NIOSH Fire Fighter Fatality Investigation and Prevention Program

F2019-09

Paid-On-Call Fire Fighter 

Becomes Disorientated and Dies 

Following Stairway Collapse in 

Two-Story Vacant Structure Fire –

Illinois
NIOSH Fire Fighter Fatality Investigation and Prevention Program 2

Summary

• On May 5, 2019, a 24-year-old 

career firefighter became 

disorientated and died 

following a stairwell collapse 

on the 2nd floor during a fire in 

a vacant commercial structure. 

• Upon arrival the Engine 201 

lieutenant and the assistant 

chief noticed heavy smoke on 

Side Charlie and the 2nd story 

windows on Side Bravo.

• Engine 204 arrived and 

connected to a hydrant on 

Side Bravo. 

• The lieutenant and a firefighter 

from Engine 201 made entry 

after forcing open the south 

door on Side Bravo to search 

the 1st floor. 

Side Bravo of the fire building.

(NIOSH photo)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 3

Summary • Engine 201 took tools and a 13⁄4-

inch hoseline off Engine 204 into 

the structure to perform a search. 

• They encountered a mattress and 

debris on fire near the middle of 

the structure and some fire along 

an east wall (Side Delta). 

• After extinguishing the fire and 

completing their search of the 1st

floor, they exited the building, and 

changed their SCBA cylinders.

• At approximately 0357 hours, the 

municipal fire chief and additional 

resources arrived on scene. Ground 

ladders were placed at windows on 

Side Bravo while a Side Bravo door 

was forced open. 

• The lieutenant and firefighter from 

Engine 201 were preparing to reSide Bravo north and south doors, shown left to right. Engine enter the building. 

201 firefighters placed a ground ladder to the completely 

cleared window on the 2nd floor. NIOSH Photo
NIOSH Fire Fighter Fatality Investigation and Prevention Program 4

Summary

• They came to the open door and 

noticed the stairs to the 2nd floor. 

• Several stairs appeared to be 

structurally unsound, so a roof 

ladder was used to bridge the 

stairs. 

• They ascended to the 2nd floor with 

a hoseline, hand tools, and a 

thermal imager carried by the 

lieutenant. 

• The thermal imager indicated heat 

on the Side Delta wall but no fire. 

• They met the assistant chief, who 

had ascended one of the ground 

ladders to the 2nd floor. 

The stairwell against Side Charlie where the lieutenant and 

firefighter made entry to 2nd floor. The lieutenant was 

rescued by RIT underneath of the stairwell.

Photo by NIOSH
NIOSH Fire Fighter Fatality Investigation and Prevention Program 5

Summary

• Assistant Chief 2 felt his ears starting to burn and said that the firefighters 

needed to back out of the 2nd floor. 

• Assistant Chief 2 indicated he was going to exit via the ground ladder. 

• The lieutenant misunderstood and thought Assistant Chief 2 was getting 

low on air. 

• The lieutenant noticed conditions worsening and indicated to the 

firefighter the need to exit the 2nd floor. 

• The lieutenant believed the firefighter was right behind him as he started 

down the stairs. 

• As he stepped on the roof ladder lying on the stairs, the stairs collapsed 

sending him under the stairwell, covering him with debris. 

• The lieutenant immediately called a Mayday. 

• The lieutenant called out for the firefighter. 
NIOSH Fire Fighter Fatality Investigation and Prevention Program 6

Side Charlie door with A/C unit over top of it. The stairwell 

landing to 2nd floor that collapsed is just above door and A/C 

unit inside the wall.

Photo by NIOSH

The Delta Exposure 1 first floor roof. The third window 

from left was used by RIT to recover firefighter.

Photo by NIOSH
NIOSH Fire Fighter Fatality Investigation and Prevention Program 7

Summary

• The rapid intervention team (RIT) was sent in and was able to pull the lieutenant out. 

• The lieutenant indicated the firefighter must still be on the 2nd floor. 

• RIT teams made several attempts to access the 2nd floor via the ground ladders. 

• They could not advance towards the middle of the building due to deteriorating 

conditions. 

• The strategy was switched to defensive operations until the fire was knocked down. 

• At approximately 0541 hours, Engine 3 from an adjoining county fire department arrived 

with a specialized RIT crew of four firefighters. 

• The RIT accessed the firefighter by using the roof of the one-story Side Delta exposure 

(Delta 1). 

• The RIT entered a 2nd floor window on Side Delta of the fire building. 

• Following the sound of a personal alarm safety system alarm, the RIT located the 

firefighter, approximately 2 hours and 27 minutes after the Mayday. 

• The fallen firefighter was placed in a stokes basket, lowered to the ground, and loaded 

into an ambulance.
NIOSH Fire Fighter Fatality Investigation and Prevention Program 8

A view of the 2nd floor looking from Side Charlie/Delta 

corner to the Side Alpha/Side Bravo corner. The hole in 

the floor is approximately 10 feet x 25 feet on Side 

Charlie/Side Delta corner where the stairwell was located. 

The downed firefighter (indicated by red star) was located 

approximately 10 feet to the right of the mattress near the 

right corner of the hole. Photo by NIOSH

A view of the 2nd floor from Delta 1 Exposure roof. Note the 

hole in the Side Charlie/Side Delta corner. The red star 

indicates the approximate location of downed firefighter.

Photo by NIOSH
NIOSH Fire Fighter Fatality Investigation and Prevention Program 9

Contributing Factors

• High risk/low frequency event – abandoned commercial structure

• Lack of firefighter survival skills

• Insufficient incident management

• Lack of crew integrity

• Lack of mutual aid box alarm system training
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Recommendations

• Fire departments should ensure a standard operating procedure/standard 

operating guideline for high risk/low frequency events is developed, 

implemented, and firefighters are trained for fires in commercial 

structures.

• Fire departments should ensure firefighters are properly and repetitively 

trained in “out of air” and “low air” SCBA emergencies. 

• Fire departments should ensure Mayday training programs are developed 

and implemented so firefighters are prepared to call a Mayday. 

• Fire departments should ensure crews are properly assigned when 

operating in an Immediately Dangerous to Life and Health atmosphere.

• Fire departments should ensure firefighters communicate critical incident 

benchmarks to the incident commander throughout the incident.

• Fire departments should ensure all fireground ventilation is coordinated 

with firefighting operations. 
NIOSH Fire Fighter Fatality Investigation and Prevention Program 11

Recommendations

• Fire departments should ensure a single, effective incident management 

system is established with one designated incident commander, especially 

when multiple fire departments respond to automatic aid incidents.

• Fire departments should ensure firefighters are trained in fireground survival 

procedures. 

• Fire departments, local and municipal governments, and authorities having 

jurisdiction that have adopted the Mutual Aid Box Alarm System should 

participate in joint area-wide training exercises so that consistent procedures 

can be implemented and enforced. 

• 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.

• Municipalities should ensure fire department telecommunicators are properly 

trained and certified, which includes the operation of alarm box cards for 

proper dispatching of resources. 
NIOSH Fire Fighter Fatality Investigation and Prevention Program 12

CONTACT US

Fire Fighter Fatality Investigation and Prevention Program

Surveillance and Field Investigations Branch

Division of Safety Research

NIOSH 1000 Frederick Lane, MS 1808

Morgantown, West Virginia 26505-2888

FFFIPP Webpage

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