommended because they have shown to be the best combination of cutting ability and ease of 

use. The size and shape of the Cable Cutter’s blade helps prevent the tool from slipping off the 

material during a cut (See Photo 4). 

 
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Wire cutters can help free firefighters that have become entangled in a variety of wires such as cable 

television wires, plastic air conditioning duct work coiled wire, and suspended ceiling wire supports. 

The utility of the tool becomes readily apparent to any firefighter in an entanglement training prop. 

The ideal location to carry wire cutters is a pocket accessible by either hand. In the past, the radio chest 

pocket found on most turnout coats was an excellent location. However, as radios have decreased in 

size, the radio pocket has also become smaller. Storing cutters in the smaller pocket can result in the 

handles of the cutters being exposed and becoming an entanglement hazard themselves. If a chest 

pocket is not a viable option, the next best location is a pocket accessible to the dominant hand. In our 

experience the chest/radio pocket is the best option, especially if you wear a radio strap. 

In this incident, it is unclear if E101B was entangled in wires or if a pair of wire cutters could have 

allowed a self-rescue. However, as a member of the RIC, the captain of Engine 71 had a pair of wire 

cutters. He used the wire cutters to untangle other members of the rapid intervention group who 

became tangled in loose wires in the crawlspace.

Recommendation #19: Fire departments should ensure that all members engaged in emergency 

operations receive annual proficiency training and evaluation on fireground operations, including 

live fire training. This training should be conducted with automatic aid and mutual aid fire 

departments.

Discussion: To ensure the proficiency and competency of fire department members, fire departments 

should conduct annual skills evaluation to verify minimum professional qualifications. This evaluation 

should address the qualifications specific to the member’s assignment and job description with the 

goals of preventing skills and abilities degradation and ensuring the safety of members. Proficiency 

evaluation and training provides an opportunity to ensure that all fire officers and firefighters are 

competent in fireground operation knowledge, skills, and abilities. This process should include annual 

live fire training.

NFPA 1500, Standard for a Fire Department Occupational Safety, Health, and Wellness Program, 

requires a fire department to establish and maintain a training, education, and professional 

development program with the goal of preventing occupational deaths, injuries, and illnesses [NFPA 

2018c]. This ensures members are trained and competencies are maintained in order to execute all 

responsibilities effectively, efficiently, and safely. This process is consistent with the organizational 

Photo 4. An example of a pair of wire cutters 

useful to firefighters during firefighting 

operations.

(NIOSH Photo) 
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statement that establishes the existence of the fire department, the services the fire department is 

authorized and expected to perform, the organizational structure, and the job descriptions and functions 

of fire department members [NFPA 2018c].

As members progress through various job duties and responsibilities, the department should ensure 

they have necessary knowledge, skills, abilities, and are able to demonstrate competencies for the 

defined position. The training and education process should also ensure the ongoing development of 

existing skills [NFPA 2018c].

NFPA 1410, Standard on Training for Initial Emergency Scene Operations, defines basic evolutions 

that can be adapted to local conditions and serves as a method for the evaluation of minimum 

acceptable job performance during initial fireground operations [NFPA 2020]. Proficiency training for 

fireground operations and emergency incidents should be conducted annually. This training should 

include scene size-up, situational awareness, use of the incident management system, personnel 

accountability system, strategy and tactics, search and rescue, hoseline operations, ladder operations, 

ventilation, thermal imaging cameras, fireground communications, use of RICs, and Mayday

operations. 

Recommendation #20: Fire departments should ensure adequate incident scene rehabilitation is 

established in accordance with NFPA 1584, Standard on the Rehabilitation Process for Members 

during Emergency Operations and Training Exercises.

Discussion: NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency 

Operations and Training Exercises establishes the minimum criteria for developing and implementing 

a rehabilitation process for fire department members at incident scene operations and training exercises 

while operating within an incident management system [NFPA 2022] The physical and mental 

condition of personnel should be monitored as part of the overall assessment. This ensures a 

firefighter’s health does not deteriorate to the point it affects the safety of themselves or other 

firefighters or endangers the safety and integrity of the operation. ICs should consider the 

circumstances of each incident and make suitable provisions for rest and rehabilitation for personnel. 

This process should include medical evaluation and treatment, food and fluid replenishment, and rest 

and relief from extreme climatic conditions.

NFPA 1584 states that an IC should establish rehabilitation operations when emergency operations 

pose a safety or health risk to firefighters and other responders. Rehabilitation operations should be 

provided in accordance with fire department SOPs, NFPA 1500, Standard on Fire Department 

Occupational Safety and Health Program, and NFPA 1561, Standard on Emergency Services Incident 

Management System and Command Safety [NFPA 2014; NFPA 2018a, NFPA 2022].

Incident scene rehabilitation (“Rehab”) is a term often used for the care given to firefighters and other 

responders while performing their duties at an emergency scene. When the size of the operation or 

geographic barriers limit member’s access to the rehabilitation area, the IC should establish more than 

one rehabilitation area. The site should be far enough from the effects of the operation that members 

can safely remove their personal protective equipment and can be afforded physical and mental rest 
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[USFA 2008]. Once “Rehab” area(s) have been established, this information must be communicated 

over the radio, so all members know the location of “Rehab” or know where to report when assigned to 

“Rehab.”

Several considerations for rehabilitation sites are as follows:

• Should be in a location that will provide physical rest by allowing the body to recuperate from 

the demands and hazards of the emergency or training evolution

• Should be far enough away from the scene that personnel may safely remove their turnout gear 

and SCBA and be afforded physical and mental rest from the stress and pressure of the 

emergency or training evolution. Provisions should be available to have SCBA cylinders 

refilled

• Should provide suitable protection from the prevailing environmental conditions. During hot 

weather it should be in a cool, shaded area, and during cold weather it should be in a warm, dry 

area

• Should enable personnel to be free of exhaust fumes and noise from apparatus, vehicles, or 

equipment, including those involved in the rehabilitation group operations

• Should be large enough to accommodate multiple crews based on the size of the incident

• Should be easily accessible by emergency medical service units

• Should allow prompt re-entry back into the emergency operation upon complete recuperation

• Crews assigned to rehab will be instructed to turn portable radios off and/or have radio and 

thermal imager portable batteries recharged or exchanged [USFA 2008] (See Diagram 9).

The Rehab Group supervisor should secure all necessary resources required to adequately staff and 

supply the rehabilitation area. The supplies should include the following items:

• Fluids: water, activity beverage, oral electrolyte solutions, and ice

• Food that is easy to prepare and serve: 

 soup, broth, or stew in cold weather

 sandwiches, energy bars, or fruit in hot weather

• Medical devices: blood pressure cuffs, stethoscopes, oxygen administration devices, cardiac 

monitors, intravenous solutions, and thermometers

• Other: awnings, fans, tarps, fans, heaters, dry clothing, extra equipment, floodlights, blankets 

and towels, traffic cones, and fire line tape (to identify the entrance and exit of the 

rehabilitation area)

• Hygiene facilities to decontaminate all exposed skin surfaces

• Restroom facilities [USFA 2008].
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At this incident, informal rehab was located on Side Charlie near the swimming pool. On-scene 

rehabilitation for responding personnel was established late in the incident. The Communications 

Center requested a canteen at 0222 hours and then again at 0410 hours but did not receive a response. 

The rehabilitation area on Side Charlie was only supplied with drinking fluid from the suppression 

apparatus, which ran out quickly. Personnel from the county’s Department of Police were able to 

purchase water, sports drinks, and snacks from a convenience store at approximately 0500 hours and 

deliver the supplies to the incident scene.

Working fireground incidents need a rehab area. The rest and refreshment area can help firefighters 

rest and recover. The evaluation and treatment area can screen, treat, and transport injured firefighters. 

Recommendation 21: Fire Departments should consider a radio protocol that identifies the unit they 

are calling first (receiver), then identifies themselves (sender). 

Discussion: Many national organizations have adopted the military protocol format for effective radio 

communications. In this protocol the sender states the intended receiver’s radio designation first and 

then follows with the sender’s designation. 

Getting the receiver’s attention upfront in the message may prevent the receiver from requesting a 

repeat or missing the message. Saying the receiver’s attention upfront in the message, the receiver is 

less likely to reply. Remember that the amount of radio traffic during responses is generally high and 

Diagram 9. An example of how a “Rehab” area can be organized. There 

are many ways to establish an effective “Rehab” area. 

(Diagram courtesy of the United States Fire Administration.) 
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firefighters typically listen for their own radio designation before “tuning in” to radio traffic. This 

methodology reduces confusion and preserves airtime for more important messages [NIMSC 2010]. 

The Order Model outlines the communications steps we follow to ensure messages are always received 

and understood despite the rushed, confusing and dangerous conditions we typically face during 

operations [IAFC and NFPA 2015]. The order model also standardizes how the incident’s participants 

will exchange two-way radio communications. The Order Model’s required steps are:

• When the sender is ready to transmit a message, they call the receiver to determine if they are 

ready to receive the message

• The receiver then acknowledges the sender

• When the sender receives the readiness reply, they can transmit the message

• The receiver then gives a brief restatement of the message to acknowledge the receipt of the 

message 

• The sender restates the message if misunderstood [Blue Card 2018].

Using the Order Model will significantly decrease the amount of radio traffic on the emergency scene. 

It will also help reduce order confusion and enhance responder safety and accountability. 

References 

Abbott D [2016]. The Mayday Project. Firehouse. February 1, 2016. Date accessed: November 17, 

2022. 

Averill JD, Moore-Merrell L, Barowy AM, Santos R, Peacock RD, Notarianni K, Wissoker D [2010]. 

Report on Residential Fireground Field Experiments. NIST Technical Note 1661. Gaithersburg, MD: 

National Institute of Standards and Technology. Date accessed: October 31, 2022. 

Averill JD, Moore-Merrell L, Ranellone RT Jr, Weinschenk CG, Taylor N, Goldstein R, Santos R, 

Wissoker D, Notarianni K, Butler KM [2013]. Report on High-Rise Fireground Field Experiments. 

NIST Technical Note 1797. Gaithersburg, MD: National Institute of Standards and Technology. Date 

accessed: October 31, 2022. 

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Investigator Information

This incident was investigated by Murrey Loflin, Investigator, Dr. Thomas R. Hales, Medical Officer, 

and Matt Bowyer, General Engineer, all with the Fire Fighter Fatality Investigation and Prevention 

Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located 

in Morgantown, WV. The report was written by Murrey Loflin and Thomas Hales. An expert technical 

review was provided by Robert M. Neamy, Deputy Chief (retired) Los Angeles Fire Department and 

Peter Van Dorpe, Chief of Training (retired) of the Chicago Fire Department, and (retired) Chief of the 

Algonquin-Lake in the Hills Fire Protection District. Additional expert review was provided by Steve 

Kerber and Dan Madrzykowski of the Underwriters Laboratories, Firefighter Safety Research Institute. 

A technical review was also provided by the National Fire Protection Association, Public Fire 

Protection Division. 

Additional Information

National Institute for Standards and Technology (NIST) and Underwriters Laboratories (UL)

Over the past decade, NIST and UL’s Firefighter Safety Research Institute has worked with fire 

departments and fire service organizations to conducted research on fire behavior, fire safety issues, 

and fireground operations. Since 2019, UL’s website has made available 25 training videos on these, 

and other topics. Videos relevant to this incident include, Suppression Tactics in Single-Family 

Homes, Understanding and Fighting Basement Fires, Impact of Ventilation on Fire Patterns, Vertical 

Ventilation and Suppression Tactics in Single Family Homes. 

International Association of Firefighters (IAFF) Fire Ground Survival Program

The IAFF Fire Ground Survival Training program provides training for Mayday prevention and 

Mayday operations for firefighters, company officers, and chief officers. Firefighters must be trained to 

perform potentially life-saving actions if they become lost, disoriented, injured, low on air, or trapped. 

Funded by the IAFF and assisted by a grant from the U.S. Department of Homeland Security through 

the Assistance to Firefighters (FIRE Act) grant program, this comprehensive fireground survival 

training program applies the lessons learned from firefighter fatality investigations conducted by the 

National Institute for Occupational Safety and Health (NIOSH). It was developed by a committee of 

subject matter experts from the IAFF, the International Association of Fire Chiefs (IAFC), and 

NIOSH.
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NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety

(2020 edition) 

The primary focus of the revision to NFPA 1561 in the 2020 edition was to develop requirements 

directly aimed at reducing and eliminating fireground injuries and fireground deaths of fire department 

members. The most apparent change to this edition is the inclusion of “Command Safety” in the 

document title and the creation of a new chapter, “Command Safety.” This chapter is intended to 

provide a foundation on how to incorporate the incident management system at all emergency 

incidents, especially Type V and Type IV incidents. 

The chapter on Command Safety clearly defines the requirements for the IC to meet, including 

establishing a fixed command post, personnel accountability, the use of staff aides, rapid intervention 

crews, and the appointment of a safety officer and assistant safety officer(s)(as needed), plus the 

expectations and authority of the safety officer. Annexes cover Functional Assignments for High-Rise

Building Incidents, Development of Subordinate Officers or Implementing a More Efficient 

Management System, Incident Management for the Fire Service on Type V or Type IV Incidents, and 

Structural Fire-Fighting—Risk Assessment and Operational Expectation. 

Disclaimer 

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC). In 

addition, citations to websites external to NIOSH do not constitute NIOSH endorsement of the 

sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the 

content of these websites. All web addresses referenced in this document were accessible as of the 

publication date. Mention of any company or product does not constitute endorsement by NIOSH or 

CDC. 

 
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Appendix One

Fire & Rescue Department’s Alarms for 2018
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Appendix Two

Summary of Personal Protective Equipment Evaluation

Status Investigation Report of two

Self-Contained Breathing Apparatus

Submitted by the

NIOSH Division of Safety Research 

for the Fire Department

NIOSH Task Number 22491

Background 

As part of the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter 

Fatality Investigation and Prevention Program (FFFIPP), Investigation F2018-13 MD, the 

National Personal Protective Technology Laboratory (NPPTL) agreed to examine and evaluate a 

SCBA under NIOSH Task Number 22491. 

This SCBA status investigation was assigned NIOSH Task Number 22491. The NIOSH 

Firefighter Fatality Investigation and Prevention Program investigators and the Fire and Rescue 

department were advised that NIOSH NPPTL would provide a written report of the inspection and

any applicable test results.

The SCBA unit was delivered by a NIOSH investigator from the Division of Safety Research who 

were assigned to investigate the Fire and Rescue department’s fatal event. The investigator delivered 

the unit to Lab H1513 for secure storage at the NIOSH facility in Morgantown, West Virginia on 

August 20, 2018. The SCBA unit remained in secure storage in Lab H1513 throughout the inspection 

and testing process. 

On August 23, 2018, NPPTL employees Jay Tarley and Angie Andrews inspected the SCBA unit. 

These employees identified the SCBA from the Fire and Rescue department and visually examined the 

devise, component by component, in the condition received to determine the conformance of the unit to 

the NIOSH-approved configuration. The unit was an MSA Model G1, 4500 psi, 45-minute unit; with 

NIOSH Approval Numbers TC-13F-0798CBRN. 

SCBA Inspection

On August 23, 2018, NPPTL employees Jay Tarley and Angie Andrews inspected the SCBA unit. 

These employees identified the SCBA as a Department of Fire and Rescue Services SCBA and visually 

examined the devise, component by component, in the condition received to determine the conformance 

of the unit to the NIOSH-approved configuration. The unit was a MSA Model G1, 4500 psi, 45-minute 

unit; with NIOSH Approval Numbers TC-13F-0798CBRN. 
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SCBA Testing

Summary and Conclusions

The SCBA unit inspected and evaluated by NPPTL was a MSA Model G1, 45-minute, 4500 psi unit 

with NIOSH Approval Numbers TC-13F-0798CBRN. The corresponding facepiece and cylinder were 

provided with the unit. A cylinder, not involved in the incident, was provided by the fire department 

for testing. Overall, the SCBA was in fair condition with some heat damage and soot found on the 

straps, as well as melted debris. The NFPA approval label was present and readable. The PASS, HUD, 

and alarm systems functioned as designed. 

The SCBA did not meet the test requirement of the NIOSH Positive Pressure Test during the first run. 

The inhalation breathing resistance was negative (-.25) for the first 10 minutes of the test then became 

positive and stayed positive the remainder of the test. This could possibly be explained by a piece of 

debris jarring loose from pressure of the air. 

The unit was tested again and met the test requirements of the NIOSH Positive Pressure Test, as the 

SCBA maintained a positive pressure for the 45-minute minimum duration of the test. The unit passed 

all of the other NIOSH tests, as well as meeting the requirements of the NFPA “Airflow Performance” 

test. 

In light of the information obtained during this investigation, NIOSH NPPTL has proposed no further 

action on its part at this time. The SCBA was returned to the shipping container to be shipped back to 

the Fire and Rescue department. 

If this unit is to be placed back in service, the SCBA must be repaired, tested, cleaned, and any 

damaged components replaced and inspected by a qualified service technician, including such 

testing and other maintenance activities as prescribed by the schedule from the SCBA manufacturer. 

Typically, a flow test is required on at least an annual basis. 

The investigation under task number TN-22491 will be considered closed. 
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Appendix Three

SCBA Data Log Information 

Figure 4. The SCBA data log information for the firefighter from 

E101B. 

PASS Alarm: E101B manually activated his PASS Alarm at approximately 0229 hours. 

PASS Internal Temperature Alarm: activated at approximately 0222 hours and went 

off at approximately 0244 hours. 

MAYDAY occurred at 0220 hours and E101B was out of the structure at 0243 hours. 
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Appendix Four

Air/Gas Quality Report 

SCBA Cylinder – E101B 

Figure 5. Results of the air quality report and certification for the SCBA 

cylinder used by E101B.