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2016

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October 25, 2019

Career Fire Fighter Critically Injured During Surf Rescue Training 

Dies Two Days Later—Hawaii 

Executive Summary

On June 16, 2016, a 63-yearold male career fire fighter 

died two days after being 

critically injured during a 

surf rescue training exercise. 

The fire fighter, acting as the 

swimmer, was riding prone 

on the yellow rescue sled

being towed by a rescue 

watercraft operated by 

another fire fighter (see 

cover photo). After cresting 

a large wave, the operator of 

the watercraft noticed that 

the swimmer had fallen off 

and discovered him floating 

face down in the surf. The 

operator jumped off of the 

watercraft, swam to the 

swimmer and got his head 

out of the water. The 

operator swam the 

unconscious swimmer back

to the watercraft and placed him on the rescue sled. He boarded the watercraft and started towing the

sled towards shore, however the swimmer fell off again. The operator jumped off the watercraft a

second time to come to the aid of swimmer. This time the safety lanyard for the engine kill switch on 

the watercraft broke and the watercraft continued moving away. An off-duty fire fighter happened to 

be surfing nearby and noticed the empty watercraft motoring away and saw a fire fighter’s yellow

rescue helmet in the surf water. He surfed a wave over to the watercraft, boarded it, and drove to the 

two fire fighters in the white water. The operator and the off duty fire fighter got the swimmer onto the 

sled, continued on to the shore where they immediately initiated CPR. The fire fighters from their

company who had remained on the beach drove to the site where the swimmer had been brought to 

shore and assisted with resuscitation efforts. Rescue arrived on the scene and the swimmer was 

transported to a local hospital where he died 2 days later.

The fire fighter was a passenger laying prone on the yellow sled 

attached to the watercraft. He was severely injured and later died 

after his head struck the rear of the rescue water craft (RWC) 

while cresting over a large wave during a training session.

(Cover Photo Courtesy of Fire Department) 
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Report # F2016-12

Contributing Factors

• Fire fighter riding prone on rescue sled while cresting large wave

• High risk surf conditions

• Accountability and communications, water rescue crew operating in surf while out of visual

contact with shore-based personnel

• Water rescue crew operating alone in a dangerous high risk surf condition

• Failed safety kill switch lanyard 

Key Recommendations 

• Fire departments and organizations who operate rescue water craft (RWC) should consider

having the swimmer ride seated on the RWC vs riding kneeling or prone on the rescue sled.

• Fire departments should ensure that the incident commander conducts a risk-versus-gain

analysis prior to committing to special operations in high risk surf conditions and continues the

assessment throughout the operations.

• Fire departments should ensure that accountability and communications of all water assets are

maintained even when crews operate out of site from land based crews.

• Fire departments should consider sending two rescue water rescue craft that operate in pairs

in high risk surf conditions and always during training.

• Fire departments should ensure that a safety officer trained in the special operations discipline

is appointed at all special operation water rescue incidents and training events.

• Fire Departments should ensure that safety kill switch lanyards are replaced/repaired in

accordance with a preventative maintenance program.

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and 

Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of 

work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the 

NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire 

fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The 

agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or 

assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH 

investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop 

a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and 

interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH 

report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's 

recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page 1 

2016

12

October 25, 2019

Career Fire Fighter Critically Injured During Surf Rescue Training 

Dies Two Days Later—Hawaii 

Introduction 

On June 16, 2016, a 63-year-old male career fire fighter died after being critically injured during a surf 

rescue training exercise. On June 17, 2016, the U.S. Fire Administration notified the National Institute 

for Occupational Safety and Health (NIOSH), Division of Safety Research, Fire Fighter Fatality 

Investigation and Prevention Program of the incident. On June 30, 2016, the fire department contacted 

NIOSH to discuss the possibility of NIOSH investigating the incident. On July 24-31, 2016 an 

investigator with the NIOSH Fire Fighter Fatality Investigation and Prevention Program traveled to 

Hawaii to conduct an investigation. The NIOSH investigator met with the fire chief and executive 

officers and staff of the fire department. The investigator also met with personnel from the State of 

Hawaii Occupational Safety and Health office (HIOSH). During the investigation, witness statements 

were reviewed and interviews were conducted with the fire fighters and fire officers involved in the 

incident. The investigator also met with the representatives of the state department of Labor and 

Industrial Relations, Hawaii Occupational Safety and Health Division and officers from the 

International Association of Fire Fighters local union. The NIOSH investigator inspected the personal 

protective equipment used by the victim and the watercraft involved in the training incident and 

reviewed fire department standard operating procedures, training records from the department, and 

audio radio transmissions.

Fire Department

The fire department involved in this incident is a career department consisting of 1,150 members that 

provide fire and rescue protection as well as surf rescue. There are 43 fire stations located strategically 

throughout the city and county that serve a population of approximately 1.1 million in a geographic 

area of approximately 620 square miles. These fire stations house 43 fire engines, 16 aerial ladder 

trucks, 2 heavy rescue trucks with boats and SCUBA dive team members, 2 hazardous materials 

trucks, 2 helicoptors, and 6 tankers. The department operates 11 rescue water craft (RWC) for surf 

rescue. These are mounted on trailers and housed at 11 fire stations located throughout the island with 

370 fire fighters trained to operate them. There are 22 battalion chiefs, 4 assistant chiefs, 1 deputy fire 

chief and a fire chief. The fire department has a safety division which consists of the Battalion Chief, 

Occupational Safety and Health Office, 2 Fire Captains, 1 Safety Specialist, and a civilian. 

The training site was a popular surfing area located 600-700 feet out from the shoreline and 

approximately 3,293 feet down the beach and out of the line-of-sight site from the engine and ladder 

company staging area and RWC launch area (see training, launch and staging site Photos 1-5).
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 1. Line indicates just offshore of RWC launch area on the left and surf area where the victim 

fell off the sled on the right. Total distance traveled from launch area to incident area was 

approximately 3,293 feet or 1003 meters.

(Photo courtesy of Google Earth and modified by Fire Department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 2. Direct distance from incident area to shore is approximately 619 feet or 188 meters. This is 

the approximate path that the victim was brought to shore where emergency medical care was

provided by Engine 7 and Ladder 7.

(Photo courtesy of Google Earth and modified by Fire Department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 3. The red circled areas are the offshore breaks and training area where the incident 

occurred. The green area between the circles is a channel of deeper water to the shore. These deeper 

water channels can aid navigation (going out past the breakers and then back into shore areas) by 

having less breaking wave action.

(Photo courtesy of Google Earth and modified by Fire Department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 4. E-7, L-7 staging area and RWC launch site. 

(Photo courtesy of Fire Department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 5. E-7, L-7 staging area and RWC launch site. 

(Photo courtesy of Fire Department)
Page 7 

Report # F2016-12

Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Training and Experience 

The State of Hawaii does not have requirements for fire fighter training, however the department in 

this incident is accredited by the Commission on Fire Accreditation International (CFAI). The 

department has a comprehensive fire academy and does have minimum training requirements. They 

consist of International Fire Service Accreditation Congress (IFSAC) certification for Fire Fighter 1

and 2, Hazardous Materials Awareness level and Hazardous Materials Operations level. Additional 

academy training includes Emergency Medical Technician-Basic and Water Rescue training (48 hour 

class).

The fire fighter (victim) in this incident had more than 21 years of experience as a professional fire 

fighter with this department. He had completed the department’s required training including the 

following documented training: 

• Fire Fighter I

• Fire Fighter II

• Emergency Medical Technician (B) National Registry

• Rescue water craft/surf rescue training

The department in this incident has an extensive SOP covering surface water rescue including the 

training, operation and use of the rescue water craft. Additionally, the department requires all 

instructors for the RWC program to undergo extensive operator training and complete a water physical 

agility course that consists of:

• A 1,000 yard run followed by a 1,000 yard swim to be completed in less than 25 minutes

• A 400 yard paddelboard in less than four minutes

• A 100 yard run followed by a 100 yard swim and 100 yard run in less than three minutes

• An 80 hour rescue water craft instructor course

• The department’s water safety program (must possess a current certification card)

• The department’s operator training program for towing familiarization (one time only)

Fire department personnel who operate the rescue water craft in emergency response incidents 

complete:

• An initial 56 hour rescue water craft field operators program training course

• A minimum of 10 hours quarterly training for rescue water craft proficiency
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Report # F2016-12

History of the department and water rescue. 

The department in this incident has a mission statement that states they shall “provide for a safer 

community through prevention, preparedness and effective emergency response.” Department 

personnel respond to various types of hazardous environments which include emergencies that occur in 

the ocean up to 3 miles off-shore. The island is surrounded by 277 miles of shoreline and the 

department is often dispatched for persons that are missing or that require assistance in the ocean. They 

include surfers, kayakers, boaters, swimmers and paddle boarders. During the mid-1990’s the 

department implemented motorized watercraft as an additional resource to be used during search and 

rescues. The department has 11 rescue water craft (RWC) staged at various fire station locations 

around the island. 

Equipment and Personnel

Units that initially responded to the training site: 

• E-7 (Engine 7) with 4 personnel including an officer 

• L-7 (Ladder 7) with 3 personnel including an officer 

Water Rescue Craft and PPE. The 3 passenger RWC was manufactured in 5/2014 and was constructed 

of fiberglass reinforced plastic powered by a 4 cylinder, 1812 cubic centimeter, 180 horsepower 

inboard jet drive with 137 hours logged on the dash display. The watercraft weighed 822 pounds and 

was 140 inches in length. The model number was FB1800-NB. The victim and the operator were both 

wearing a water rescue life vest and helmet and the operator had a wrist lanyard kill switch that failed 

to stop the water craft due to a separation of the lanyard (see Photos 6-13). 
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 6. Rescue Water Craft (RWC involved in this incident ) with rescue sled attached and 

oriented in the use position. 

(Photo courtesy of fire department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 7. RWC shown with modified connection for the rescue sled attachment. The bow of the 

rescue sled is attached and riding on the rear of the RWC. The manufacturer of the water craft 

does not make the rescue sled or the transom attachment. 

(Photo courtesy of the fire department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 8. Sled orientation to rear grab bar where the victim likely struck his head. This distance 

is measured at approximately 14 inches with the rescue sled in the dowward orientation and 

decreases to 8.5 inches as seen in photo 9. Riding prone on the rescue sled has many 

disadvantages for the swimmer with the main disadvantage of the swimmer being thrown 

forward or forward inverted (the slang term for this is being scorpioned), and striking the rear of 

the RWC.

(Photo courtesy of fire department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 9a. Yellow tape and square showing the distance between the area of the rescue sled where a 

passengers head would likely be when the rear of the sled is in the upward most position. The 

distance is approximately 8.5 inches. The distance to the RWC rear seat grab bar changes 

approximately 6 inches with the rise and fall of the rear of the rescue sled.

(Photo courtesy of fire department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photos 9b and 10. The connection at the rear of the RWC and the front of the sled prevented side 

to side but not the up and down motion of the rear. The amount of up and down movement for 

the rear of the rescue sled was 18 inches. Photo 10 on right measures distance of rear of the 

rescue sled to a level running position and Photo 9b on left shows the level of rise is 

approximately 18 inches from a level running position.

(Photos courtesy of the fire department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 11. Victim’s helmet. Photo courtesy of fire department.

Photo 12. Victim’s life vest. Photo courtesy of fire department.
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 13. Most personal watercraft are equipped with a safety lanyard that either kills the engine or 

throttles the watercraft to neutral so operators who may have fallen off can re-board without the 

watercraft driving away. This watercraft had a safety lanyard that failed due to hidden corrosion

underneath the outside covering. This photo shows the corroded area where the lanyard break 

occurred. The second time the RWC driver jumped in to help the fire fighter who fell off the sled,

the RWC kept motoring away from them because the lanyard key stayed in the safety switch and the 

wristlet stayed on the operators wrist. 

(Photo courtesy of the fire department)
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Report # F2016-12

Timeline 

This timeline is provided to set out, to the extent possible, the sequence of events according to 

recorded radio transmissions. Times are approximate and were obtained from review of department 

reports, records, witness interviews, and other available information. Some of the times have been 

rounded to the nearest minute. This timeline is not intended, nor should it be used, as a formal record 

of events. 

Incident and

Fire ground Conditions Time Response & Fire ground Operations

Shift change June 14, 2016. 0800 Engine 7 and Ladder 7 crews report to 

work. 

Morning shift meeting. 0830 Quarterly rescue water craft training 

discussed to take place from 0930-1400. 

Engine 7 captain provided training 

objectives which included beach launching, 

retrieving and area familiarization by water 

for various surf entry, exit zones and 

channels.

Engine 7 captain notified Battalion 

Chief of Training scheduled for the day 

for Engine 7 and Ladder 7. 

0830 Battalion Chief acknowledged and advised

Captain to monitor the surf conditions 

because a surf swell was expected to build 

throughout the day. 

Engine 7 arrived at the training site and 

notified local lifeguard that they would 

be conducting training that day in the 

area.

1000 While waiting for Ladder 7, Engine 7 

personnel performed a risk assessment and 

noted wave heights 2-4 feet in that area. 

Ladder 7 arrived at training site. 1015-1030 Both crews started the training with launch 

procedures. Two fire fighters, 1 from 

Ladder 7 [noted in report as RWC operator] 

and 1 from Engine 7 [noted in report as 

swimmer] volunteered for the first 

evolution. 
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Incident and

Fire ground Conditions Time Response & Fire ground Operations

RWC with operator and swimmer riding 

prone on the sled proceed 200 yards off 

shore.

1033 RWC operator conducts a radio check with 

the Engine Captain while still within sight

of launch site, radio check was received as 

loud and clear, Engine Captain instructed

RWC operator to check in every 15 

minutes.

RWC operator acknowledged radio 

transmission and headed towards open 

ocean and then turned towards the 

training area in a surf zone.

1033 Training area surf zone is not within site of 

the launch area.

The RWC and sled had already crested 

over two waves described as white wash 

and the operator had looked back after 

both waves and ensured the swimmer 

was still on the sled.

1033-1043 The watercraft crested a 3rd large wave (not 

broken). The RWC operator looked back 

and saw the swimmer face down in the 

water and he jumped off the and swam to 

the swimmer approximately 5 feet away.

When the operator jumped off the 

RWC, the kill switch lanyard operated 

as designed and shut off power to the 

RWC.

RWC operator rolled him face up and was 

able to pull the unconscious swimmer onto 

the rescue sled, climbed back on the RWC, 

started it and tried to motor to shore. 

The RWC operator’s mic is keyed a 

number of times then a transmission 

from RWC operator that they needed 

help.

1044-1046 RWC operator called command and told 

them he had an injured fire fighter (victim), 

he had him on board and was heading in. E7 personnel heard the radio message and 

tried to get the RWC’s location no success. 

E-7 personnel notified life guard stand that 

they needed assistance with an injured fire 

fighter and requested lifeguard RWC 

(Rescue 1). Lifeguard contacted their 

Rescue 1 to respond.

The RWC operator was heading directly 

back to shore in white water when the 

unconscious victim fell off the sled 

again. The operator jumped off the sled 

and swam to the victim.

 Approx1046-1059This time when the operator jumped off the 

RWC, the kill switch lanyard broke and the 

retainer key stayed in the ignition lock and 

failed to kill the engine. The RWC motored 

away from both fire fighters.
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Incident and

Fire ground Conditions Time Response & Fire ground Operations

An off duty fire fighter was surfing 

nearby, saw the RWC motoring with no 

one on it and recognized it as a fire 

department RWC. He surfed a wave 

over to the RWC, abandoned his surf 

board, climbed on the RWC and 

motored over to fire fighters in the 

water.

Approx.-

1046-1059

RWC operator was with the victim and gave 

rescue breathing and chest compressions 

while holding his head above water. Both 

fire fighters were floating in the water alone 

at this point with no RWC.

The off duty fire fighter drove the RWC 

over to the two fire fighters.

Approx-1046-

1059

The off duty fire fighter, RWC operator 

were able to secure the victim to the sled 

and they drove the RWC to the shore.

The off duty fire fighter and the RWC 

operator pulled the victim on to the 

beach and began CPR and mouth to 

mouth rescue breathing, Ocean rescue 

lifeguard RWC arrived on the scene and 

assisted with CPR.

Approx-1046-

1059

Ladder 7 had left the launch site looking for 

the RWC. The drove up to a high rise and 

went to the 10th floor where they spotted the 

RWC on the beach and notified other units.

Ladder 7, Engine 7 and Ocean Rescue 

lifeguard personnel all provide BLS 

shore side and package the victim and 

moved to the roadside to meet and 

ambulance.

1059

EMS unit arrives at the roadside 

location where the crews were working 

on the victim.

1112 Advanced Life Support (ALS) is started on 

the victim and he was transported to a local 

hospital

June 16, 2016 2 days later the victim died from his 

injuries.
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Report # F2016-12

Weather and Surf Conditions

According to the department, at the time of the incident the temperature was approximately 82 degrees 

Fahrenheit with a relative humidity of 63%. Visibility was clear at 10 miles and the average wind 

speed was 15 miles per hour from the east with gusts up to 29 miles per hour. 

There was a high surf advisory on the day of the incident with surf conditions of 5 to 8-foot faces. 

Faces is a surfing term that describes the front of the wave (see Diagram 1). The department reported 

that the National Oceanic and Atmospheric Administration (NOAA) indicated that on the day of the 

incident at 2 p.m., the surf was reported to be 6 to 10-foot faces and winds 23 to 34 miles per hour. 

The department also reported that a witness who was surfing at the specific surfing area where the 

incident took place reported wave heights at 8 feet with occassional waves in the 8-10 foot range. 

Diagram 1. Wave and surf terms. Courtesy of surfing-waves.com
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Report # F2016-12

Investigation 

On June 16, 2016, a 63-year-old male career fire fighter died after being critically injured during surf 

rescue training 2 days prior. 

On 0830 hours on June 14, 2016, Engine 7 and Ladder 7 personnel attended the morning shift meeting 

to discuss a planned quarterly rescue water craft (RWC) training that was scheduled to take place that 

day from 0930-1400 (Note: The Rescue Water Craft and attached rescue sled are referred to in this 

report as RWC). The captain from Engine 7 provided the training objectives which included specific 

practical training on launching and recovering the RWC and water/surf operations with the RWC that 

included towing the rescue sled with the RWC driver and passenger and familiarization of the specific 

watercraft operating areas. The purpose of the familiarization was to identify areas where the RWC

could operate such as channels in the surf area and entry and exit zones to get in and out of break zones 

and back and forth to shore areas. 

The training session goals were to provide recurring training and familiarization with RWC launch 

procedures, and increase familiarization with the surfing spots that consist of looking for entry and exit 

points through the surf line and hazards. This quarterly training requires a minimum of 10 hours of 

practical skill training per quarter.

The Engine 7 Captain notified the Battalion Chief of the training that day for both Engine 7 and Ladder 

7, the estmated length of the training and the location of the staging and launch area for Engine and 

Ladder 7 and the RWC. The Battalion Chief acknowledged and advised the Captain to monitor surf 

conditions because the surf swell was expected to build throughout the day. 

The site where Engine 7 and Ladder 7 staged and launched the RWC was identified as one of the 

primary launch sites within the companies’ district. It provides a launch site protected from large 

waves and also provides easy access to launch the RWC through the sand into the water (see Photo 5). 

After Engine 7 arrived, they notified the local lifeguard in the stand that they would be conducting 

RWC training that day. Note: The lifeguard service is a professional career municipal service 

providing lifeguard service in many (but not all) beach areas for swimmers. The life guard service also 

has a RWC. 

While waiting for Ladder 7 to arrive at the launch site, Engine 7 personnel performed a risk 

accessment and reported wave heights in the immediate area at 2 to 4 feet (see Diagram 1). The 

department reported that the increased wave heights that day provided an opportunity for personnel to 

observe surf breaks that are not apparent until larger wave heights are present. 

Ladder 7 arrived at the launch site and the training began with launching of the RWC and two 

personnel. Two fire fighters volunteered for the first training mission, 1 from Ladder 7 as RWC 

operator and 1 from Ladder 7 as swimmer. 
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

They launched the RWC and motored out from shore approximately 200 yards. The RWC operator 

conducted a radio check with Command (E-7 Captain) and Command answered loud and clear and 

also told RWC to check in every 15 minutes. The RWC with the operator seated on the ski and with 

the swimmer riding prone on the sled, headed in a northerly direction parallel to the shore 

approximately 1000 meters to the training area (see Photo 1 ). 

After traveling to the training area where the surf break was occuring, they entered the area and started 

to operate in the heavy surf. This area was approximately 188 meters offshore in a surf zone (see 

Photos 2, 3).

The RWC crested over a couple of large waves, then after cresting one of the waves, the operator 

noticed that the swimmer had fallen off. This is the likely point where the swimmer struck his head on 

the rear of the RWC and sustained blunt force injury of head and neck. The operator turned the RWC 

around and motored over toward the swimmer and discovered him face down floating in the surf 

water. The operator jumped off of the watercraft, got the swimmer’s head out of the water and placed 

him back aboard the sled. The operator boarded the RWC and headed towards shore. The RWC 

operator called over the radio to Command and advised that he had an injured fire fighter and that he

was able to place the swimmer (victim) on the sled and he was heading in. Command called the RWC 

back on the radio trying to identify their location. They did not receive a radio response (Note: The 

portable radio that the RWC operator was using was sealed in a water proof plastic pack, however an 

ear piece modification had been added so the user could hear the radio in the noisy operating 

conditions. The FD Safety office discovered during a post incident inspection that the ear piece wire 

had severed and the plastic seal modification had failed and water had penetrated and came in contact 

with the portable radio).

Approximately half way in to the shore the victim fell off again and the operator jumped off and swam 

to him a second time. The RWC operator was able to keep the now unconsious victim’s head out of the 

water, however, the kill switch lanyard on the watercraft had broken when the operator jumped off and 

the engine did not shut down. The RWC motored off with no one on it.

Back at the launch site Engine 7 made multiple attempts to radio the RWC with no success. One of the

E-7 members walked over to the lifeguard stand and notified them that they had an injured fire fighter 

on their RWC and to request the lifeguard service send their lifeguard RWC (Rescue 1) to help. One of 

the radio transmissions from the fire department’s RWC noted “Suicides Surf Break” (a well known 

surf site) and personnel from Ladder 7 heard the broken transmission and headed to the site by land.

The RWC operator kept the victim’s head above the water and began in-water resusitation. These 

events took place in deep water almost 200 meters from shore. The operator could not stand up on the 

ocean floor to gain an advantage for lifting or positioning the swimmer. Additionally, the remote mic 

for operator’s portable radio had stopped working and his whistle was not on the end of the safety 

lanyard on his wrist. The operator now had very little ability to signal distress.
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

An off duty fire fighter happened to be surfing nearby, noticed the empty RWC motoring riderless and 

saw a fire fighter’s yellow rescue helmet in the surf water. He surfed a wave and paddeled over to the 

rescue watercraft, boarded it and motored back to the two fire fighters in the white water (white water 

is a term used to describe the wash of very turbulent water just after the wave has crashed and before 

the next wave hits, see example in Photo 14). Since the kill switch key was still connected in the 

switch, the engine was still running and the off duty fire fighter was able to operate it.

The RWC operator and off-duty fire fighter got the victim onto the sled and all three fire fighters made 

their way to shore. The three got to the beach and CPR was begun. The lifeguard service Rescue 1 

(RWC) arrived at the beach and assisted with resusitation.

The Engine 7 and Ladder 7 fire fighters drove to their location and also assisted with resusitation 

efforts. Ladder 7’s automated external defibrillator (AED) was placed on the victim with multiple “no 

shock advised”. Full C-spine protocols were administered and the victim was moved from the beach to 

a shore wall with CPR continuing throughout. An advanced life support (ALS) rescue unit arrived on 

the scene and the victim was transported to the hospital. He was successfully resusitated on the way to 

the hospital where he was admitted, however he died 2 days later.
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Photo 14. Whitewater example, note the surfer in center of the photo. 

(Photograph courtesy of awanderingwombat.com, downloaded from bing images.com )
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Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii 

Report # F2016-12

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 led to the 

fatality: 

• Fire fighter riding prone on rescue sled while cresting large wave

• High risk surf conditions 

• Accountability and communications, water rescue crew operating in surf while out of visual 

contact with shore-based personel 

• Water rescue crew operating alone in a dangerous high risk surf condition 

• Failed safety kill switch lanyard

Cause of Death

According to the chief medical examiner’s report, the fire fighter acting as swimmer died from blunt 

force injury of head and neck with cervical vertebrae fractures and spinal cord injury. Blood gases for 

CO were unremarkable at 2%.

Recommendations 

Recommendation #1: Fire departments and organizations who operate rescue water craft should 

consider having the swimmer ride seated on the RWC vs kneeling or prone on the rescue sled.

Discussion: Riding the rescue sled has many disadvantages for the swimmer with the main 

disadvantage of the swimmer being thrown forward or forward inverted (the slang term for this is

being scorpioned), and striking the rear of the RWC. The passenger riding prone cannot see the 

conditions that the operator sitting on the RWC can see and therefore cannot brace for impact as the 

RWC crests over a wave. This poses a risk for being thrown forward and striking the rear of the RWC

as occurred in this incident. Most rescue water craft are can easily carry both the operator and 1 or 2 

passengers while towing the rescue sled to the scene. Once on the scene the swimmer can get off of the 

RWC and ride on the sled while securing a victim to the sled until a safe area out of the surf zone in 

deeper water or the shore is reached. 

An additional benefit of the swimmer not riding the rescue sled out to the scene is a reduction in 

exposure time to exhaust fumes from the rescue water craft [NIOSH 2012]. In 2006, exposure to 

carbon monoxide from a personal watercraft contributed to the drowning death of a fire fighter during 

surf rescue training [NIOSH 2006]. 

In this incident the RWC was in a heavy surf zone and the operator crested a wave. After cresting over 

the top, the RWC, the rescue sled maneuvered in such a way that the victim was thrown forward and 

struck his head on the rear of the RWC breaking his neck and falling off into the water.
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Recommendation #2: Fire departments should ensure that the incident commander, safety officer or 

lead instructor conducts a risk-versus-gain analysis prior to committing to operations involving a 

high surf condition. 

Discussion: High surf rescue using rescue water craft is a high risk-low frequency event for most 

organizations. The term high surf is relative and has different meaning among surfers on the east and 

west coasts of the United States and certainly may have a different meaning in Hawaii. There are other 

factors that add to the dangers of water rescue beyond wave height and all of those factors have to be 

considered when sizing up a water rescue event, whether for training or actual rescue response. The 

difference is that in a training event there is discretionary time to make a decision based on the highrisk, low frequency analysis. In an emergency event there is little or no discretionary time for decision

making. 

A risk analysis often occurs at three levels, the strategic level, the tactical level and the task level. A 

risk analysis at the strategic level involves evaluating the risk and deciding if the organization is 

willing to accept the risk. An example would be a special operations group for water rescue being 

performed by the fire department. The department can take a number of actions after a comprehensive 

evaluation of the risk and the organizations ability to solve or remediate the risk. The department may 

decide to:

• not accept the risk and not perform the activity, 

• share the risk with other organizations (mutual aid or other public safety organizations), 

• accept the risk wholly and have a special operations group responsible for the program. 

There are many fire departments across the country that have special operations groups for water 

rescue and SCUBA diving. There are few departments globally that perform surf rescue with rescue 

water craft on the size and scale required for the locality of this incident. If a department decides at the 

strategic level to accept the risk or share the risk, there has to be a total commitment to provide the 

resources and training and continued program support. If this commitment level changes due to 

financial or other reasons, a strategic level risk analysis should be repeated. 

At the strategic and tactical level, the incident commander must perform a risk analysis to determine 

what hazards are present, what the risks to personnel are, how the risks can be eliminated or reduced, 

and the benefits to be gained [Kipp JD, Loflin ME 1996]. The difference between an emergency 

incident and a training event should be factored into the risk analysis. The incident commander or lead 

instructor should consider all of the factors and in a training event. Using the discretionary time 

available for the case of training events gives the IC or lead instructor an advantage that can add to fire 

fighter safety. 
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At the task level, the group leaders or rescue team leaders need to perform a risk analysis of the 

operation that they are directly involved in. If as in this incident, they are out of sight of the command 

post and/or the conditions may be too dangerous or exceed the capabilities of the team, the team leader 

needs to be capable of recognizing the risk and calling off or relocating the operation to a less risky 

location, or waiting for additional resources. 

The following language from NFPA 1561 provides guidance for risk management on the fire ground 

and emergency scene and is applicable for water rescues and special operations as well. NFPA 1561 

Standard on Emergency Services Incident Management System and Command Safety, 2014 Edition, 

Chapter 5.3.19 states, “The following risk management principles shall be utilized by the incident 

commander: [NFPA 2014a] 

1. Activities that present a significant risk to the safety of responders shall be limited to situations

that have the potential to save endangered lives. 

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

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

3. No risk to the safety of responders shall be acceptable where there is no possibility to save 

lives or property.

Recommendation #3: Fire departments should consider sending two rescue water rescue craft that 

operate in pairs in high risk surf conditions and always during training. 

Fire departments and other agencies that provide water rescue services should consider sending two rescue 

water craft (assets) that can operate in pairs in high risk conditions. These agencies should always have two 

rescue water craft assets in training evolutions. The risks to the rescuers is similar in both training and 

actual rescue events, however the incident commander and training officer always has time on his or her 

side in a training evolution. This time can be used to wait for a thorough risk/benefit assessment of the 

conditions, number of assets, proper staffing with consideration of personnel capabilities, experience and 

the Knowledge, Skills and Abilities (KSA’s) to be gained. 

The water rescue safety officer should also ensure that a minimum of two water rescue craft are operational 

as the areas of surf rescue operations are frequently not accessible to other land based assets or rescue 

boats. Rescue water craft used in surf rescue require highly trained and skilled operators as well as 

swimmers that accompany them. The rescue water craft are likely the only craft that can assist one another 

in a dangerous surf zone. The personnel riding on these craft may not be able to communicate if they get 

knocked over or off of the craft. The second rescue water craft cannot only assist the first craft but may be 

able to communicate the situation to command. Essentially, this second craft can assist the first craft on the 

rescue or be a water-borne Rapid Intervention Team (RIT). The safety officer should also help identify 

other possible RIT assets such as pre-staging additional Rescue Water Craft (RWC) and air assets from 

their or other agencies. 

Based upon the size and complexity of an incident, the Incident Commander should delegate 

responsibilities that include safety for the technical discipline being performed and also assign a safety 

officer for the incident scene. The incident command system can be expanded to include functions 
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necessary to effectively command and control an incident. Though the Incident Commander is still 

responsible for the safety and welfare of all members and first responders on-scene, this responsibility 

is delegated to the Incident Safety Officer [NFPA 2014a]. Upon confirmation, the water rescue safety 

officer should obtain the following information: 

• Meet with the Incident Commander, command staff and water rescue team leader and discuss 

the needs and advise on the risk vs. benefit analysis at the strategic level and the tactical level. 

Does the benefit of the operation justify the risks to the personnel to achieve it?

• Overall situation status and resource status, resource capabilities 

• Strategy and incident action plan (rescue plan)

• Known hazards and concerns (weather, surf height, degree of difficulty, water and 

environmental complications)

• Status of water rescue crews, crew leaders, crew capabilities, crew competencies, air assets,

equipment, and personnel accountability

• Ensuring the water rescue crews are following the plan and accurate event monitoring and 

recording are taking place

• Back-up water rescue team assets

• ALS standby for medical care for rescuers

• Establishment of the rehabilitation group 

• Confirmation of established radio communication channels (command channel, tactical 

channels) 

The water rescue safety officer should don the personal protective equipment appropriate for the 

potential hazards that he/she will be exposed to (e.g., auto-inflating or standard personal floatation 

device (PFD) or float coat for colder weather). Also, the water rescue safety officer should be 

identified by a vest or helmet. 

The water rescue safety officer should meet with the Technical Rescue Group Leader, Incident Safety 

Officer, and Incident Commander and develop a communication plan and coordinate their activities. 

The Incident Safety Officer is responsible for overall safety of the incident scene and reports to the 

incident commander. The water rescue safety officer reports to the Technical Rescue Group Leader, 

however coordination and communication between the safety officers can be advantageous on large 

complex missions. 

NFPA 1521 Standard for Fire Department Safety Officer Professional Qualifications defines the role 

of the Incident Safety Officer (ISO) at an incident scene and identifies duties such as recon of the 

incident scene and reporting pertinent information back to the Incident Commander; ensuring the 

department’s accountability system is in place and operational; monitoring radio transmissions and 
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identifying barriers to effective communications; and ensuring established safety zones and other 

designated hazard areas are communicated to all members on scene [NFPA 2015].

The presence of an Incident Safety Officer or technical rescue group Safety Officer does not diminish 

the responsibility of individual rescuers and group leaders (e.g., boat teams) for their own safety and 

the safety of others. The dedicated Incident Safety Officer and water rescue safety officer add a higher 

level of training, attention, and expertise to help the Incident Commander. The Incident Safety Officer 

and water rescue safety officer must have particular expertise in analyzing safety hazards and must 

know the particular uses and limitations of protective equipment. For example, while the technical 

rescue group safety officer may be focused on the safety of the water craft rescuers, the incident safety 

officer can help ensure the safety of the land support fire fighters and other agencies that may be on 

scene [Dodson 2007; Dunn 2000; NIOSH 2009].

The water rescue safety officer has a different area of responsibility than the Incident Safety Officer. 

He/she has the specific knowledge, skills, qualifications, and experience to oversee the safety of the 

members of the technical rescue group and the mission they are performing. Experience in the 

technical rescue discipline being performed is an extremely valuable resource. They must have that 

level of experience to recognize realistic mission goals, team and resource capabilities, team member 

capabilities, and team member limitations and have the discipline and authority to add, change, 

modify, intervene or stop an unsafe operation. This is especially important in technical rescue high surf 

training operations (where time is on their side to wait for additional rescue water craft to arrive and 

provide a RIT resource). The Incident Safety Officer working together with a trained and experienced 

water rescue safety officer can provide a fire department with a higher level of expertise to perform the 

necessary incident scene functions and assist the Incident Commander with incident scene safety. 

Recommendation #4: Special operations water rescue teams should have a Safety Officer on scene 

who is trained in the discipline before commencing rescue water craft operations. 

Discussion: NFPA 1670, Standard on Operations and Training for Technical Search and Rescue 

Incidents, Chapter 4.5.2, states that “at technical search and rescue training exercises and in actual 

operations, the incident commander shall assign a safety officer with the specific knowledge and 

responsibility for the identification, evaluation, and where possible, correction of hazardous conditions 

and unsafe practices [NFPA 2014b]. The assigned safety officer should meet the requirements 

specified in NFPA 1521 Standard for Fire Department Safety Officer [NFPA 2015]. It is especially 

important to have that specialized and local knowledge when confronted with geographical conditions 

that are not found in many other locations (e.g. regular and extremely large surf conditions and 

frequent emergency incident call demands for rescue).

Safety officers assigned to special operations incidents, such as technical rescue water rescue incidents, 

need expertise in the specific technical rescue field to effectively evaluate surf hazards and provide 

direction with respect to the safety of all personnel [NFPA 2013]. A qualified fireground safety officer 

might not possess the necessary expertise in water rescue craft operations and, therefore, might not 

recognize or understand capabilities of the team members, severity of the surf conditions, limitations 

and hazards to rescue workers, the need for specialized equipment appropriate for water rescue 
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operations problems with equipment, or performance issues of personnel (e.g., undertrained for the 

mission at hand). NFPA 1521 notes, “in cases where the designated incident safety officer does not 

possess the technician-level training, appointing a technician-level trained assistant or technical 

specialist with the necessary training will help satisfy the safety needs of the technician-level 

members.” As stated earlier, this incident occurred in a locality that experiences surf conditions seldom 

experienced by other water rescue agencies in the United States. It is extremely important to have a 

qualified water rescue safety officer with experience in the expected conditions.

The water rescue safety officer has the critical advisory role to the Incident Safety Officer (ISO) and 

the incident commander on the risk vs. benefit on the strategic and tactical levels. A safety officer 

properly trained in the technical rescue field being performed can also help prevent a swimmer from 

attempting a skill beyond their level of training. The incident safety officer should be integrated into 

the incident command structure [NFPA 2015].

A safety officer, specifically trained and qualified water rescue can evaluate, monitor, and advise the 

incident commander on the incident action/rescue plan. He/she can help with primary decisions 

regarding rescue/recovery, weather, surf, resources team capabilities, outside resources, water

conditions, rescue plan activities such as approach paths, escape paths, water depth, water rescue plan 

complications, and operations to determine whether they fall within the criteria as defined by the fire 

department’s risk management plan. He/she should also ensure pre-incident safety checks as well as 

monitor the health and well-being of the rescuer’s pre-incident and post-incident. 

NFPA 1561 Standard on Emergency Services Incident Management System and Command Safety 

states in Paragraph 5.3.1 that "the Incident Commander shall have overall authority for management of 

the incident"[NFPA 2014a]. NFPA 1561 Paragraph 5.3.2 states, "The Incident Commander shall 

ensure that adequate safety measures are in place" [NFPA 2014a]. However, technical rescue incidents 

require that the incident commander have a safety officer who is trained in the discipline e.g. SCUBA, 

Water Rescue, Confined Space Rescue, High Angle Rescue, Hazmat, and Trench Rescue) and dedicated to 

the specific operation. 

A safety officer for a technical rescue water rescue incident should also be located where the operation is 

taking place. They can help to evaluate and monitor the water conditions, the incident action plan, the 

operation, evaluate resource status, ensure accountability and pre-incident safety and equipment checks, 

continuously evaluate member abilities and capabilities, and ensure that all operational function positions 

are staffed and qualified backup rescue personnel are in place to aid in the event of complications.

Recommendation #5: Fire departments should ensure that a stationary command post is established 

and effectively communicate with the team members on training as well as actual special operations 

incidents.

Discussion: Fire departments should train their command officers to establish a stationary command 

post and effectively communicate with the team members on training incidents as well as actual 
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special operations water rescue incidents. Often, the conditions that create the high risk events are 

present in training evolutions (e.g. dangerous heavy surf, far from shore).

While it may be easy for some command officers to effectively command a rescue event from a mobile 

position (on foot away from a command post) when everything is going well, when critical 

communications occur or significant events occur it is possible to miss those communications with all 

of the incident and environmental noise and confusion that can occur. 

Much like Command responsibilities at small residential fire incidents or other smaller events, some 

officers may be more comfortable with operating outside or away from a formal stationary command 

post because they may have a very good comfort level developed from past experience. However, this 

comfort level can easily be challenged when faced with unexpected conditions such as a Mayday or an 

overturned rescue water craft, an empty RWC floating in the surf zone, missing water rescue members.

or an emergency radio transmission that may not be heard by the incident commander.

A critical function of command is to allow for clear communications with his/her divisions, dispatch 

and other agencies. Many times, a mobile commander may not hear an emergency communication due 

to many outside influences or factors. If the incident commander is mobile and a emergency or 

Mayday transmission is made by radio on a different channel, the incident commander may miss the 

transmission and a delay in taking action could occur.

In addition to a stationary command post, effective communication can assist the incident commander 

to formulate a rescue plan by using RIT and/or building a rescue group comprised of multiple RIT 

crews and a rescue group leader. In many instances an already established RIT can be put into action 

and managed by the incident commander. However in some cases, the responsibilities may be divided 

and a rescue group established and given direction by a division commander. 

Many things need to be coordinated once a Mayday has occurred. If the Incident Commander is trying 

to perform all of these functions away from a formal command post setting (by themselves), they can 

be quickly over tasked and may overlook critical needs. Building a command team at a formal 

command post can help an incident commander develop and organize the strategy and tactics that will 

match the incident. A command team that is properly set up can provide direction, assign 

responsibilities and have the advantage of clear communications.

An incident action plan and command of an emergency incident scene is best performed by a 

command team at a stationary command post with functions written down. In the rare event such as a 

Mayday, a check list may help to trigger response functions. We have included an example Mayday 

check sheet for fire incidents that can be modified for special operations in the appendix.

Muscle memory/repetitive skill training is just as important for an incident commander as it is for fire 

fighters “knowing their SCBA.” This ability to command emergency incidents is learned not only 

through didactic training but skill development with hands on training. Consistently establishing a 

formal command on smaller incidents or training incidents is a good method to build command 
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training skillsets (including special operations incidents). This can benefit the experienced incident 

commander, however it is a critical skill building process for newer officers or those “acting” in these

roles. 

Everyone on the emergency incident scene benefits from repetitive skill training including command 

officers. 

Recommendation #6: Fire Departments should ensure that safety kill switch lanyards and other 

critical components of the RWC exposed to salt water are replaced/repaired in accordance with a 

preventative maintenance program.

Discussion: Many RWC are equipped with a safety lanyard that either kills the engine or throttles the 

watercraft to neutral so the operator fell off, he/she could swim back and re-board without the 

watercraft driving away. This watercraft had a wrist mounted safety lanyard that failed due to hidden 

corrosion underneath the outside covering. Photo 13 (page 15) shows the corroded area where the 

lanyard separation occurred. In this incident, the second time the RWC driver jumped in to help the 

fire fighter who fell off the sled, the RWC kept motoring away from them because the lanyard key 

stayed in the lock and the wristlet stayed on the operator’s wrist. 

As part of an overall preventative maintenance and safety pre-check, critical components exposed to 

salt water including but not limited to the safety kill switch and wrist lanyard, should be inspected and 

replaced on an established schedule. Old lanyards or other safety devices that are replaced should be 

destroyed or made inoperable so they can’t be mistakenly used or placed back in service. 

Recommendation #7: Incident commanders should ensure accountability and maintain situational 

awareness on special operations water rescue events and incidents.

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. All officers 

and fire fighters operating at technical rescues (i.e. special operations, water rescue, SCUBA, swift 

water events) should maintain accountability and situational awareness. The nature of the technical 

rescue demands disciplined accountability and a continuous risk assessment throughout the incident. 

Fire departments need to ensure and maintain accountability for all responding and operational 

personnel at the task, tactical and strategic levels. 

An accountability system can be as simple as a team using the buddy system (task level) on a single 

unit minor emergency medical response to a formal command (tactical and strategic level) 

accountability function established such as a technical rescue or large fire response. 

A personnel accountability system can help to reduce exposure to hazardous areas and also potentially 

hazardous areas. A personnel accountability system is a system that readily identifies both the location 

and function of all members operating at an incident scene [NFPA 2014a]. The accountability system 

should be inclusive of all sizes and types of emergency incidents. 
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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. An integral part of the accountability system is to make sure the fire fighters who are 

assigned and operating in the hazard zone are accounted for, starting with the initial operations and 

throughout the entire incident. Also, a system should be in place to periodically check to make sure 

that all members operating in the hazard zone are accounted for.

One of the most important functions of command safety is for the incident commander to initiate a 

personnel accountability system that includes the functional and geographical assignments at the 

beginning of operations until the termination of the incident. NFPA 1561, Standard on Emergency 

Services Incident Management System and Command Safety states in Paragraph 8.12.4, “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 2014a].

Officers, fire fighters/rescuers should report changing or unsafe conditions to the Incident Commander 

or Safety Officer. It is important to train fire fighters and officers to maintain their accountability and 

situational awareness especially regarding performance under changing, unexpected or high surf 

conditions. The training should include a description of what accountability and situational awareness 

are and how it is accomplished in specific technical rescue operations.

The book Essentials of Fire Fighting and Fire Department Operations [IFSTA 2013] defines 

situational awareness as an awareness of the immediate surroundings. On all fire and emergency 

incidents, emergency personnel should be trained to be constantly alert for changing and unsafe 

conditions. Even though a safety officer may have been designated for the incident, it is the obligation 

of all personnel to remain alert to their immediate surroundings. They must maintain their situational 

awareness and be alert for unsafe or previously unseen conditions, e.g., changing surf or weather 

conditions.

Situational awareness can be described as a heightened consciousness of what is currently developing 

or occurring. The opposite of situational awareness is tunnel vision where the personnel become so 

focused on operational assignments or their comfort with past training sessions that they fail to sense 

changes in their environment. 

The International Association of Fire Chiefs (IAFC), Safety, Health and Survival section developed the 

“Rules of Engagement for Structural Fire Fighting”. Although the rules were developed for structural 

fire fighting, they are applicable to special operations water rescue incidents.

The incident scene can create a significant risk to fire fighters and other emergency responders, and it 

is the responsibility of the incident commander and command organization officers to minimize 

emergency responder exposure to unsafe conditions and stop unsafe practices [IAFC 2013].
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The rules of engagement can assist the Incident Commander, company officers, fire fighters and 

emergency responders who are at the highest level of risk in assessing their situational awareness. 

The rules integrate the fire fighter into the risk assessment decision making process. These members 

should be the ultimate decision maker as to whether it’s safe to proceed with assigned objectives. 

Where it is not safe to proceed the rules allow a process for that decision to be made while still 

maintaining command unity and discipline. The following are excerpts from the IAFC rules of 

engagement: 

Rules of Engagement for Fire Fighter Survival:

• Size-up your tactical area of operation (to cause the company officer and fire fighters to pause 

for a moment and look over their area of operation and evaluate their individual risk exposure 

and determine a safe approach to completing their tactical objectives).

• Maintain continuous awareness of your situation, location and emergency scene conditions 

• Constantly monitor communications for critical radio reports.

• You are required to report unsafe conditions or practices that can harm you. Stop, evaluate, 

decide (prevent exposure to unsafe conditions or practices that can harm them and allowing any 

member to raise an alert about a safety concern without penalty and mandating the supervisor 

address the question to ensure safe operations).

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

you (be aware and cause an early exit to a safe area when they are exposed to deteriorating 

conditions, unacceptable risk and a life-threatening situation).

• Declare a mayday as soon as you think you (or another fire fighter) are in danger (ensure the 

fire fighter is comfortable with declaring a mayday as soon as they think they are in trouble)

[IAFC 2013].

The Incident Commander’s rules of engagement for fire fighter safety:

• Rapidly conduct or obtain a size-up of the incident (determine the safest approach to tactical 

operations as part of the risk assessment plan and action development plan before fire fighters 

are placed at substantial risk).

• Conduct an initial risk assessment (and utilize a safety officer and all command staff to 

continue to perform a continuing risk assessment) and implement a safe action plan (cause an 

incident commander to develop a safe action plan by conducting a size-up, assess the survival 

profile and completing a risk assessment before fire fighters are placed in high risk positions on 

the emergency scene).

• If you do not have the resources to safely support and protect fire fighters, seriously consider a 

defensive strategy (prevents the commitment of fire fighters to high risk tactical objectives that 

cannot be accomplished safely due to inadequate resources on the scene).

• Maintain frequent two-way communications and keep interior crews informed of changing 

conditions.

• Obtain frequent progress reports and revise the action plan.
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Ensuring the accountability of every fire fighter, their location and status causes the incident 

commander and command organizational officers to maintain a constant and accurate accountability of 

the locations and status of all fire fighters within a small geographic area of accuracy within the hazard 

zone and aware of who is presently in or out of the zone [IAFC 2013]. 

References 

Dodson D [2007]. Fire department incident safety officer. 2nd ed. New York: Thomson Delmar 

Learning.

Dunn V [2000]. Command and control of fires and emergencies. Saddle Brook, NJ: Fire Engineering 

Book and Videos.

IFSTA [2013]. Essentials of fire fighting, 5th ed. Stillwater, OK: Fire Protection Publications, 

International Fire Service Training Association. 

IAFC [2013]. Rules of engagement for structural firefighting. Fairfax VA: International Association of 

Fire Chiefs, Safety, Health and Survival Section 

http://www.iafcsafety.org/downloads/Rules_of_Engagement_short_v10_2.12.pdf 

Kipp JD, Loflin ME [1996]. Emergency incident risk management. New York: Van Nostrand 

Reinhold. 

NFPA [2013]. NFPA 1500, Standard on a fire department occupational safety and health 

program. 2013 ed. Quincy, MA: National Fire Protection Association.

NFPA [2014a]. NFPA 1561 standard on emergency services incident management system and 

command safety. Quincy, MA: National Fire Protection Association. 

NFPA [2014b]. NFPA 1670 standard on operations and training for technical search and rescue 

incidents. Quincy, MA: National Fire Protection Association. 

NFPA [2015]. NFPA 1521 standard for fire department safety officer and professional qualifications. 

Quincy, MA: National Fire Protection Association.

NIOSH [2006]. Career Captain Dies from Complications of a Drowning Incident due to a Combination 

of Exhaustion, Hypothermia and Carbon Monoxide Poisoning During Surf Rescue Training – 

Washington, By Tarley, J. Morgantown, WV: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, 

F2008-32, https://www.cdc.gov/niosh/fire/pdfs/face200614.pdf 

NIOSH [2009]. Career fire fighter dies while diving for a civilian drowning victim—Rhode Island. By 

Miles S.T., Tarley J, Morgantown, WV: U.S. Department of Health and Human Services, Centers for 
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Disease Control and Prevention, National Institute for Occupational Safety and Health, F2008-32, 

https://www.cdc.gov/niosh/fire/pdfs/face200832.pdf. 

NIOSH [2012]. Evaluation of Carbon Monoxide Exposures During Rescue Operations Using Personal 

Watercraft – Florida By Robert E. McCleery, Alberto Garcia, Cincinnati Ohio, U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, Health Hazard Evaluation Report 2008-0014-3151, 

https://www.cdc.gov/niosh/hhe/reports/pdfs/2008-0014-3151.pdf. 

NIOSH [2016]. Career Probationary Fire Fighter Runs Out of Air and Dies in Commercial Structure 

Fire—Michigan. By Miles S.T., Bowyer M. Morgantown, WV: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, FACE Report F2013-14 https://www.cdc.gov/niosh/fire/pdfs/face201314.pdf. 

Investigator Information

This incident was investigated by Stephen Miles, Investigator/Safety and Occupational Health 

Specialist with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Surveillance 

and Field Investigations Branch, Division of Safety Research, located in Morgantown, WV. 

An expert technical review was provided by Chief Steven Orusa, Fire Chief for the Fishers Fire and 

Emergency Services, Fishers, Indiana. Chief Orusa is also the author of Dive Rescue Specialist, 

Operational Training for Public Safety Divers. He has served over 33 years in law enforcement and 

fire service positions. He is past director of the International Association of Dive Rescue Specialists 

Response Team and has served on public safety and military dive operations worldwide. 

A technical review was also provided by the National Fire Protection Association, Public Fire 

Protection Division. This report was authored by Stephen Miles. 

Disclaimer 

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 

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Page 36

Career Fire Fighter Critically Injured and Dies Two Days Later 

After Falling off Water Rescue Craft During Training—Hawaii

Report # F2016-12

Appendix 1

Exemplar fire-ground Mayday check-off sheet. Departments can modify for special operations.