NIOSH Fire Fighter Fatality Investigation and Prevention Program

F2018-13

Firefighter Dies after Falling 

Through a Floor at a Large Area 

Residential Structure Fire –

Maryland
NIOSH Fire Fighter Fatality Investigation and Prevention Program 2

Summary

• ~0120 hours - Lightning strikes a 

tree in the backyard and travels 

into home through piping in the 

ground.

• 0151 hours - Homeowner calls 911 

to report a lightning strike and 

the odor of smoke in the home, 

but no visible fire.

• 0152 hours – Local box alarm for 

Box 5-62 dispatched: Engine 51 

(E51), Engine 101 (E101), Tower 10 

(TWR10), Battalion Chief 1 (BC1), 

and Paramedic 56 (P56).

An aerial view of the home showing the sides of the house as 

defined by the fire & rescue department.. Note that Side 

Charlie has an upper (1st floor) and lower (below grade) level 

with a swimming pool. 

(Photo courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 3

Summary

• 0200 hours - E51 arrives on-scene and 

reports smoke showing and requests a 

full box alarm for Box 5-62.

• 0201 hours - BC1, enroute, asks E51 if they 

can use the pool in the backyard as a 

water source (E51 is equipped with a 

hydraulic pump).

• 0202 hours - TWR10 arrives on-scene and 

positions on Side Alpha. E101 arrives onscene.

• 0203 hours – E51 re-positions on Side 

Charlie to access swimming pool. Owner 

advises E51 that most of the heavy smoke 

is in the basement. E51 notifies BC1 that 

they will make entry from the “back.” 

• BC1 acknowledges, arrives on-scene, 

establishes Command, and commits to 

offensive strategy.

Crews operating in a defensive strategy working to knock down 

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

taken at approximately 1000 hours.

(Photo courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 4

Summary

• 0206 hours - BC1 aide completes 3600 

size-up. Notifies Command that there 

was smoke in a finished basement on 

Sides Charlie and Delta. 

• 0207 hours - With a charged hoseline, 

E51 and TWR10 enter the structure 

through the laundry room door on Side 

Charlie. E101A and B were on Side 

Charlie with a charged hoseline. Smoke 

conditions were noted with no fire. 

Thermal imagers showed some heat at 

the ceiling and floor, but no fire. Attack 

crews exit the structure.

• 0208 hours - E51 notified Command 

that the fire attack group (E51, TWR10 , 

and now E101) would try to enter 

through the basement.

Diagram of the 1st floor.

(Diagram courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 5

Summary

• 0209 hours – E71 approaching the 

scene asks Command regarding 

water supply. Command responds 

that they will need to bring water 

from the main road, (1,300 feet from 

the driveway).

• 0210 hours – Attack crew enters the 

basement on Side Charlie.

• 0211 hours –Power to the home is 

secured.

• 0212 hours – IRIC in place on Side 

Alpha. All 3 occupants are accounted 

for and outside the home.

• 0213 hours – BC2 arrives on-scene: 

assigned to Division Charlie.

Diagram of the 1st floor.

(Diagram courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 6

Summary

• 0215 hours – E51A notifies Command that 

the fire attack crew has smoke in the 

basement but cannot find the fire. 

• 0216 hours – E101A notifies Command that 

there is heavy fire on the first floor Side 

Charlie (see arrow in photograph). E101A 

orders E101B out of the baseline and they 

begin to pull a 200-foot 1 3⁄4-inch hoseline 

from E51 to the laundry room door. 

• 0217 hours – Command is confused about 

where the attack group is entering the 

structure. TWR10A clarifies that E101 and 

E51 are entering the 1st floor on Side Charlie 

and the basement still has floor to ceiling 

smoke. The attack crew exited the 

basement, closed the door, and headed to 

the laundry room door on the upper level 

of Side Charlie. 

Upper-level Side Charlie. Arrow shows 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 & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 7

Summary

• 0218 hours – T7 assigned to RIC on Side Alpha.

• 0217 hours - E101B advances a 1 3⁄4-inch hoseline through the laundry room and into 

the kitchen/breakfast area with E101A trailing a significant distance behind. 

• 0219 hours - E101B falls through the floor of the breakfast area into a basement level 

crawlspace with heavy fire conditions. 

• 0220 hours - E101A transmits a Mayday on Bravo 1.

• 0221 hours - E101A transmits on Bravo 1 that E101B is in the basement, and they are 

trying to pull him out via the hoseline. Simultaneously, E101B transmits a clear WhoWhat-Where statement on Bravo 2 consistent with Mayday training. 

• E51 and TWR10 try to find E101A and E101B in the zero-visibility conditions. E51B found 

E101A reaching into the hole trying to reach/pull E101B out. E51B began flowing water 

into the hole. E51B also tries to pull E101B out. Due to deteriorating fire and structural 

conditions, E51B, E101A, and TWR10 had to exit the laundry room. 

• 0222 hours - 2

nd Alarm requested for Box 5-62.
NIOSH Fire Fighter Fatality Investigation and Prevention Program 8

Summary

• 0227 hours - PAR requested and two 

members of E51 were unaccounted (E51C and 

E51E). Both were returned to E51 and were 

accounted for by 0229 hours. 

• 0228 hours - Laundry room is about to flash.

• 0231 hours - E51D advises Command “We are 

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

water.”

• 0237 hours - Hydraulic pump in the pool is 

now working and E51 has a water source.

• 0239 hours - 2nd RIC established.

• 1008 hours - Fire declared under control.

• 1158 hours - Fire declared out.

Heavy black smoke pouring out of the 1st floor laundry room 

door during RIC operations.

(Photo courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 9

Summary

Rapid Intervention Operation

• 0220 hours - E71 and P56 join T7 on the 

rapid intervention group and re-position to 

Side Charlie. 

• ~0228 hours – The rapid intervention group 

enters the basement with 300-foot 1 3⁄4-inch 

hoseline. “Cold smoke” conditions with poor 

visibility. Right-handed search used. 

• ~0230 hours - The rapid intervention group 

encountered a second set of steps in the 

utility room leading into to the crawlspace 

with high heat and visible fire. The rapid 

intervention group moved in the direction 

of E101B’s alarming PASS device. Wires, and 

storage items impede progress. E71C 

reaches E101B who is unconscious. The rapid 

intervention group pulls/passes E101B along 

the extraction route (blue dotted line in the 

diagram).

Sketch of the basement. The red “X” marks the 

approximate location where E101B was found. Blue dotted 

line is the extraction pathway. The red dotted line is the 

hoseline used by E101B on the 1st floor.

(Diagram courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 10

Summary

Rapid Intervention Operation 

Continued

• 0243 hours - E101B removed from the 

structure. CPR begins. The rapid 

intervention group located and 

extricated E101B in 15 minutes after 

entry; 22 minutes after the Mayday.

• 0246 hours - Command orders all 

companies to evacuate the structure 

and orders a defensive strategy.

• 0254 hours - Medic 105 enroute to the 

hospital with CPR in progress.

• 0312 hours - E101B pronounced 

deceased at the hospital.

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

where E101B was found. Blue dotted line is the extraction pathway. The 

red dotted line is the hoseline used by E101B on the 1st floor.

(Diagram courtesy of the Fire & Rescue Department.)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 11

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
NIOSH Fire Fighter Fatality Investigation and Prevention Program 12

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.

• 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.
NIOSH Fire Fighter Fatality Investigation and Prevention Program 13

Recommendations

• Fire departments should ensure that critical incident benchmarks and 

fire conditions are communicated to the incident commander 

throughout the incident. This requires 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 

the incident commander during multi-alarm incidents.

• Fire departments should ensure that the designated accountability 

officer is not assigned additional duties.
NIOSH Fire Fighter Fatality Investigation and Prevention Program 14

Recommendations

• Fire departments should develop a training program for staff aides, 

incident command technicians, or staff assistants. 

• Fire departments should ensure incident commanders maintain 

control of situation status, resource 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 the strategic-level safety responsibilities 

are being incorporated into the command functions throughout the 

incident.

• Fire departments should review their SOG/SOP 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.
NIOSH Fire Fighter Fatality Investigation and Prevention Program 15

Recommendations

• Fire departments 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) and Underwriter’s Laboratories (UL) 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.

• 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). 
NIOSH Fire Fighter Fatality Investigation and Prevention Program 16

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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