Page i

2014

09

March 2, 2016

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Executive Summary

On March 26, 2014, a 43-year-old male career fire lieutenant and a

33-year-old fire fighter died during fire-fighting operations in an 

occupied multifamily residential structure (brownstone). Engine 33 

was the first-due engine company assigned to Box 1579. Engine 33 

arrived on scene and reported: “We have a four-story with smoke 

showing from the first floor. Engine 33 is stretching a 13⁄4-inch 

hoseline in the front doorway.” The lieutenant and the fire fighter 

stretched the 13⁄4-inch hoseline up the front steps (uncharged), 

through the front door, and into the front hallway. When the 

lieutenant was informed the fire and a possible victim were in the 

basement, Engine 33 took the hoseline down the steps. The Engine 

33 pump operator charged the line, but the line lost its water due to 

the rapidly deteriorating fire conditions which compromised the 

hose. Engine 7 arrived on scene and stretched a 2 1⁄2-inch hoseline as 

a back-up line to Engine 33. Engine 7 stretched their line in the front 

door following Engine 33’s hoseline. Engine 22 was on-scene and 

was preparing to stretch a hoseline into the basement apartment 

underneath the front steps. The crew from Engine 7 was moving 

their hoseline towards the stairwell leading to the basement, when 

conditions changed drastically. Fire and heat came up the 

steps from the basement. This was due to a maintenance 

worker leaving the rear door of the attached shed open while 

investigating the smoke detector activation. The conditions 

became untenable for the fire fighters from Engine 7. They 

moved out of the building to the landing of the front steps.

Also, the interior door at the top of the basement stairs was 

open, the front exterior doors were left open by an occupant 

fleeing the fire, and a rear basement door or window failed. Once the rear door or window burned 

through, this created an unrestricted flow path from the basement to the first floor plus the floors 

above, thereby triggering a rapid progression of fire conditions. This trapped the officer and fire fighter 

from Engine 33 in the basement. The fire, heat, and smoke through the basement and first floor created 

untenable conditions on both floors. Due to the intense heat and fire conditions, the 13⁄4-inch attack 

hose burned through. Command then ordered the building to be evacuated. Approximately 1 minute 

later, the Engine 33 lieutenant called Command and said they were running out of water. The 

dispatcher replied, “OK Engine 33, we are going to get you water.” Command immediately called a 

A view of fireground from Side 

Charlie. The fire started near the onestory shed (located against the fence) 

and extended into hallway on the 

basement of the structure.

(Photo courtesy of the fire department)
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Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

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Report #F2014-09

second alarm for Box 1579. Several companies tried to make entry into Side Alpha from both the 

basement and the first floor of the structure, but were pushed back by heavy fire and smoke. Crews 

pushed through the Side Bravo exposure to initiate fire attack on Side Charlie. Crews took a 21⁄2-inch 

hoseline into the basement apartment on Side Charlie. Approximately 15 minutes later, crews located 

the fire fighter from Engine 33 in the kitchen area of this apartment. The fire fighter was removed from 

the apartment and immediately taken to an ambulance for transport to the hospital. The fire fighter 

from Engine 33 was pronounced dead at the hospital. After the fire fighter was removed, conditions 

changed and the structure became fully involved. Crews were removed from the structure and the 

strategy was changed to defensive operations. Once the fire was completely knocked down and 

conditions allowed fire fighters to safely re-enter the structure, a search was made for the lieutenant of 

Engine 33. The lieutenant was found at the bottom of the stairs near the entrance to Apartment #10 in 

the basement. The lieutenant was pronounced dead at the scene.

Contributing Factors • Delayed notification to the fire department

• Uncontrolled ventilation by a civilian 

• Occupied residential building with immediate life safety concerns

• Staffing

• Scene size-up

• Lack of fire hydrants on Side Charlie (a private street)

• Lack of training regarding wind-driven fires

• Unrestricted flow path of the fire

• Lack of fire sprinkler system

Key Recommendations

Fire departments should define fireground strategy and tactics for an occupancy that are based upon 

the organization’s standard operating procedures. As part of the incident action plan, the incident 

commander should ensure a detailed scene size-up and risk assessment occurs during initial 

fireground operations, including the deployment of resources to Side Charlie. Scene size-up and risk 

assessment should occur throughout the incident.

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).

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.
Page 1

2014

09

March 2, 2016

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Introduction

On March 26, 2014, a 43-year-old career fire lieutenant and a 33-year-old fire fighter died during firefighting operations in a multifamily residential structure (brownstone). On April 4, 2014, the U.S. Fire 

Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this 

incident. On April 8, an investigator and safety engineer from the NIOSH Fire Fighter Fatality 

Investigation and Prevention Program (FFFIPP) traveled to Massachusetts to meet with the fire 

commissioner, senior staff, International Association of Fire Fighters (IAFF), and the IAFF local

president to develop a plan for the investigation process. On April 10, 2014, a general engineer and 

two occupational health and safety specialists traveled to Massachusetts to join the investigator to 

begin the investigation process. During this segment of the investigation, the NIOSH Fire Fighter 

Fatality Investigation Team met with the fire commissioner, the chief of operations, a safety chief, the 

president of the IAFF local, superintendent of the Fire Alarm Office, and the county’s assistant district 

attorney assigned to this incident. The Fire Fighter Fatality Investigation Team inspected and 

photographed the turnout gear and self-contained breathing apparatus (SCBA) from the lieutenant and 

fire fighter. The team departed on April 16, 2014.

On May 3, 2014, the same members of the NIOSH Fire Fighter Fatality Investigation Team returned to 

Massachusetts to complete the field investigation. Two subject matter experts joined the NIOSH Fire 

Fighter Fatality Investigation Team during this segment of the investigation. The Fire Fighter Fatality 

Investigation Team toured the incident scene, photographed the interior and exterior of the structure, 

and interviewed investigators with the fire investigation unit and members of the fire training division.

The NIOSH Fire Fighter Fatality Investigation Team conducted interviews with fire department 

officers and fire fighters who operated at Box 1579 on March 26, the superintendent of the fire alarm 

office, the superintendent of the fire department’s fleet division, and members of the city’s Inspectional 

Services Department (Building Officials Office). A closing meeting was held on May 9, 2014, with the 

fire commissioner and senior staff, the president and members of the IAFF local, the subject matter 

experts, and the NIOSH Fire Fighter Fatality Investigation Team.

Fire Department

This career fire department has 35 stations with 1,606 members of which 1,467 are uniformed 

members. The department protects a population of approximately 646,000 within an area of about 48 

square miles.

The fire department consists of the following members:

1 fire commissioner and chief of department

2 chiefs of operations
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2 deputy fire commissioners

14 deputy chiefs

51 district chiefs (battalion chiefs)

1 fire alarm superintendent

1 assistant fire alarm superintendent

75 captains

219 lieutenants

1,092 firefighters

92 civilian personnel

56 fire alarm personnel

The rank structure for the fire department is as follows: fire commissioner/chief of the department, 

chief of operations, deputy fire commissioner, deputy chief, district chief, captain, lieutenant, senior 

fire fighter, fire fighter, and probationary fire fighter. 

The fire department consists of nine divisions: Fire Suppression; Fire Prevention; Training; Special 

Operations; Office of Field Services; Information Technology; Personnel; Safety, Health, and 

Wellness; Fire Alarm Office.

Fire Suppression: The services provided include fire-fighting, medical evaluation, vehicle extrication, 

hazardous material response, confined space rescue, structural collapse rescue, trench collapse rescue, 

and more. The department operates engine companies, ladder companies, and rescue companies, each 

providing distinctly separate services at a fire or other emergency.

The fire department operates 33 engine companies, 20 ladder companies, 2 tower ladder companies, 2 

heavy rescue companies, 9 district chiefs (battalion chiefs) (Car 1, Car 3, Car 4, Car 6, Car 7, Car 8, 

Car 9, Car 11, Car 12), 2 deputy chiefs (C6 [Division 1] and C7 [Division 2]), 1 marine unit, 1 fire 

brigade, 2 tunnel/confined space units, 2 brush units, 1 hazardous materials unit, 1 mobile air supply 

unit, 1 rehab unit, 1 mobile command unit, 1 mobile decontamination unit, and 1 hydrant thawing unit.

The district chief and deputy chiefs are each staffed with an incident command technician (ICT).

Division 1 has District 1, District 3, District 4, District 6, and District 11. Division 2 has District 7, 

District 8, District 9, and District 12.

All fire stations are under the supervision of a captain (station captain) and are divided into four 

working groups (shifts). Three of the four working groups are under the supervision of a lieutenant. 

All companies are staffed with a minimum of one officer and three fire fighters per shift. The riding 

assignments for each engine company, ladder company, and rescue company are as follows:

Engine Company

Engine xx Officer (Right front seat)

Engine xx Pump (Left front seat)

Engine xx Pipe (Right rear seat)
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Engine xx Hydrant (Left rear seat)

Engine xx Loop (Rear seat, as staffing allows)

Ladder Company

Ladder xx Officer (Right front seat)

Ladder xx Open-up Man (Left rear seat) (Halligan and Maul)

Ladder xx Rake (Right rear seat)

Ladder xx Chauffeur/Roof man (Left front seat)

Ladder xx Vent (Rear seat, as staffing allows)

Rescue Company

Rescue x Officer (Right front seat)

Rescue x Chauffeur, Alpha (Left front seat)

Rescue x Bravo (Right rear seat)

Rescue x Charlie (Rear middle seat)

Rescue x Delta (Left rear seat)

Members assigned to the Fire Suppression Division work a 24-hour shift (0800–0800), followed by 48 

hours off, then 24 hours on duty, and followed by 96 hours off.

In 2014, the fire department responded to 75,176 emergency incidents. The fire department responded 

to:

5,704 fire incidents

33,624 rescue/EMS incidents

3,303 hazardous incidents—no fire

11,001 service calls

7,122 good intent calls

14,139 false alarms and false calls

283 miscellaneous calls

Fire Prevention: This division is responsible for maintaining records, granting permits, conducting 

public education, inspecting buildings, and conducting fire investigations. The Fire Marshal’s Office

consists of the following: 

3 fire protection engineers

1 plans reviewer (engineer)

1 chemist

45 uniformed fire inspectors

20 civilian personnel

25 uniformed fire investigators (Fire Investigation Unit) 

Training: This division provides recruit training, company in-service training, live fire training, and 

professional development for all members of the department. Also, the division conducts research to 

improve techniques and equipment, evaluating new tools before their implementation. The Emergency 

Medical Services and the Safety Operations Unit are also within this division.
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Special Operations: The Special Operations Division of the fire department is tasked with duties 

concerning hazardous materials, technical rescue, and marine operations. These duties include 

developing and delivering training and creating operational plans and standard operating procedures 

for the three functions with Special Operations. 

Office of Field Services: The department’s Office of Field Services provides for the planning and 

logistical needs for the fire department. This includes acting as a liaison with outside agencies, 

monitoring the hazardous building list, coordinating the local emergency planning committee (LEPC), 

managing special projects, and planning for special events.

Information Technology: This division supports staff within the fire department operations (e.g.,

computer-aided dispatch), operational support (e.g., training and fire prevention records), and 

administrative support (e.g., payroll and personnel). The Information Technology Division reports to a

chief of operations.

Personnel: This division includes the Administration Section, Selection Unit, Medical Office, 

Personnel Assignments of Officer’s Section, and the Employees Assistant Program. The division keeps 

the records of each fire fighter; communicates with other departments, unions, and agencies; and hears 

grievances, disciplinary hearings, and appeals.

Safety, Health, and Wellness: The functions of this division, established in 2014, are to monitor and 

research current safety procedures and policies and to promote solutions when problems are 

discovered. The overall goal is the reduction of fire fighter injuries and illnesses on the fireground and

in training and chronic occupational health issues. The Safety, Health, and Wellness Division is also 

tasked with writing and revising the department’s standard operating procedures. This is to promote 

greater safety and fireground effectiveness, injury and illness prevention, and improvements in training 

practices and fireground operations. This division also investigates department injuries and motor 

vehicle accidents.

Fire Alarm Office: The Fire Alarm Office (FAO) serves as the dispatch center and base of 

communications for the department. The FAO enters all calls for service from any source into the 

computer-aided dispatch system to initiate the proper response, deploy resources, and expedite all 

alarms in accordance with standard operating procedures. The FAO also reads, adjusts, and maintains 

fire alarm circuits and recorders. Also, FAO staff repairs and adjusts equipment in the dispatch center 

as needed. All FAO operators are versed in the department’s fireground standard operating procedure 

with a special emphasis on fireground safety.

Training and Experience

The Commonwealth of Massachusetts has no mandatory minimum requirements to become a fire 

fighter. For cities and towns that have adopted the Commonwealth of Massachusetts civil service 

system, a candidate must pass the state’s fire fighter civil service written examination and successfully 

complete the Candidate Physical Ability Test. The Commonwealth of Massachusetts Civil Service 
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Commission administers the fire fighter written examination and physical agility exam for the 

municipality. The applicants are ranked and then given to the city’s human resources division. The 

municipality conducts the following:

• Background check

• Drug screen 

• Medical examination, which meets the requirements of NFPA 1582 Standard on Comprehensive 

Occupational Medical Program for Fire Departments (1997 edition) [NFPA 1997]

• Physiological exam

• City residency requirements check

Once a candidate is hired by this fire department, the candidate is required to attend a 20-week recruit 

school at the department’s training academy. Five weeks of the academy training consists of the 

National Registry of Emergency Medical Technician—Emergency Medical Technician course. Upon 

completion of the recruit school, the recruit fire fighter will have completed more than 745 hours of 

instruction and will be certified (ProBoard Certification) per NFPA 1001 Standard for Fire Fighter 

Professional Qualifications [NFPA 2013c] to the level of Fire Fighter I and Fire Fighter II and per 

NFPA 472 Standard for Competence of Responders to Hazardous Materials/Weapons of Mass 

Destruction Incidents [NFPA 2013b] to the level of Hazardous Materials—Awareness Responder and 

Operational Responder. The recruit fire fighter becomes a probationary fire fighter and then completes 

a probationary period of 32 weeks. Upon the successful completion of the probationary period, the 

individual becomes a fire fighter.

The officer of Engine 33 was hired by the department on December 8, 2004. He completed recruit 

school in April 2005 and was assigned to Ladder 15 as a probationary fire fighter. He successfully 

completed his probation and was assigned as a fire fighter to Ladder 15. He was promoted to lieutenant 

on April 3, 2012. His current assignment was a lieutenant on Engine 33. His qualifications included 

NFPA 1001, Fire Fighter I and II; Hazardous Materials Awareness level and Operations level per 

NFPA 472; Massachusetts EMT/Basic; and a ProBoard-certified Hazardous Materials Technician per 

NFPA 472. Other training included Radio Communications; Driver/Operator Training; Mayday

procedures; EMS continuing education units; hazardous materials refresher training and certifications; 

weekly in-service training on standard operating procedures and EMS protocols pursuant to 

department General Orders; and the fire department fire college.

The fire fighter from Engine 33 was hired by the department on November 5, 2007. He completed 

recruit school in March 2008 and was assigned to Ladder 2 as a probationary fire fighter. He 

successfully completed his probation and was assigned as a fire fighter to Ladder 2. His current 

assignment was as a fire fighter to Ladder 15. He was detailed to Engine 33 on March 26, 2014. His 

qualifications included NFPA 1001, Fire Fighter I and II—ProBoard certification; Hazardous Materials 

Awareness level and Operations level per NFPA 472—ProBoard certification; and Massachusetts 

EMT/Basic. Other training included IAFF Emergency Response to Terrorism Course—Operations;

Hazardous Materials Training—CBRNE, Response to Radiological Incidents; Air/Gas Monitoring, 

Chlorine Training, and Highway Tanker Emergencies; and EMS continuing education units.
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Equipment and Personnel

All 9-1-1 calls are answered by the city’s police dispatch center. If the 9-1-1 call is for a fire or a 

medical emergency, the call is then routed to the fire department’s Fire Alarm Office (FAO). In the 

event of a structure fire, the FAO assigns the appropriate number and type of companies to the 

incident. All incidents are assigned a box number based upon the location of street boxes, which are 

also used as a method of transmitting alarms to the FAO. The fire department communicated 

information from an incident to the Fire Alarm Office by a street box, which was done primarily before 

the radio system came into existence. The fire department still has telegraph alarm boxes located on 

street corners throughout the city and in various businesses and occupancies.

Types of Alarms for Structure Fires

Still Alarm. Usually any emergency call received by telephone at the Fire Alarm Office or verbal 

notification by a citizen at a fire station. Under certain conditions the FAO may treat a box alarm as a 

still alarm.

Still Alarm Assignment: 1 engine, 1 ladder

Box Alarm

First Alarm Assignment: 4 engines (1 engine for rapid intervention team [RIT]), 2 ladders, 1 

rescue, 1 district chief

Downtown First Alarm Assignment: 4 engines (1 for RIT), 2 ladders, 1 tower ladder, 1 rescue, 1 

district chief, and 1 division chief

High-rise Fire Response First Alarm Assignment: 4 engines (1 for RIT), 2 ladders, 1 rescue, 3 

district chiefs (1 for operations, 1 for evacuation, 1 for accountability), 1 division chief, safety 

chief, air supply unit

Full Box Alarm/Confirmed Fire with RIT and Rehab Assignment: 1 ladder (RIT), 1 tower ladder, 1 

district chief (RIT), safety chief, rehab unit

Second Alarm

Second Alarm Assignment: an additional 3 engines, 1 ladder, 2 district chiefs (1 for accountability), 

1 division chief, air supply unit, fire investigation unit, and 1 public information officer

Third Alarm

Third Alarm Assignment: an additional 2 engines, 1 ladder, special unit, and field/tactical 

communications unit

Fourth Alarm 

Fourth Alarm Assignment: an additional 2 engines

Fifth Alarm

Fifth Alarm Assignment: an additional 2 engines and 1 ladder

Sixth Alarm

Sixth Alarm Assignment: an additional 2 engines
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Seventh Alarm

Seventh Alarm Assignment: an additional 2 engines and 1 ladder

Eighth Alarm

Eighth Alarm Assignment: an additional 2 engines

Ninth Alarm 

Ninth Alarm Assignment: an additional 2 engines

Total apparatus on scene: 21 engine companies, 7 ladder companies, 1 tower ladder, 1 heavy rescue 

company, 6 chiefs (1 deputy/5 district), 1 special unit, 1 rehabilitation unit, and 1 air supply unit.

Types of Alarms for Specific Incidents

Motor Vehicle Accident

Motor Vehicle Accident Assignment: 1 engine, 1 ladder

Motor Vehicle Accident (Pin or Entrapment)

Motor Vehicle Accident (Pin or Entrapment) Assignment: 1 engine, 1 ladder, 1 district chief, 1 

rescue

Vehicle Fire

Vehicle Fire Assignment: 1 engine

EMS Response

EMS Response Assignment: 1 company only (either an engine, ladder, rescue, or tower ladder 

company)

HazMat Level 0

HazMat Level 0 Assignment: 1 engine, 1 ladder

HazMat Level 1 (Upgrade)

HazMat Level 1 Assignment: 1 district chief, special unit, 1 HazMat inspector, 1 engine 

(HazMat), 1 ladder (HazMat), safety chief (H1)

HazMat Level 2 (Upgrade)

HazMat Level 2 Assignment: 1 district chief, HazMat unit, fireground rehab/mass casualty unit, 

field/communication tactical unit, 1 police department environmental safety group unit

HazMat Level 3 (Upgrade)

HazMat Level 3 Assignment: 2 engines (decontamination), 1 division chief, 1 public information 

officer, 1 fire investigation unit, fire department photography unit

Fireground Communications

Department’s Fire Alarm Office

The department operates a dispatch and communication center (Fire Alarm Office), which started 

operation on December 27, 1925. All fire alarm circuits, along with radio and telephone 

communications, are controlled from the Fire Alarm Office (FAO). The radio shop for the fire 
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department is located at the FAO. Personnel designated to maintain the street boxes and circuits are 

assigned to the FAO.

All 9-1-1 calls are answered by the 9-1-1 police dispatcher. Requests for fire and EMS responses are 

routed to the FAO, which only dispatches fire department resources. The fire department still has 

telegraph alarm boxes located on street corners throughout the city and in various businesses and 

occupancies.

The department’s communication system consists of ultra-high-frequency (UHF) radios:

5 channels

42 receiver sites

4 simulcast sites

5 portable radios assigned to each fire apparatus

312 high-rise sites in the city with repeater systems

The portable radios can be used (on the fireground) with the repeater or line of site; a computer 

automatically selects the appropriate mode of operation. The district chiefs and deputy chiefs have 

repeaters in their vehicles, which boost the signal from 5 watts to 100 watts.

The staffing for the FAO is 1 superintendent, 1 assistant superintendent, and 32 dispatchers. The FAO 

staffs each shift (4 shifts) with 7 dispatchers with a minimum staffing of 5 dispatchers. The dispatchers 

work a 24-hour shift (0800–0800), followed by 48 hours off, then 24 hours on duty, and followed by 

96 hours off. Each shift works with the same operational staff as members of the Fire Suppression 

Division, so dispatchers are familiar with the shift’s deputy chiefs and district chiefs.

The FAO dispatches an average of 250–275 incidents per day. Each incident is assigned a box number 

based upon the street boxes located throughout the city. When an incident occurs, a dispatcher is 

assigned to that incident and maintains communications on the dispatch and tactical channel(s) from 

the beginning of the incident until the incident is terminated. If the incident goes to a fifth alarm, an 

additional dispatcher is called back, plus the superintendent and assistant superintendent respond to the 

FAO. 

Role of the Dispatcher during a Mayday

Dispatchers should be the voice of calm during a Mayday. This takes practice. Dispatchers should train

in performing their responsibilities so when a Mayday is called, they react instinctively and without 

delay. A dispatch center/communications center supports fire fighter safety best when adequately 

staffed. In addition to the call taker and dispatcher, at least one other dispatcher should monitor the fire 

ground tactical channel during working incidents. In some cases, units on the fire ground DID NOT

hear the Mayday, but dispatchers and fire department resources did. In order to ensure fire fighter 

survivability, the tactical channel should be monitored at all times during working incidents. 

Dispatchers should also be authorized to immediately contact Command upon hearing any Mayday or 

emergency traffic communications. This confirms that Command has heard the message and is taking 

action. The same applies if the dispatcher received an emergency activation from a fire fighter’s 
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portable radio. Command should be notified and take action to confirm whether the message is an 

emergency or an accidental activation. 

If the fire department’s radios are equipped with channels from other fire departments, the dispatcher 

should immediately advise these departments of the Mayday situation. Fire fighters have accidentally 

selected the wrong frequency, and contacted another fire department on their radio. These agencies 

should be advised that if they hear communications from the distressed fire fighter. This agency’s 

dispatch center should maintain contact with them. DO NOT change frequencies. The other agency 

should immediately advise the department’s dispatcher of the contact, followed by a notification to 

Command. Command or other designated officer should go to that tactical channel and communicate 

directly with the distressed fire fighter. DO NOT ask the fire fighter to change channels. The fire 

fighter may not be able to do so, or even worse, end up on another channel [IAFF 2010]. 

The FAO plays an integral role in the department’s daily fireground operations. The FAO had a 

positive impact on the Mayday operation at Box 1579 on March 26, 2014. Upon transmission of the 

Mayday, the FAO immediately confirmed that the incident commander was aware of the Mayday 

transmission. Also, FAO dispatchers transmitted the alert tome and ordered radio silence, confirmed 

the Mayday fire fighter’s location, maintained contact with the Mayday fire fighter, assigned a tactical 

channel for non-RIT operations, confirmed additional alarms with Command, dispatched additional 

RIT resources, dispatched additional technical rescue resources, ordered advanced life support from 

the city’s emergency medical services, and assisted in conducting a personnel accountability report 

with Command.

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 the dispatch 

records, witness interviews, and other available information. NIOSH investigators have attempted to 

include the potential radio transmissions. This timeline is not intended, nor should it be used, as a 

formal record of events.

Incident and Fireground 

Communications Time

Response and Fireground

Operations

March 26, 2014

9-1-1 call reported building filled with 

smoke.

1441 Hours
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Incident and Fireground 

Communications Time

Response and Fireground

Operations

Alert tone announcement for the 

transmission of Box 1579 by Fire 

Alarm Office (FAO): “Engine 33, 

Engine 7, Engine 22, Ladder 24, 

Ladder 26, Rescue 1 [R01], and District 

4 [Car 4] dispatched for structure fire 

for Box 1579; Channel 2 is the 

fireground channel.”

1442 Hours 

1445 Hours Engine 33 (E33) reported on scene and 

assumed command; Command advised 

smoke showing from the first floor. The 

E33 officer and E33 Pipeman (right 

jumpseat) stretched a 13⁄4-inch hoseline 

(uncharged) up the front steps and into the 

first floor.

For “smoke showing,” FAO dispatched 

District 3 (Car 3), Engine 37, Tower 

Ladder 3 (TL3), and Ladder 18 as RIT. 

Also dispatched were H1 (safety 

officer) and W25 (mobile air unit).

1446 Hours Car 4 arrived on scene and assumed 

command for Box 1579. An unknown unit 

radioed that occupants were trapped on the 

fourth floor.

H1 (safety officer) enroute. 1447 Hours Rescue 1 arrived on scene.
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Incident and Fireground 

Communications Time

Response and Fireground

Operations

Per the orders of Command, transmit a 

second alarm for Box 1579.

1448 Hours Car 3, E7, E22, E37, H1, L18, L24, L26, 

and TL3 arrived on scene.

Command reported, “We have a four-story 

brick residential; the fire is in the basement; 

the occupants of the fourth floor have selfevacuated off the fire escape.”

E33’s 13⁄4-inch hoseline is charged and 

going down the stairs to the basement.

Note: Due to a rapid progression of fire 

conditions, E33 hoseline is burned through

and loses pressure. The officer of E33 is 

unaware this has occurred. The water never 

reaches the nozzle. E7 backed up E33 with 

a 21⁄2-inch hoseline into the first floor. 

Conditions rapidly change due to a rapid 

progression of fire conditions and E7 was 

forced out to the front stoop. 

FAO transmitted Box 2-1579. Engine 

4, Engine 17, Engine 10, Ladder 17, 

Rescue 2, C6 (Division 1 Deputy 

Chief), District 7 (Car 7) 

(Accountability), and District 9 (Car 9) 

are dispatched for Box 2-1579.

14:49:09 

Hours

14:49:12 

Hours

E33 officer called Engine 33 to have the 

hoseline charged.

14:49:22 

Hours

Command radioed FAO and advised,

“Emergency Traffic...everyone off the first 

floor, everyone off the first floor.”

14:49:31 

Hours

FAO advised all companies operating at 

Box 2-1579 to “get out of the first floor.”

14:49:45 

Hours

E33 declares a Mayday. “Mayday E33, 

Mayday E33.”

FAO radioed, “E33 has a Mayday on 

Fireground Channel 2 in the basement; 

E33 has a Mayday on Fireground 

Channel 2 in the basement. OK Car 4?”

14:49:57 

Hours
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Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

FAO transmitted again, “E33 has a 

Mayday on Fireground Channel 2 in the 

basement. OK Car 4?”

1450 Hours Command acknowledged the message.

Command to FAO, “I want all members 

out of the building, all members out of 

the building immediately.”

14:50:17 

Hours

FAO transmitted this message on 

Channel 1, Fireground Channel 2, and 

Fireground Channel 3.

14:50:26 

Hours

14:50:38 

Hours

FAO transmitted on Fireground Channel 2 

to E33 to charge the 13⁄4-inch hoseline going 

to the crew of E33 in the basement.

14:50:43 

Hours

Ladder 26 called FAO. “Tell Command, we 

need a line to the back [of the building –

Side Charlie]; We have fire showing on the 

first floor. There is a shed attached to the 

basement level in the rear. Have companies 

come around to the street in the rear. The 

companies can attack the fire from Side 

Charlie.”

1451 Hours The officer of E33 asked for the line to be 

charged.

FAO transmitted the following message 

on Channel 1, Fireground Channel 2, 

and Fireground Channel 3: “All 

companies operating at Box 1579, 

switch to Fireground Channel 3. 

Fireground Channel 2 is the Mayday

Channel. All companies operating at 

Box 1579, use Fireground Channel 3.

Fireground Channel 2 is the Mayday

Channel.”

14:51:07 

Hours

14:51:42 

Hours

The officer of E33 radioed, “33, we need 

water now, charge 33’s pipe.”
Page 13

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

Command to FAO, “Give me a third 

alarm. Have the second-alarm 

companies report to the rear.”

14:51:45 

Hours

14:52:02

Hours 

E33 officer radioed FAO, “Both of us are 

trapped in the basement towards the front of 

the building. We got water, but the hoseline 

is burnt through. You have got to charge our 

line.”

FOA to Command, “E33 is trapped in 

the basement. They are trying to head to 

the front of the building. They need 

water.”

14:52:34 

Hours

14:52:50 

Hours

Command acknowledged the message.

14:52:53 

Hours

FAO to E33 officer, “They are trying to get 

you water.”

14:52:59 

Hours

The officer of E33 radioed, “We are on the 

stairway and it’s getting hot down here.”

14:53:30 

Hours

The chauffeur of E33 radioed, “I am 

running out of water, I am running out of 

water.” Note: E33 was operating off water 

from the booster tank which 750 gallons. A 

supply line for E33 had not been established 

at this time.

FAO to Command, “E33 is in the 

basement heading toward the front of 

the building. I will verify.”

14:53:36 

Hours

14:53:58 

Hours

FAO transmitted Box 3-1579; Engine 

29, Engine 42, and Ladder 15 are 

dispatched for Box 3-1579.

1454 Hours
Page 14

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

14:54:31 

Hours 

E33 officer radioed, “We are in the 

basement towards the front of the building.”

14:55:20 

Hours

E33 officer radioed FAO, “It’s getting hot 

down here. Getting hotter.”

14:55:35 

Hours

FAO to E33 officer, “OK 33, they are going 

to get you water.”

14:56:43 

Hours

FAO to E33 officer, “E33, they are coming 

to get you.”

Command to FAO, “We have 

companies in the front of the basement 

now. Tell E33’s officer if he can find a 

way out, to get out.”

14:56:56 

Hours

14:57:24 

Hours 

The last radio transmission from E33 

officer. He radioed, “Need a line in the 

basement, right away; a big line.”

FAO to Command, “L26 officer reports 

they need a line in the rear and E33 is 

still calling for water.”

14:57:43

Hours

14:57:51 

Hours

L26 to FAO, “Tell Command we need a 

line on the backside of the building. We 

have heavy fire on Side Charlie.”

“Per the orders of Command, transmit a 

fourth alarm for Box 1579.” FAO 

transmitted: “A fourth alarm has been 

struck for Box 1579. The fireground 

channel is Channel 3. Stay off Channel 

2, it is the Mayday Channel.” 

14:58:51 

Hours 
Page 15

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

“Division 1 Deputy Chief (C6) on 

scene.”

FAO transmits: “C6 is assuming 

Command of Box 1579. On the orders 

of the Deputy Chief, he is requesting a 

fourth and fifth alarm for Box 1579. 

Have the fourth and fifth alarm 

companies respond to the rear of the 

building (Side Charlie).”

14:59:07 

Hours

Engine 5 and Engine 3 are dispatched 

for Box 4-1579.

Engine 28, Engine 55, and Ladder 14, 

and C1 (Commissioner) are dispatched 

for Box 5-1579.

14:59:22 

Hours 

15:00:21 

Hours

Car 4 to Command, “We have heavy fire in 

the rear; we are trying to get water back 

here.”

Command to FAO, “Have the thirdalarm ladder companies go to the front 

of the building (Side Alpha) with 35’s 

and the first-due engines on the fourth 

and fifth alarms to the rear of the fire 

building and run big lines into the 

basement.”

15:00:29 

Hours

FAO radioed to third-alarm ladder 

companies respond to the front of the 

building and fourth-alarm engine 

companies respond to the rear.

15:01:00 

Hours 

Command to FAO, “We have 

companies trying to advance into the 

basement now.”

15:03:48 

Hours

1504 Hours C7 (Division 2 Deputy Chief) on scene. C7 

assigned as Division Charlie.
Page 16

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

15:06: 18 

Hours

C7 to Command, “We have 3 big lines 

going in the rear moving towards the front 

of the building.” 

15:07:18 

Hours

C7 to Command, “Have a couple of 

ambulances come to Side Charlie in case we 

pull these guys out the rear door.”

15:07:35 

Hours

C7 to Command, “Companies are making 

progress. They are 20 to 25 feet inside the 

basement and they keep going.”

“Per the orders of Command strike the 

sixth alarm and seventh alarm for Box 

1579.”

15:08:16 

Hours

15:08:59 

Hours

Rescue 1 to FAO, “Have all members reset 

their PASS devices. We have multiple 

PASS devices going off.”

FAO transmitted the following message 

on Channels 1, 2, and 3: “All companies 

reset PASS devices due to multiple 

PASS devices in alarm.”

15:09:35 

Hours

FAO dispatched Engine 30 for Box 6-

1579.

FAO dispatched Engine 8, Engine 21, 

and Ladder 4 for Box 7-1579.

15:09:46 

Hours

Command to FAO, “Urgent, Urgent, I 

want everybody out of the building, 

everybody out of the building.”

15:10:14 

Hours

A rapid progression of fire conditions 

occurs in the structure.
Page 17

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

FAO transmitted the following message 

on Channels 1, 2, and 3. “Per the orders 

of Command, All companies operating 

at the seventh alarm for Box 1579, get 

out of the building, all companies out of 

the building.”

15:10:28 

Hours

15:11:11 

Hours

Command to all companies on Fireground 

Channel 3, “Everybody out the building.”

FAO transmitted the following message 

on Channels 1, 2, and 3. “Per the orders 

of Command, All companies operating 

at the seventh alarm for Box 1579, get 

out of the building, all companies out of 

the building.”

15:11:31 

Hours

“Per the orders of Command strike the 

eighth alarm and ninth alarm for Box 

1579.” “Have these companies report to 

Command in front of the building.”

15:13:00 

Hours

FAO dispatched Engine 49 and Engine 

24 for Box 8-1579.

15:13:37 

Hours

FAO dispatched Engine 39, Engine 14, 

and Tower Ladder 10 (TL10) for Box 

9-1579.

15:13:52 

Hours

15:15:34 

Hours

C7 to Command, “Do we still have 

members missing?”

C1 to FAO, “Yes, there is still a member 

unaccounted for in the basement.”

15:16:38 

Hours

C7 to FAO, “Companies are going back 

in.”

15:16:48 

Hours

C1 to FAO: “Negative. No companies 

are going in anywhere. Stay out and 

away from the building.”

15:17:03 

Hours
Page 18

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

15:17:11 

Hours

C7 to C1: “We are aware of the collapse 

potential. We can see in front of us. We can 

hear a PASS device inside the building.”

C1 to FAO: “We can’t put anybody in 

there at the front door or back door. 

That OK? Other than that, stay out of 

the building.”

15:18:09 

Hours

C7 to FAO, “I copy the message.” 15:18:30 

Hours

C7 to FAO, “Tell C1 I am pulling 

companies back out again.”

15:19:07 

Hours

15:19:30 

Hours

C7 to Command, “We are getting the guy 

[fire fighter from E33] out now. Get EMS 

to the rear [Side Charlie].”

FAO to C1, “Tower Ladder 3 just 

brought a member [fire fighter from 

E33] out the rear of the building.”

15:20:59 

Hours 

15:21:37 

Hours 

C7 to Command, “Are there still members 

inside?”

C1 to FAO: “We are doing an 

accountability check right now. We are 

looking into that right now.”

15:21:52

Hours

C7 to FAO, “Can you ask Command if 

all the members of E33 are accounted 

for at this time?”

15:23:56 

Hours

FAO to C7: “Command is doing an 

accountability check. They are doing an 

accountability check right now.”

15:24:04 

Hours 

FAO dispatched Engine 32 to Box 9-

1579. E32 is special called.

1531 Hours
Page 19

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

Command to FAO: “All first-alarm and 

second-alarm companies do a PAR with 

Accountability 7. They can do it in 

person or send a member. I want an 

accountability PAR for the first-alarm 

and second-alarm companies.” 

15:35:21 

Hours

Accountability 7 to FAO, 

“Accountability 7 is located across the 

street from the fire building.”

15:36:08 

Hours 

FAO transmitted the following message: 

“Engines 37, 33, 22, 3, 4, and 39, L15, 

L17, L26, and TL3 report your PAR to 

Accountability 7 who is located across 

the street from the fire building.”

15:37:18 

Hours

15:40:09 

Hours

C7 to Command: “We are going to 

defensive operations in the rear. I am 

getting members away from the building.”

15:40:27 

Hours

Command to C7: “The fire is through the 

roof. I am sure you are aware that we are 

trying to get ladder pipes flowing and Blitz 

guns in operation on adjacent roofs to try 

and knock down the fire.”

Command to FAO, “I want all lines shut 

down. I want all exterior lines shut 

down.” FAO repeats this message on 

Fireground Channel 2 and Fireground 

Channel 3. 

15:50:18 

Hours

15:51:14 

Hours

Command to C7: “Give me a report. It 

seems that heavy fire is through the roof and 

coming from the rear forward. Is that 

accurate?”

15:51:32 

Hours

C7 to Command, “Yes, I really can’t see the 

fire from the ground, but we know there is 

heavy fire on the roof in the rear.”
Page 20

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

Accountability 7 to FAO, “Can you list 

the third-alarm companies?” FAO 

replied, “Engine 10, Engine 17, and 

Ladder 18 for the third alarm at Box 

1579.”

15:54:15 

Hours

15:57:34 

Hours 

C7 to Command: “The heavy fire in the rear 

on the third floor and fourth floor has been 

knocked down by the deck guns. We still 

have heavy fire on the second floor. We are 

going to hit that with the Blitz guns. I have 

set up collapse zones in the rear.” Command

acknowledged report.

FAO to Accountability 7, “All members 

accounted for?”

1605 Hours

FAO dispatched Engine 51 to Box 9-

1579. E51 is special called.

1614 Hours

1624 Hours C7 to Command, “We have everyone back 

11⁄2 times the height of the building.” 

Command acknowledged. 

Command to FAO: “I want all heavy 

stream appliances and exterior lines shut 

down. I want all exterior lines shut 

down.” FAO transmitted the message on 

Fireground Channel 3. 

1629 Hours

FAO dispatched Engine 16 to Box 9-

1579. E16 was special called.

1633 Hours

FAO dispatched HazMat 1 to Box 9-

1579. HazMat 1 was special called.

1635 Hours

“Per the orders of Command, respond a 

structural engineer and the medical 

examiner to the fire building.”

1706 Hours 

FAO dispatched Ladder 16 to Box 9-

1579. L16 is special called.

1744 Hours
Page 21

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Incident and Fireground 

Communications Time

Response and Fireground

Operations

1848 Hours Crews from R01 and R02 located the 

lieutenant of E33 near the bottom of the 

stairs near the rear basement apartment.

1911 Hours The officer of Engine 33 was removed from 

the building and placed in an ambulance for 

transport to the hospital.

Command to FAO: “Place this fire 

under control. I am requesting 1 district 

chief, two engines and 1 ladder for “Fire 

Detail.” FAO dispatched Engine 2, 

Engine 41, Ladder 19, and District 11 

(Car 11) to Box 9-1579 as Fire Detail.

2125 Hours

March 27, 2014

Command to FAO, “I am transmitting 

an “All out” for Box 9-1579.”

0743 Hours

Building Construction and History

The structure involved in this incident was called a “brownstone.” Brownstone is the common name 

for a variety of brown, red, and pink sandstone widely used as building materials from the mid-1800s 

until the early 1900s [New York Landmarks Conservancy 2003]. Note: In the city involved in this 

incident, the bottom or ground floor is called the basement. The floor entered by the front steps is 

called the first floor. The bottom or ground floor identified as basement is different from most 

basements as there is access from the front and rear of the structure and access by interior stairs; 

more than half of the basement was above street level. 

The layout of the interior apartments of the fire building (See Photo 1) were numbered as follows: 

• Basement: the basement (e.g., partially below grade) had two apartments, Apartment #9 in the front 

(Side Alpha) and Apartment #10 in the rear (Side Charlie).

• First Floor: the first floor was previously two separate apartments but had been combined into a 

single apartment identified as Apartment #1 at the time of the fire.

• Second Floor: the apartment on the second floor has a similar floor plan as Apartment #1 and was 

numbered as Apartment #3.
Page 22

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

• Third Floor: the third floor was made up of two apartments, Apartment #5 in the front (Side Alpha) 

and Apartment #6 in the rear (Side Charlie).

• Fourth Floor: the fourth floor was made up of two apartments, Apartment #7 in the front (Side 

Alpha) and Apartment #8 in the rear (Side Charlie).

• With the exception of Apartment #1 and Apartment #3, all of the apartments only had windows 

facing either the front or the rear, depending on the position of the apartment. 

Extension and Spread of Fire

In order to better understand fire growth and development during this incident, it may be useful to 

understand how fire generally spreads in these types of buildings. A brownstone will generally be 

classified as Type III (Ordinary) construction, with masonry walls and combustible (i.e., dimension 

lumber), interior load-bearing construction.

In addition to typical problem areas associated with Type III buildings, particular points of 

examination inside a brownstone could include dumbwaiter shafts, hot air ducts, and registers running 

Photo 1. The fire building is the one with the bay windows from the basement to the 

fourth floor. The entrance to the basement apartment is under the steps.

(Photo source: World Wide Web.)
Page 23

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

throughout the building. Because of the nature of mechanical systems installed at the time of 

construction, these interior connected voids are much larger than would be found in today’s Type III 

buildings. Also consider that when built, any brownstone was likely to be a single-family home. It is 

entirely possible that these voids were not sealed off when the building was subsequently divided into 

apartments.

Some brownstone buildings may have open stairs in the rear of the building, which was originally for 

use by servants. Their existence allows for areas of fire spread that may not be recognized or known by 

those unfamiliar with this type of building. Additionally, the large, open, and often wood-paneled main 

stairway provides a continuous combustible flue from the first floor to the ceiling of the top floor and 

is typically terminated at a skylight. This will allow fire to spread rapidly and cut off escape routes for 

the occupants. Transom windows, which may be found over the interior doors, can fail under fire 

conditions and allow heat and smoke into the hallway areas. This also will allow fire to spread more 

easily [FDNY 2009a, FDNY 2013a].

The Fire Building

The structure involved in the fire was built in 1899 with a total living space of 6,376 square feet. The 

structure had five floors including a basement. The lot size is 3,600 square feet. The construction is 

Type III (Ordinary).

When built, the structure was designed as a single-family dwelling. In 1974, the owner divided the 

building into apartments with one apartment each on the first floor and the second floor and with two 

apartments each in the basement, third floor, and fourth floor. The basement was divided into two 

separate apartments with separate entrances. The basement unit at the front of the building (Apartment 

#9) could only be entered from the exterior entrance below the stairs on Side Alpha. The basement unit 

at the rear of the structure (Apartment #10) could be entered from the interior stairs at the center of the 

common hall on the first floor and from an exterior grade-level entrance on Side Charlie (See Diagram 

1). The main entrances to the apartments on the second through fourth floors were reached by a 

common interior stairwell. Secondary means of egress from apartments on the first through fourth 

floors were provided by exterior fire escapes.
Page 24

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

The first floor consisted of one apartment, which included a bedroom in the front (Side Alpha), a large 

living area in the rear (Side Charlie), a kitchen, a bathroom, another bedroom, and a common entry 

foyer, which had access to the basement (Apartment #10) and the apartments on the floors above (See 

Diagram 2). Prior to its conversion to apartments, the building had an elevator that went from the 

basement to the first floor. The elevator had been used to bring prepared food from the basement to the 

first floor when the structure was a single-family dwelling. The elevator was not in service at the time 

of the fire. The elevator was located on the Side Bravo wall. 

Diagram 1. The diagram of the basement of the fire building. The front apartment is 

#9 and the rear apartment is #10. The shed was attached to the structure on Side 

Charlie, behind the rear entrance doors for the rear apartment.
Page 25

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

The block where the fire occurred consisted of predominately brownstone buildings. In-fill structures

abutted the buildings on either side of them, just as the original structures did. Parking was allowed on 

the street in front of the buildings. Parking was also allowed on a private, narrow street on the Charlie 

side of the building. As indicated in the diagram, several buildings had garages for tenant parking (See 

Diagram 3).

Diagram 2. The diagram of the first floor (Apartment #1) of the fire building. The 

stairs leading down to the basement are marked by the red arrow.
Page 26

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

Diagram 3. The street diagram and location of the fire building.
Page 27

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

The fire started in a shed in the rear of the structure. The shed was attached to the building by the rear 

entrance. The shed served as the office, storage, and work facility for the property maintenance staff of 

the affected building (See Photo 2).

Personal Protective Equipment

At this incident, each officer and fire fighter was wearing a station/work uniform, turnout pants, 

turnout coat, helmet, boots, and an SCBA with integrated personal alert safety system (PASS). Note:

At the time of this incident, the department did not mandate the use of protective hoods.

NIOSH investigators inspected and photographed each victim’s personal protective equipment at the 

Arson Division office. The inspected SCBA and turnout gear exhibited a variety of thermal damage as 

the result of the exposure to the fire. Two SCBA units were shipped to the NIOSH National Personal 

Protection Technology Laboratory (NPPTL) in Pittsburgh, Pennsylvania, for evaluation.

On February 27, 2015, NPPTL personnel in Pittsburgh evaluated the SCBA and the summary 

evaluation report is included as “Appendix One: Status Investigation Report of Two Self-contained 

Breathing Apparatus.”

Photo 2. A view of Side Charlie and the location of the maintenance shed. 

(Photo source: Google Earth.)
Page 28

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

On April 8, 2015, an independent contractor was requested to evaluate the personal protective 

equipment. The summary evaluation report is included as “Appendix Two: Personal Protective 

Equipment Evaluation.”

Weather and Road Conditions

The weather temperature at 1454 hours was 34 degrees Fahrenheit (34o F) with a wind chill factor of 

20o F. The humidity was 27% and the barometric pressure was 29.59 inches. Visibility was 10 miles 

and the winds were 32 miles per hour from the southeast. The winds gusted as high as 69 miles per 

hour during this incident. The skies were overcast and no precipitation was reported in the previous 24 

hours [Weather Underground 2014].

Investigation

On March 26, 2014, at 1441 hours, the Fire Alarm Office (FAO) received a 9-1-1 call that reported a 

building was filling with smoke. At 1443 hours, the FAO dispatched Engine 33, Engine 7, Engine 22, 

Ladder 24, Ladder 26, Rescue 1, and District 4 (Car 4) for Box 1579. Note: The first-due ladder 

company (Ladder 15) was out of service due to maintenance; Ladder 24 (third-due ladder company) 

was dispatched as the first-due ladder company. The second-due ladder company (Ladder 17) was out 

of service due to training; Ladder 26 (fourth-due ladder company) was dispatched as the second-due 

ladder company. Both Ladder 15 and Ladder 17 responded after the initial dispatch.

Engine 33 arrived on scene at 1445 hours and parked in front of the fire building. The officer from 

Engine 33 advised FAO that “Engine 33 is in command and we have a four-story with smoke showing 

from first floor.” Due to the active and dynamic situation plus the immediate life safety concerns of an 

occupied residential building encountered at this incident, the Engine 33 officer assumed fast-attack 

mode as the command mode. Note: Fast-attack mode can also be known as fast-action mode or mobile 

command. This command mode is selected in situations that require immediate action to stabilize and 

requires the company officer’s assistance and direct involvement in the attack. 

The Engine 33 lieutenant and Engine 33 (Pipeman) right jumpseat fire fighter stretched a 13⁄4-inch 

hoseline up the front steps and into the first floor. A civilian was coming down the front fire escape 

while Engine 33 was making their stretch. The Engine 33 chauffeur charged the 13⁄4-inch hoseline as 

Engine 33 moved down the steps to the rear basement apartment. At 1445 hours, Car 4 had arrived on 

scene and assumed command from the officer of Engine 33. Car 4 established command in front of 

Engine 33.

At 1446 hours, FAO dispatched District 3 (Car 3) and Engine 37 on the Rapid Intervention Team 

(RIT) assignment. At 1446 hours, FAO completed the RIT dispatch for Box 1579. FAO dispatched 

Tower Ladder 3 and Ladder 18. The safety officer (H1-Safety District Chief) assisted the RIT chief 

and RIT operations on Side Alpha. A concurrent RIT operation was ongoing on Side Charlie. 

The fire fighter assigned to the left jump seat (Hydrant) of Engine 33 was preparing to pull the 4-inch 

supply line when a female civilian told him that someone might be in the basement apartment. The fire 
Page 29

Lieutenant and Fire Fighter Die and 13 Fire Fighters injured in a 

Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

fighter took a halligan tool and went down the exterior steps and into the front basement apartment 

(Apartment #9). The fire fighter forced two doors and entered the front basement apartment. The fire 

fighter came out of the apartment and met with Command who was in the street. The fire fighter 

advised Command that the fire was in the rear basement apartment (Apartment #10) and a hoseline 

needed to be deployed to the basement.

Engine 7 arrived on scene at 1447 hours from the east and parked facing Engine 33 and laid a 4-inch 

supply line from the hydrant on the corner and then ran a 21⁄2-inch supply line to Engine 33. Engine 33 

was entering the front door as Engine 7 arrived on scene. The crew (officer and two fire fighters) from 

Engine 7 pulled a 21⁄2-inch hoseline to the front steps. Engine 7 stretched a 21⁄2-inch hoseline up the 

front steps following Engine 33’s charged 13⁄4-inch hoseline. As Engine 7 moved the hoseline toward 

the stairs, the conditions started to change as the first floor became extremely hot. The Pipeman from 

Engine 7 asked the Engine 7 officer to call for water. The conditions became untenable and Engine 7 

left the building. As Engine 7 pulled the 21⁄2-inch hoseline out of the building, the hose was burned.

The time was approximately 1449 hours (See Diagram 4).

Engine 22 responded to Box 1579 as the third-due engine. Engine 22 laid a 4-inch supply line from a 

hydrant in the previous block, arrived on scene at 1448 hours, and parked behind Engine 7. The 

Diagram 4. The initial hoseline operations entering through the front door of the first floor. 

Engine 33 has taken a 13⁄4-inch hoseline into the basement. Engine 7 is pulling a 21⁄2-inch 

hoseline into the front hallway of the first floor, moving toward the basement steps. The time 

is approximately 1449 hours. 
Page 30

Lieutenant and Fire Fighter Die and 13 Fire Fighters are injured in 

a Wind-driven Fire in a Brownstone—Massachusetts

Report #F2014-09 

chauffeur pulled a 200-foot 21⁄2-inch hoseline to the front walkway of the fire building. The captain and 

right jump seat fire fighter from Engine 7 took the 21⁄2-inch hose into the first floor with the “Hydrant” 

fire fighter from Engine 33. At the same time, Rescue 1 and Engine 37 were pulling a 13⁄4-inch 

hoseline through the front door, down the steps, and into the basement. All companies were forced out 

of the building at this point due to a rapid progression of fire conditions. The Engine 22 “Hydrant” fire 

fighter went back to Engine 22 to pull another 21⁄2-inch hoseline when conditions changed.

Ladder 24 arrived on scene at 1448 hours and parked behind Engine 33. The captain and two fire 

fighters entered the first floor of the fire building. Ladder 24 crawled down the hallway to the stairs 

going to the second floor. The captain of Ladder 24 stated they were engulfed in black smoke and the 

heat increased, which forced them out of the building. Crews had to pull the captain of Ladder 24 out 

of the building. At the same time, the chauffeur from Ladder 24 put the aerial ladder to the roof. He 

went to the roof and vented the roof.

Ladder 26 arrived on scene at 1448 hours and parked on Side Charlie, directly behind the fire building.

The captain of Ladder 26 observed the rear door of the maintenance shed was open and fire in the 

shed. The captain advised his crew not to break any windows. The captain radioed Command and 

asked for water on Side Charlie but was unable to reach Command due to radio traffic. He instead 

called FAO and advised that fire was showing on the first floor in the rear of the building. He 

requested an engine company on Side Charlie for water. The captain of Ladder 26 then forced his way 

through Exposure Bravo to get to Side Alpha (See Diagram 5).
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Diagram 5. The diagram of the initial engine company operations with Engine 33, 

Engine 7, and Engine 22 making entry into the fire building. The time is 

approximately 1449 hours.
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The captain of Ladder 26 met with Command on Side Alpha regarding the need for water on Side 

Charlie. Several members of Rescue 2 pulled a 21⁄2-inch hoseline through Exposure Bravo to Side 

Charlie. The captain of Ladder 26 returned to Side Charlie and entered the rear apartment through a 

window. He went in with crews from Ladder 17 and Rescue 2. Prior to entering the structure, a rapid 

progression of fire conditions occurred. Another rapid progression of fire conditions occurred while 

they were operating in the rear basement apartment. The time was approximately 1511 hours. 

Rescue 1 arrived on scene at 1447 hours and parked at an intersection behind Tower Ladder 3. Rescue 

1 was assigned to assist companies with making entry into Side Alpha. As Rescue 1 was approaching 

the scene, the smoke conditions changed drastically from the time of arrival. The smoke conditions 

changed from brown smoke to thick, black smoke. Rescue 1 entered the basement with Engine 37. Due 

to the tremendous heat, both companies were forced out of the basement. Rescue 1 moved to the rear 

(Side Charlie) of the fire building and made entry into the rear basement apartment. The time was 1511

hours. 

At 1448 hours, Command ordered a second alarm for Box 1579. C6 (Division 1 Deputy Chief), 

District 7 (Accountability), District 9, Engine 4, Engine 17, Engine 10, Ladder 17, Ladder 15, and 

Rescue 2 were dispatched on the second alarm for Box 1579 (Box 2-1579). At 1449 hours, the 

lieutenant from Engine 33 called Engine 33 and said “charge the line.” After this radio transmission, 

Command ordered all companies out of the building. The lieutenant radioed a Mayday at 14:49:45.

The lieutenant said, “E33 has a Mayday in the basement.” At 1450 hours, the dispatcher advised 

Engine 33 to charge the hoseline. At 1451 hours, the lieutenant from Engine 33 called and said, “We 

need water now; charge E33’s pipe.” At 14:51:07 hours, FAO moved fireground operations to Tac 

Channel 3. Tac Channel 2 was assigned for the Mayday. At 1452 hours, the lieutenant from Engine 33 

radioed FAO and said: “Both of us are trapped in the basement toward the front of the building. We 

got the water but my line is burnt through. You have got to charge our line.” At 1453 hours, FAO 

announced, per the orders of Command, a third alarm was being struck for Box 1579 (Box 3-1579).

FAO dispatched Engine 29, Engine 42, and Ladder 15 for the third alarm on Box 1579. Note: Based 

upon the information from interviews with fire officers, fire fighters, and fire investigators, Engine 33 

stretched an 13⁄4-inch into the fire building, up the front stoop, and into the first floor. Engine 33 found 

the stairs leading to the basement and stretched the charged hoseline into the basement. A 

maintenance worker opened the rear door of the shed and left it open while investigating the smoke 

detector activation. Also, the interior door at the top of the basement stairs was open, the front exterior 

doors were left open by an occupant fleeing the fire, and a rear basement door or window failed. This 

created an unrestricted flow path from the basement to the first floor plus the floors above, thereby 

triggering a rapid progression of fire conditions. This trapped the officer and fire fighter from Engine 

33 in the basement. The fire, heat, and smoke through the basement and first floor created untenable 

conditions on both floors. Due to the intense heat and fire conditions, the 13⁄4-inch attack hose burned 

through.

At 1453, FAO advised the officer of Engine 33 that they were trying to get water to him. At 1454 

hours, the lieutenant of Engine 33 repeated his message of his location in the basement. At 1455 hours, 
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the lieutenant stated, “It is getting hot down here and getting hotter.” At 1456 hours, FAO called the 

lieutenant of Engine 33 and said, “They are coming to get you.” At 1457 hours, the captain from 

Ladder 26 made another request for water on Side Charlie. He stated, “We need a line on the backside 

of the building; we have heavy fire on Side Charlie.” The last transmission from the lieutenant of 

Engine 33 was at 1457 hours. He radioed, “Need a line in the basement, right away; a big line.”

At 1459 hours, per the orders of Command, a fourth alarm was struck for Box 1579 (Box 4-1579).

Engine 5 and Engine 3 were dispatched on the fourth alarm. At 14:59:07 hours, C6 assumed Command

of Box 1579, and District 4 was assigned as Division Charlie. Command advised FAO to have the 

fourth-alarm and fifth-alarm companies respond to the rear of the building. At 14:59:22 hours, a fifth

alarm was struck for Box 1579 (Box 5-1579). FAO dispatched Engine 28, Engine 55, Ladder 14, and 

C1 (Commissioner).

At 1500 hours, Engine 10 laid a supply line from Engine 4 to Side Charlie. The first attempt to enter 

the basement from the rear of the building had three 21⁄2-inch hoselines operated by Engine 10, Engine 

4, and Engine 24. Rescue 1 was attempting to locate the officer and fire fighter from Engine 33. Crews 

from Ladder 26, Ladder 15, Ladder 17, Tower Ladder 3, and Engine 42 were operating in the rear of 

the building at this time. The officer of Rescue 1 notified C7 of hearing a PASS Alarm as he exited the 

building. The crews were only able to get about 5–10 feet into the apartment when a rapid progression 

of fire conditions occurred in the basement and on the first floor. Crews exited the building, regrouped, 

and re-entered the basement apartment. The time was 1506 hours. The crews re-entered the building 

and continued the search for the missing lieutenant and fire fighter from Engine 33. Crews were

operating about 20–25 feet in the rear basement apartment.

At 1509 hours, the sixth alarm and seventh alarm for Box 1579 were dispatched. Engine 30 was 

dispatched on Box 6-1579 and Engine 8, Engine 21, and Ladder 4 were dispatched for Box 7-1579.

Another rapid progression of fire conditions occurred at the front of the building at approximately 

1511 hours. Command contacted FAO and ordered all crews out of the building. This was done on all 

three channels. At 1511 hours, a rapid progression of fire conditions occurred at the rear of the first 

floor while crews were operating in the rear basement apartment (See Photo 3). At 1513 hours, 

Command ordered the eighth alarm and ninth alarm for Box 1579. Engine 49 and Engine 24 were 

dispatched for Box 8-1579. Engine 39, Engine 14, and Tower Ladder 10 were dispatched for Box 9-

1579.
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Photo 3. A rapid progression of fire conditions occurred on the first floor at approximately 

1511 hours. Crews were operating on Side Charlie (upwind side) and making entry into the 

rear basement apartment via the windows. This photo shows the force of the rapid 

progression of fire conditions.

(Photo courtesy of the fire department.)
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Command ordered defensive operations on Side Alpha due to the severity of the fire conditions. At 

1515 hours, Division Charlie (C7) contacted Command regarding whether fire fighters were still 

missing. C1 (Commissioner) advised that a member was unaccounted for in the basement. Crews from 

Engine 10, Engine 4, Engine 24, Rescue 1, Rescue 2, Ladder 17, Ladder 15, Ladder 26, Tower Ladder 

3, and Engine 42 were operating on Side Charlie. Members from Rescue 2 found the fire fighter from 

Engine 33 in the rear basement (Apartment #10) near the kitchen. The fire fighter was covered with 

debris. Members of Rescue 2 moved the fire fighter from Engine 33 to the rear window (See Diagram 

6). Crews outside picked up the fire fighter and put him on a stretcher.

The time was 1519 hours when the fire fighter was removed from the structure. The fire fighter was 

taken on the stretcher to an EMS ambulance located at a cross street near Side Alpha. He was 

transported to the nearest trauma center. The fire fighter was pronounced dead at 1607 hours.

Shortly after the fire fighter from Engine 33 was removed from the structure, C7 allowed two 

companies—Engine 21 and Rescue 1—to re-enter the rear basement apartment for approximately 30–

60 seconds to listen for the PASS Alarm from the Engine 33 lieutenant. When no device was heard, C7 

ordered the companies out of the building due to the severely deteriorating conditions.

Diagram 6. Crews from Engine 10, Engine 42, Ladder 15, Ladder 17, and 

Rescue 2 are operating the rear basement apartment searching for the 

lieutenant and fire fighter from Engine 33. Rescue 2 finds the fire fighter from 

Engine 33 and removed him from the building. The time is 1519 hours. The 

lieutenant was not located until 1848 hours.
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Diagram 7. Defensive operations. Ladder pipes, a tower ladder, and 

numerous deck guns plus hoselines are in operation. The time is 

approximately 1645 hours.
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The defensive operations continued on Side Alpha and Side Charlie until approximately 1635 hours

(See Diagram 7 and Photo 4). At 1831 hours, a request was made for a chief inspector from the city’s 

Inspectional Services Department, a structural engineer, and the medical examiner. At 1840 hours, a 

request was made for the structural engineer to report to Division Charlie. After consultation with a 

structural engineer, Command advised Division Charlie to attempt to locate the lieutenant from Engine 

33.

Division Charlie (C7) tasked Rescue 1 and Rescue 2 to make another search to locate the officer of 

Engine 33 in the rear basement apartment. At approximately 1848 hours, members of Rescue 1 and 

Rescue 2 located the officer of Engine 33. He was pronounced dead at the scene. At 1911 hours, the 

officer was removed from the rear basement apartment and transported by an EMS ambulance to the 

nearest trauma center. 

The fire for Box 9-1579 was declared “All Out” by Command at 0743 hours on March 27.

Photo 4. Defensive operations on Side Alpha of the fire building. Three ladder pipes, a tower 

ladder, numerous deck guns, and hoselines are in operation. The time is approximately 1615 hours.

(Photo courtesy of the fire department.)
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Fire Behavior/Wind-driven Fire

The fire was unintentionally started by welders who were installing a railing on the left side staircase at 

the rear entrance of Exposure Delta next to the fire building. The welders started work at 

approximately 1230 hours. At approximately 1439 hours, the occupant of Apartment #10 heard the 

building’s fire alarm activate. The occupant walked out of the apartment and went up the steps and 

notified the occupant in Apartment #1. The occupant of Apartment #10 called 9-1-1 at 1441 hours.

Another occupant telephoned the building’s maintenance supervisor and advised him of the smoke in 

the building. The welders realized that the shed behind the fire building was on fire. They attempted to 

extinguish the fire with water and snow. Due to the wind, the smoke extended into the fire building.

At approximately 1445 hours, the maintenance supervisor arrived and parked on Side Charlie in the 

rear parking lot of the fire building. He went to the rear of the building due to fire apparatus blocking 

the entrance on Side Alpha. He noticed smoke coming from the shed and went to open the back 

exterior door going into Apartment #10. He placed his key in the door and opened the door 

approximately 3 inches. The maintenance supervisor stated when he opened the door, “Fire came at 

me.” The maintenance supervisor also stated that he thought he could see fire through the window of 

the interior door to Apartment #10 (See Diagram 1). The maintenance supervisor left the door open 

and then moved back to the parking lot.

Engine 33 had entered the fire building through the front door and moved the hoseline to the stairwell 

to go down to the basement. With the rear basement doors and the front doors open, the fire had a flow 

path from the basement, up the stairs to the first floor and floors above. This occurred after the interior 

rear door or window leading into the hallway in the basement failed.

Wind has been recognized as a contributing factor to fire spread in wildland fires and large-area 

conflagrations. Wildland fire fighters are trained to account for the wind in their tactics. While 

structural fire departments have recognized the impact of wind on fires, in general, the standard 

operating procedures for structural fire-fighting have not changed to address the hazards created by a 

wind-driven fire inside a structure.

The results of the "no-wind" and "wind" fire simulations demonstrate how wind conditions can rapidly 

change the thermal environment from tenable to untenable for fire fighters working in a single-story 

residential structure fire, in a multi-family residential structure fire, and high-rise structure fire. The 

simulation results emphasize the importance of including wind conditions in the scene size-up before 

beginning and while performing fire-fighting operations and adjusting tactics based on the wind 

conditions [NIST 2013b].

The National Institute of Standards and Technology (NIST) has conducted research and testing on the 

impact of wind-driven fires and fireground operations. Adjusting fire-fighting tactics to account for 

wind conditions in structural fire-fighting is critical to enhancing the safety and the effectiveness of 

fire fighters. Studies have demonstrated that applying water from the exterior into the upwind side of 

the structure can have a significant impact on controlling the fire prior to beginning interior operations.
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It should be made clear that in a wind-driven fire, it is most important to use the wind to your 

advantage and attack the fire from the upwind side of the structure, especially if the upwind side is the 

burned side. Interior operations need to be aware of potentially rapidly changing conditions [Fire 

Protection Research Foundation 2013].

The research conducted by NIST also provides potential guidance for fire fighters as a part of a scene 

size-up and when approaching the room of fire origin. Note: Fire fighters should check for wind 

conditions in the area of the fire, look for “pulsing flames” or flames not exiting a window opening, 

examine smoke conditions around closed doors within the potential flow path, and maintain control of 

doors within the flow path. Even if flames are being forced out of adjacent windows with a high 

amount of energy, there could still be sufficient energy flows on the fire floor to create a hazard for fire 

fighters.

The data from this research will also help to identify fire-fighting tactics to improve standard operating 

procedures for the fire service to enhance fire fighter safety, improve fireground operations, and to 

encourage the use of wind control devices. If the demonstrated technologies continue to prove 

effective in the field trials and pilot programs, the next step may be to examine the need for standards 

and standardized test methods to define a minimum level of acceptable performance of these devices

[NIST 2013a].

Flow Path and Fire Control

“A flow path is composed of at least one inlet opening, one exhaust opening, and the connecting 

volume between the openings. The direction of the flow is determined by difference in pressure. Heat 

and smoke in a high pressure area will flow through openings toward areas of lower pressure.” Based 

on varying building designs and the available ventilation openings (doors, windows, etc.), several flow 

paths can exist within a structure. Any operation conducted in the exhaust portion of the flow path will 

place members at significant risk due to the increased flow of fire, heat, and smoke toward their 

position [FDNY 2013a; NIST 2013a].

Fire fighters must be aware and understand that the critical first step in evaluating the potential for a 

wind-impacted fire is recognition of any smoke movement in the flow path, wind speed, smoke being 

forced under doors, and/or pulsing smoke or fire. The incident commander and company officers must 

be notified immediately when any of these conditions are observed. The communication of this 

critical information to the incident commander and company officers operating inside the 

building must be acknowledged.

Due to the doors on Side Charlie being left open or failing, the interior door at the top of the basement 

stairs being left open, and the front doors on Side Alpha being left open by an occupant fleeing the fire, 

an unrestricted flow path was created from the basement to the first floor and floors above. The fire 

hose that Engine 33 deployed was impacted by the fire and heat generated by the flow path.
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Fire Origin and Cause

The fire was ruled accidental by the county’s district attorney. According to fire investigators, 

employees from a welding company accidentally started a fire in the maintenance shed in the rear of 

the fire building. The welding company employees were installing pre-fabricated wrought-iron railings

in the rear of the Delta Exposure building. It was the opinion of the Fire Investigation Unit that the area 

of origin of this fire was the rear of the fire building, outside the shed wall facing the rear Delta 

Exposure. The cause of the fire was a heat source too close to combustible material, with combustion 

accelerated by high winds. 

Contributing Factors

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

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

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

led to the fatalities:

• Delayed notification to the fire department

• Uncontrolled ventilation by a civilian 

• Occupied residential building with immediate life safety concerns

• Staffing 

• Scene size-up

• Lack of fire hydrants on Side Charlie (a private street)

• Lack of training regarding wind-driven fires

• Unrestricted flow path of the fire

• Lack of fire sprinkler system

Cause of Death

The medical examiner listed the manner of death of the lieutenant and fire fighter from Engine 33 as 

accidental. The cause of death for the lieutenant was smoke inhalation and thermal injuries. The cause 

of death for the fire fighter was smoke inhalation and thermal injuries as well as blunt force trauma to 

the abdomen. 

Recommendations

Recommendation #1: Fire departments should define fireground strategy and tactics for an 

occupancy that are based upon the organization’s standard operating procedures. As part of the 

incident action plan, the incident commander should ensure a detailed scene size-up and risk 

assessment occurs during initial fireground operations including the deployment of resources to 

Side Charlie. Scene size-up and risk assessment should occur throughout the incident.

Discussion: Fireground standard operating procedures (SOPs) define the initial strategy and tactics for 

a coordinated deployment of departmental resources for specific incidents and occupancies. SOPs are 

based on factors not limited to but including department staffing; deployment capabilities; knowledge 

and skill levels; apparatus, tools, and equipment; building information including height, area, 
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construction class, and type of occupancy; and potential life hazards. The first arriving resource will 

assume command and control of the incident. This ensures initial responding units understand the 

strategy and the operational goals and can deploy tactics at incidents with or without a chief officer on 

the scene. The intent is to maximize efficiencies while minimizing confusion and duplication of effort.

The incident commander develops a strategy and tactics based upon scene size-up and the risk 

assessment, including the factors listed above. This is a process that must be made in a short period of 

time involving a dynamic and fluid situation. Most importantly the strategy and tactics should include 

an observation and/or report from all sides of the structure, especially Side Charlie. The goal of 

effective fireground procedures is to increase the safety of the members, eliminate confusion, and 

prevent the loss of life [NIOSH 2015].

Occupancies define the space inside the class of building. Construction types/classes of construction 

define how the building is constructed with either combustible or non-combustible materials. 

Occupancies exist inside the constructed building. Fire departments must consider numerous factors 

that affect operations when developing these SOPs. This will ensure essential strategic-, tactical-, and 

task-level functions are performed by the incident commander, division/group supervisors, company 

officers, and fire fighters. Additionally, this process compliments the defined knowledge, skills, 

abilities, competencies, and fireground experience to assist:

• The incident commander to plan and implement an effective strategy and Incident Action Plan.

• Division/group supervisors to formulate and follow tactics.

• Company officers to successfully carry out assigned tasks.

• Individual members to effectively perform their duties [FDNY 2009a; FDNY 2009b; FIRESCOPE 

1994].

Tasks that need to occur at any fire, regardless of the occupancy, are an initial on-scene report upon 

arrival, initial risk assessment, situational report, water supply, deployment of hoselines and backup

hoselines, search and rescue, ventilation, initial rapid intervention crews (IRIC), ground and aerial 

ladder placement, fire attack and extinguishment, and salvage and overhaul.

At any incident, life safety is always the first priority, followed by incident stabilization (second 

priority) and then property conservation (third priority). Ensuring for the safety of fire fighters is a 

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

evaluated and matched with the actions and conditions. The following risk management principles 

shall be use by the incident commander: 

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

that have the potential to save endangered lives. 

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

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

• No risk to the safety of fire fighters shall be acceptable where there is no possibility to save lives or 

property [Brunacini 2002; NFPA 2014a].
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The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and 

situational report by the first arriving officer. If physical barriers make the 360-degree size-up 

impractical for the first arriving officer, the size-up of Side Bravo, Side Charlie, and Side Delta may be 

delegated to another fire department resource. The priority is to get a fire department resource to the 

rear of the structure (Side Charlie). However, unless an obvious life safety issue exists (e.g., visible 

victims requiring immediate assistance), interior fire-fighting operations should not commence until a 

report from Side Charlie is received. A radio report of conditions, including those on Side Charlie, 

should be transmitted over the assigned tactical channel to the incident commander and the dispatch 

center. The transmission should include the following information:

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

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

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

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

implement. 

• If there were critical building description information through the critical incident dispatch system 

(CIDS) for the address, then this information would aid in implementing or adjusting SOPs. CIDS 

could contain information that would necessitate alternative action to fulfill said operational goals.

• Building features (e.g., number of stories), particularly if there is a difference between Side Alpha 

and Side Charlie.

• Basement access and type.

• Any other life or safety hazards.

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

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

radio channel [Township of Spring Fire Rescue 2013; FDNY 2011]. Command is then obligated to rebroadcast and receive acknowledgement from all operating companies.

The procedures developed for fireground operations should be flexible enough to allow for change if 

any of the following issues occur or are present:

• Life hazard (must be given first priority)

• Problems with water supply and water application

• Volume and extent of fire, requiring large caliber streams

• Location of the fire, if inaccessible for hand-line operations

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

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

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

of the building and the intensity and duration of the fire [ISFSI 2013]
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In this incident, the initial on-scene size-up and evaluation was made by Engine 33 as the first-alarm 

companies arrived on scene on Side Alpha. The officer of Engine 33, based upon life safety issues and 

smoke showing, made the decision to initiate an offensive attack (fast attack). The first fire department 

unit on Side Charlie was Ladder 26, which was after interior fire-fighting operations had started. It is 

essential that during the initial stages of an incident, at least one company (preferably an engine 

company) is designated to Side Charlie of a structure, even if a 360-degree walk-around is conducted. 

This ensures that Command has a complete initial assessment of the fireground and a continuous risk 

assessment and situational report from Side Charlie.

Recommendation #2: Fire departments should ensure that once command is established at an 

incident, the incident commander maintains control of situation status, resource status, and 

communications, plus ensures the completion of the tactical objectives. 

Discussion: Based upon the design of the Incident Command System, the standard assumption of 

command establishes the organizational authority to perform the command functions starting at the 

very beginning of the incident. When the first officer arrives on scene, this officer has the 

responsibility to evaluate incident conditions, develop an incident action plan, determine how to 

progress toward the completion of the tactical objectives, address any safety consideration, deploy and 

assign operating companies, and determine if there is a need for additional resources [Brunacini 2002].

It is the responsibility of the incident commander to develop an organizational structure, using standard 

operating procedures, to effectively manage the incident scene. The development of the organizational 

structure should begin with deployment of the first arriving fire department unit and continue through a 

number of phases, depending on the size and complexity of the incident. The command structure must 

develop at a pace that stays ahead of the tactical deployment of personnel and resources. In order for 

the incident commander to manage the incident, they must first be able to direct, control, and track the 

position and function of all operating companies. Building a command structure is the best support 

mechanism the incident commander can use to achieve a balance between managing personnel and the 

needs of the incident [NFPA 2014a].

The eight basic functions of command define standard activities that are performed by the incident 

commander to achieve the tactical objectives. The responsibilities of an incident commander include

the following:

• The first arriving fire department resource has responsibility for the incident and assumes 

command of the incident.

• The incident commander conducts an initial and on-going situational assessment of the incident.

• The incident commander establishes an effective communications plan.

• The incident commander develops the incident objectives from the situational assessment and 

forms appropriate strategy and tactics.

• The incident commander deploys available resources and requests additional resources based upon 

the needs of the incident.

• The incident commander develops an incident organization for the management of the incident.
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• The incident commander reviews, evaluates, and revises the strategy and tactics based upon the 

needs of the incident.

• The incident commander provides for the continuity, transfer, or termination of command 

[Brunacini 2002].

As command is transferred, so is the responsibility for these functions. The first six functions must be 

addressed immediately from the initial assumption of command [Brunacini 2002].

At most incidents the initial incident commander will be a company officer. The company officer of 

the first arriving unit shall formally establish command and give an arrival report. The company officer 

should remain in command until properly relieved by a member of higher rank who is on scene.

The initial incident commander remains in command until command is transferred, the incident is 

stabilized, or command is terminated. The first arriving fire department unit initiates the command 

process by giving an initial radio report. A standard initial radio report (arrival report) includes the 

following:

• Location of the incident.

• Location of the command post.

• Title of the incident.

• Brief report (e.g., building size, construction type, and occupancy).

Other information that must be transmitted to the dispatcher and on the tactical channel are the 

following:

• Obvious problem/conditions

Nothing showing (indicates checking or investigating)

Smoke showing (amount and location)

Fire showing (amount and location)

Working fire

Fully involved

• Actions taken

Assuming command

Laying a line, attacking with ..., and so forth

Declaration of strategy—offensive or defensive

• Command confirmation with name

• Follow-up radio report

Any immediate safety concerns

Accountability started (announce the initial accountability location)

Disposition of resources (situational status)

• Define initial rapid intervention crew (IRIC) [FIRESCOPE 1994; NFPA 2014a]
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The following is an example of an arrival report:

“Engine 9 is on scene at 945 Saratoga Street and Engine 9 is assuming Saratoga Command. 

We have fire showing from floor #2 on Side Alpha of an occupied, three-story, wood frame 

dwelling, which is approximately 20 feet by 30 feet. This is a working fire. Engine 9 did not 

lay in, Engine 19 lay a line for us. This is an offensive fire and E9 is in the fast-attack mode. 

E9 is attacking the fire with a 13⁄4-inch hoseline. Command has established accountability at 

E9 and IRIC has been established.”

Once the location of command has been established (e.g., Saratoga Command), the incident 

commander may announce that he/she is resorting to “fast-attack mode” and proceeding to the incident 

location with his/her company. By announcing that he/she is resorting to “fast-attack mode” the 

incident command retains command of the incident. Fast-attack mode is employed only in the initial 

stages of an incident. The initial incident commander determines which type of command mode is 

more appropriate based upon the specifics of the incident. The three modes of command create a 

standard method of getting the role of command functional during the initial stages of an incident. The 

three command modes are:

• Nothing Showing (Investigation) Mode

• Fast-Attack Mode

• Command Mode [FIRESCOPE 1994, Brunacini 2002]

Where fast intervention is critical, utilization of the portable radio will permit the company officer’s 

involvement in the attack without neglecting the responsibilities of the incident commander. The fast 

attack mode should not last more than a few minutes and will end with one of the following: 

• The situation is stabilized.

• The situation is not stabilized and the company officer must withdraw to the exterior and establish 

an incident command post.

• Command is transferred to another higher ranking officer (e.g., battalion chief, district chief). 

When a chief officer is assuming command, the chief officer may opt to return the company officer 

to his/her crew, or assign him/her to a subordinate position [Brunacini 2002].

When operating in the fast-attack mode, communication is a critical issue. Though this function only 

operates in a short period of time (e.g., 3–5 minutes), a lot can occur during this time frame. 

Fireground communications is an essential element to ensure for effective command and control. The 

officer (Command) must maintain communications with the dispatcher plus first-alarm companies.

Hopefully, this can be done on one radio channel—preferably a tactical channel. This allows the 

immediate access to the dispatcher to provide an update of the incident. Also, this allows Command to 

communicate directions to other company officers to ensure that tactical objectives are being met. The 

communication component allows the officer to maintain situational status (what is the incident doing) 

as well as resource status (what are the assigned companies doing).

All this information gathering is essential, especially when the battalion chief or district chief arrives 

on scene and the transfer of command must occur. When the transfer of command occurs, the optimum 
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scenario is a face-to-face exchange of information. In this situation, the company officer has the 

responsibility to provide an update of:

• Incident conditions.

• The incident action plan.

• The status of tactical objectives.

• Any safety consideration.

• Deployment and assignment of operating companies (situational status).

• Personnel accountability (resource status) [Brunacini 2002; NFPA 2014a].

If the arrival of the battalion chief or district chief is more than a few minutes, the second-due resource 

may need to assume command in a standard position (outside the hazard zone) monitoring 

communications, updating, reviewing, and reinforcing the initial size-up, backing-up the initial attack, 

and verifying the safety, welfare, and accountability of crews.

At this incident, the officer of Engine 33 gave his scene size-up and assumed command of the incident 

at 1445 hours. Car 4 (District 4) arrived on scene 40 seconds later and assumed command of the 

incident. There was no communications from the officer of Engine 33 to Car 4 during the transfer of 

command. The next resources didn’t arrive on scene until 1448 hours. The next communications from 

the officer of Engine 33 was at 1449 hours when he called Engine 33 to charge the hoseline. The 

Mayday was called 45 seconds later.

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

procedures, training programs, and tactics for wind-driven fires.

Discussion: Based on the analysis of this fire incident and results from current research and field

studies, adjusting fire-fighting tactics to account for wind conditions in structural fire-fighting is 

critical to enhancing the safety and the effectiveness of fire fighters. A wind-driven fire may be one of 

the most dangerous operations fire fighters will encounter. The term “wind-driven” fire is used to 

describe a fire in which the wind has the potential to, or is already causing, a dramatic and sudden

increase in fire, heat, and smoke conditions. Experienced fire officers and fire fighters who have 

survived wind-driven fires have all described the following:

• Upon arrival, conditions appeared to be routine.

• Within seconds, fire, heat, and smoke conditions changed without warning “from routine to life 

threatening.”

• An operating 21⁄2-inch hoseline flowing from the downwind position or into the exhaust portion of 

the flow had little or no effect on the incredible heat being produced; flowing water into the intake 

or inlet side of the flow path is very effective.

• Directly attacking these fires with one or even two 21⁄2-inch hoselines proved ineffective and 

ultimately led to fire fighters incurring serious injuries [FDNY 2013a].

When responding to a reported structure fire, an overriding consideration concerning size-up must be 

wind conditions and its potential effect on the fire. The key to successfully operating at wind-impacted 
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fires in a structure depends on recognizing the wind-impacted fire conditions that may change a 

seemingly routine fire into a “blowtorching” fire. “Blowtorching” is the appropriate description of 

what will occur when fire conditions are impacted by wind conditions.

The impact of the wind will be affected by the size of the window opening, the fuel load, and the stage 

of the fire when the window failed. When wind-impacted fire conditions exist in a structure, the 

incident commander should notify the dispatcher so this information can be relayed to all 

responding units. Also, the incident commander needs to make an announcement on the tactical 

channel as well. Once the contributing factors are identified, steps can be taken to minimize the 

hazards to fire fighters [FDNY 2013a].

Fire departments should develop standard operating procedures for incidents with high-wind 

conditions ad for areas where high-wind conditions are likely. It is important that fire officers and fire 

fighters develop an understanding of how wind conditions influence fire behavior and impact 

fireground tactics that may be necessary under wind-driven conditions. Wind conditions can have a 

major influence on structural fire behavior. When wind speeds exceed 10 mph (16 km/hr.) the incident 

commander, division/group supervisors, company officers, and fire fighters should use caution and 

take wind direction and speed into account when selecting a strategy and developing tactics. The 

National Institute of Standards and Technology (NIST) has determined that wind speeds as low as 10 

mph (16 km/hr.) are sufficient to create wind-driven fire conditions if the flow path is uncontrolled 

[NIST 2013a]. NIST, in a recent study on wind-driven fires in structures, has shown that wind speeds

as low as 10 mph can turn a routine “room and contents fire” into a floor to ceiling fire storm or 

“blowtorch effect,” generating untenable conditions for fire fighters, even outside of the room of 

origin. Temperatures in excess of 600 oC (1100 oF) and total heat fluxes in excess of 70 kW/m2 were 

measured at 4 feet above the floor along the flow path between the fire room and the downwind exit 

vent. These conditions were attained within 30 seconds of the flow path being formed by an open vent 

on the upwind side of the structure and an open vent on the downwind side of the structure [NIST 

2013a].

Fire departments are encouraged to develop and implement a standard operating procedure addressing 

such issues as obtaining the wind speed and direction, considering the possible fuel load associated 

with a particular occupancy, determining proper strategy and tactics for fireground operations, 

consideration of ventilation, and establishing possible scenarios associated with the wind speed based 

upon risk assessment. Under wind-driven conditions, an exterior attack from the upwind side of the 

fire may be necessary to reduce fire intensity to the extent that fire fighters can gain access to the 

involved compartments [Fire Protection Research Foundation 2013].

The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and 

situational report by the first arriving officer. If physical barriers make the 360-degree size-up 

impractical for the first arriving officer, the size-up of Side Charlie may be delegated to another fire 

department unit. However, unless an obvious life safety issue exists (e.g., visible victims requiring 

immediate assistance), interior fire-fighting operations should not commence until a report from Side 

Charlie is received [Fire and Rescue Departments of Northern Virginia 2013].
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In simulations and in previous full-scale experiments, it has been demonstrated that wind can increase 

the thermal hazards of a structure fire [Fire Protection Research Foundation 2013; ISFSI 2013]. 

Therefore, wind must be considered as part of the initial size-up of the fire conditions and must be 

monitored and reported throughout the fire incident. It is critical for fire fighters to not be in the 

exhaust portion of the fire flow path. The directional nature of the fire gas flow path results in higher 

temperatures than the area adjacent to the flow path or upwind of the fire. The flow path can be 

controlled by limiting ventilation. Previous studies demonstrated that applying water from the exterior 

into the upwind side of the structure can have a significant impact on controlling the fire prior to 

beginning interior operations [Fire Protection Research Foundation 2013; ISFSI 2013].

Current fire control training guides state, “Whenever possible, approach and attack the fire from the 

unburned side to keep it from spreading throughout the structure.” It should be made clear that in a 

wind-driven fire, it is most important to use the wind to your advantage and attack the fire from the 

upwind side of the structure, especially if the upwind side is the burned side. The unexpected 

ventilation from a broken window can suddenly change the interior thermal conditions. Interior 

operations must be aware of potentially rapidly changing conditions.

A fire department should incorporate the following into their training and education component on 

wind-impacted fires:

• Ensure that an adequate initial size-up and risk assessment of the incident scene is conducted 

before beginning interior fire-fighting operations.

• Ensure that fire fighters, company officers, division/group supervisors, and the incident 

commander have a sound understanding of fire behavior and the ability to recognize indicators of 

fire development and the potential for extreme fire behavior (such as smoke [color, velocity, and

density], visible fire, and heat).

• Ensure that fire fighters and company officers are trained to recognize the potential impact of 

windy conditions on fire behavior and implement appropriate tactics to mitigate the potential 

hazards of wind-driven fire.

• Ensure the incident commander’s strategy considers high-wind conditions, if present.

• Ensure that fire fighters understand the influence of ventilation on fire behavior and effectively 

apply ventilation and fire control tactics in a coordinated manner.

• Ensure that fire fighters and officers understand the capabilities and limitations of thermal imagers.

• Ensure a thermal imager is used as part of the size-up process.

• Ensure that fire fighters are trained to check for fire in overhead voids upon entry and as charged 

hoselines are advanced.

• Develop, implement, and enforce a comprehensive Mayday standard operating procedure and train 

and educate fire fighters to ensure they understand the process and know how to initiate a Mayday.

• Ensure fire fighters are trained in fireground survival procedures.

• Ensure all fire fighters on the fire ground are equipped with radios capable of communicating with 

the incident commander and the dispatch center [FDNY 2013b].
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At this incident, the wind was blowing against the fire building on Side Charlie. Due to the doors on 

Side Charlie being left open or failing, the interior doors at the top of the basement steps being left 

open, and the front doors on Side Alpha being left open by an occupant fleeing the fire, an unrestricted 

flow path was created from the basement to the first floor and the floors above. This allowed the fire to 

spread from Side Charlie to Side Alpha. One of the key issues was the captain of Ladder 26 recognized 

the conditions of a wind-driven fire and ordered no windows to be broken on Side Charlie.

Recommendation #4: Fire departments should ensure adequate staffing for deployment to urban 

incidents involving high hazard occupancies and concentrated population.

Discussion: Interdependent and coordinated activities of all fire-fighting personnel deployed are 

required to meet these priority objectives. A number of tasks are related to each of the priorities, and 

these tasks (e.g., stretching a hoseline to the fire, ventilation, search and rescue) can be conducted 

simultaneously, which is the most efficient manner, or consecutively (one after the other), which 

delays some task(s) thereby allowing risk escalation to occur. A number of resources, such as the 

International Association of Fire Fighters, the National Fire Protection Association, and National 

Institute of Standards and Technology, can assist policy makers and fire service leaders in planning for 

adequate resource deployment in their community to ensure that fire fighter intervention in a risk event 

occurs in a timely and coordinated manner to limit risk escalation and negative outcomes. 

NFPA 1710 Standard for the Organization and Deployment of Fire Suppression Operations,

Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments 

contains recommended guidelines for minimum staffing of career fire departments [NFPA 2013e].

NFPA 1710 states the following: “On-duty fire suppression personnel shall be comprised of the

numbers necessary for fire-fighting performance relative to the expected fire-fighting conditions.

These numbers shall be determined through task analyses that take the following factors into

consideration:

• Life hazard to the populace being protected.

• Provisions of safe and effective fire-fighting performance conditions for the fire fighters.

• Potential property loss.

• Nature, configuration, hazards, and internal protection of the properties involved.

• Research by NIST and UL on methods for strategically ventilating and isolating fires to delay or 

prevent flashover by use of manual door control (requires additional staffing).

• Types of fireground tactics and evolutions employed based on standard operating procedures, 

staffing, type of apparatus used, and results expected to be obtained at the fire scene [NFPA 

2013e].

Following a community hazard/risk assessment, fire service leaders prepare a plan for timely and 

sufficient coverage of all hazards and the adverse risk events that occur. This plan is often referred to 

as a Standard of Response Coverage. Standards of response coverage can be defined as those written 

policies and procedures that establish the distribution and concentration of fixed and mobile resources 

of an organization [NIST 2013a].
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Resource distribution is associated with geography of the community and travel time to emergencies. 

Distribution is typically measured by the percent of the jurisdiction covered by the first-due units 

within a specified time frame [NFPA 2013e]. Concentration is also about geography and the arranging 

of multiple resources, spacing them so that an initial “effective response force” can arrive on scene 

within the time frames established by community expectation and fire service leadership. Response 

time goals for first-due units (distribution) and for the total effective on-scene emergency response 

force (concentration) drives fire department objectives like fire station location, apparatus deployed 

and staffing levels. The service level objectives established in any community drives response time 

performance by all responding resources and the assembly of effective on-scene fire-fighting (or EMS) 

response force. Both response time performance and assembly times subsequently drive resource 

distribution and concentration. If response times and force assembly times are low, it is more likely 

that sufficient resources have been deployed, which is associated with more positive outcomes from 

risk events. Conversely, if response times and force assembly times are high, it is more likely that

insufficient resources have been deployed, which is associated with more negative outcomes. Fire 

service leaders must take into account several other considerations when preparing a standards of 

response coverage. These considerations should include an assessment of the probability or likelihood 

that a particular event will occur [NFPA 2013a].

In many departments, company officers are primarily responsible for crew management, crew safety, 

crew accountability, and communication with other operating units on scene and with the incident 

commander. These company officers do not directly engage in stretching hoselines, advancing and 

operating hose streams, normal truck company operations including ventilation, or related tasks. The 

officer can be available to focus on crew management, situational awareness and crew accountability. 

However, officers will assist in conducting searches and removing victims when necessary. These 

officer tasks are essential to fire fighter and civilian life safety, since studies show that situational 

awareness and human error are contributing factors in nearly 20% of the fireground line-of-duty 

deaths, and that 40% of fire fighter injuries are attributed to situational awareness [NIST 2013a].

Urban fire departments should staff companies commensurate with the tactical hazards, high-hazard 

occupancies, high incident frequencies, geographic restrictions, and other pertinent factors as are 

common in urban environments. For example, the Fire Department of New York (FDNY) staffs rescue 

companies and ladder companies with a minimum of one officer and five fire fighters. FDNY engine 

companies are staffed with one officer and four fire fighters. The Chicago Fire Department staffs 

rescue companies with one officer and five fire fighters. Also, Chicago Fire Department ladder 

companies and engine companies are staffed with one officer and four fire fighters [NIST 2013b]. 

At this incident, engine and ladder companies operated with an officer and three fire fighters. The 

heavy rescues are staffed with an officer and three fire fighters. The staffing levels are consistent 

throughout the city. Based upon the workload of the fire department (call volume, working fires, and 

deployment criteria), the staffing allows for tasks to be completed based upon the capabilities of the 

company. At the beginning of the incident, Engine 33 arrived on scene, but the 4-inch supply line 
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could not be stretched to the hydrant due to the lack of staffing. Also, first-alarm companies had to 

perform the rescue of building occupants, which required companies to be split.

Recommendation #5: Fire departments should ensure that a tactical worksheet is used by Command

during initial fireground operations and maintained throughout the incident. 

Discussion: The tactical worksheet is a vital piece of equipment because it helps the incident 

commander organize the incident from the initial onset of the incident. The benefit of using a tactical 

worksheet is that critical information is documented as well as providing reminders, prompts, and a 

convenient workspace for tracking companies and apparatus. For fire departments that provide a staff 

assistant or incident command technician, the district chief or battalion chief has the ability of starting 

the tactical worksheet enroute to the incident. The incident commander has the ability to record vital 

information that may help them make future operational decisions. By documenting the assignments of 

division/group supervisors, and division/group resources, the incident commander creates a visual 

reference of the overall fireground organization and deployment [NFPA 2014a].

The use of a tactical worksheet can assist the incident commander to track various task assignments on 

the fireground. It can be used along with preplan information and other relevant data to integrate 

information management, fire evaluation, and decision making. The tactical worksheet should record 

unit status and benchmark times and include a diagram of the fireground, occupancy information, 

activities checklist(s), and other relevant information. The tactical worksheet can also help the incident 

commander in continually conducting a situation evaluation and maintaining personnel accountability 

[NFPA 2014a].

The advantages of using a tactical worksheet are:

• Includes a location to quickly note individual assignments.

• Provides prompts for the incident commander, such as time, air management and strategy.

• Provides tactical benchmarks, such as “primary search complete,” “fire under control,” and “loss

stopped.”

• Facilitates consistent, organized information.

• Documents assignments and responsibilities.

• Expedites passing of command or support for the incident commander.

• Provides resource status [NFPA 2014a].

The tactical worksheet is also an excellent tool when the "passing of command" must occur. On the 

fireground, the officer taking over command can quickly check the worksheet and obtain a strong 

understanding of the initial deployment of resources, the need for additional apparatus and equipment, 

and the status of units in the staging area.

The department in this incident has Standard Operating Procedure (SOP) #207 Personnel 

Accountability System, which states, “All District and Deputy Chiefs carry the “Tactical Command 

Sheet,” designed to assist the initial incident commander with accountability during the early stages of 
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the incident prior to the set-up of the Command Board. It is an abbreviated and more portable version 

of the full command board.” The command board is set up upon the arrival of the deputy chief on a 

second alarm.

At this incident, Car 4 arrived on scene with Engine 7. The incident command technician (ICT) parked 

the vehicle across the street from the fire building. Engine 33 was already on the scene and stretching a 

line in the front door. The ICT donned his turnout gear and SCBA and entered the building with 

Engine 7 and helped stretch Engine 7’s hoseline. Car 4 assumed command of the incident. As the ICT 

and Engine 7 entered the building, a violent change in fire conditions occurred. The conditions became 

untenable for the fire fighters from Engine 7. They moved out of the building to the landing of the 

front steps. Then the officer of Engine 33 called a Mayday.

The tactical worksheet is a vital resource because it helps the incident commander organize fireground 

operations. Also the tactical worksheet provides reminders, prompts, and a convenient workspace for 

tracking companies and apparatus. It allows the incident commander to slow down during an incident 

(although the worksheet can be used for fires big and small, as well as EMS incidents, to help develop 

proficiency) and record vital information that may help make future operational decisions. By 

documenting the assignments of division/group officers, and division/group resources, the incident 

commander creates a visual reference of the overall fireground organization and deployment [NFPA 

2014a]. The tactical worksheet provides the necessary documentation when command of an incident is 

transferred. Upon arrival of C6 (deputy chief), the Car 6 ICT initiated the command board and Car 7 

was assigned Accountability Officer (Resource Status).

Recommendation #6: Fire departments should implement a personnel accountability system to be 

used at all emergency incidents.

Discussion: The personnel accountability system was designed and is operated to ensure that fire 

fighters do not become lost or missing in the hazard zone. The system is designed to track fire fighters 

by location and function. An integral part of the accountability system is to make sure that the fire 

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

operations through the entire incident. Also, a process must be in place to periodically check to make 

sure that all members operating in the hazard zone are accounted for by this system. 

A personnel accountability system is a system that readily identifies both the location and function of 

all members operating at an incident scene [NFPA 2013a; NFPA 2014a]. 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. 

One of the most important functions of Command Safety is for the incident commander to initiate an 

accountability system that includes the functional and geographical assignments at the beginning of 

operations until the termination of the incident. It is very important for the first on-scene resource to 
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initiate an accountability system. This initial system allows the passing or transfer of information to the 

next officer who assumes command upon his/her arrival [NFPA 2014a].

A functional personnel accountability system requires the following: 

• Development and implementation of a departmental SOP.

• Necessary components and hardware.

• Training all members on the operation of the system.

• Strict enforcement during emergency incidents.

There are many different methods and tools for resource accountability. Some examples are: 

• Tactical worksheets.

• Command boards.

• Apparatus riding lists.

• Company responding boards.

• Electronic bar-coding systems.

• Accountability tags or keys (e.g., PASSPORT System) [NFPA 2014a].

Resource accountability should be assigned to personnel who are responsible for maintaining the 

location and status of all assigned resources at an incident. As the incident escalates, resource status 

would be placed under the Planning Section. This function is separate from the role of the incident 

commander. The incident commander is responsible for the overall command and control of the

incident. Due to the importance of responder safety, resource status should be assigned to a dedicated 

member as the size and complexity of the incident dictates. A number of positions could function in 

this role including an incident command technician, staff assistant, chief officer, or other defined 

member. As the incident escalates and tactical-level management components (e.g., divisions or 

groups) are assigned, the resource status officer (accountability officer) works with the division or 

group supervisors to maintain an on-going tracking and accountability of members [FIRESCOPE 

2012]. A properly initiated and enforced personnel accountability system enhances fire fighter safety 

and survival. It is vital that resources can be identified and located in a timely manner.

An important aspect of a personnel accountability system is the personnel accountability report (PAR). 

A PAR is an organized on-scene roll call in which each supervisor reports the status of their crew when 

requested by the incident commander [NFPA 2014a]. The PAR should be conducted every 15–20 

minutes or when benchmarks are met.

In order for the personnel accountability system to properly function, the process should include a 

standard operating procedure that defines each function’s responsibility in making this process 

successful on the fireground. Also a training component—both classroom and practical—should occur 

to ensure this process operates properly during emergency incidents.

The department in this incident has a Standard Operating Procedure (SOP) #207 Personnel 

Accountability System, which states, “All District and Deputy Chiefs carry the “Tactical Command 
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Sheet,” designed to assist the initial incident commander with accountability during the early stages of 

the incident prior to the set-up of the Command Board. It is an abbreviated and more portable version 

of the full Command Board.” The Command Board is set up upon the arrival of the deputy chief on a 

second alarm.

At this incident, Command called for a personnel accountability report at 1521 hours, which was 39 

minutes into the incident and Box 1579 was operating at the eighth alarm. Car 7 was assigned as 

accountability officer. Due to the number of companies operating at the incident plus companies in 

staging, a personnel accountability report was not completed until after 1605 hours. The personnel 

accountability system should be initiated with the first arriving resource. The department provides each 

district chief with an incident command technician (ICT). The ICT can start the personnel 

accountability process upon arrival and maintain this process throughout the incident.

Recommendation #7: Fire departments should provide the incident commander with a Mayday

tactical checklist in the event of a Mayday. 

Discussion: When a Mayday is transmitted for whatever reason, the incident commander has a very 

narrow window of opportunity to locate the lost, trapped, or injured member(s). The incident 

commander must restructure the strategy and Incident Action Plan (tactics) to include a priority rescue 

[NFPA 2014a].

Some departments have adopted the term LUNAR—location, unit assigned, name, assistance needed, 

and resources needed—to gain additional information in identifying a fire fighter who is in trouble and 

needs assistance. The incident commander, division/group supervisors, company officers, and fire 

fighters need to understand the seriousness of the situation. It is important to have the available 

resources on scene and to have a plan established prior to the Mayday [NFPA 2013d; NFPA 2014a].

A checklist is provided in Appendix Three, Incident Commander’s Tactical Worksheet for 

Mayday, which can assist the incident commander in the necessary steps for clearing the Mayday as 

quickly and safely possible. This checklist serves as a guide and can be tailored to any fire 

department’s Mayday procedures. The checklist format allows the incident commander to follow a 

structured worksheet. This process is too important to operate from memory and risk missing a vital 

step that could jeopardize the outcome of the rescue of a fire fighter who is missing, trapped, or 

injured.

At this incident, when the Mayday occurred, the incident commander quickly called for additional 

resources and conducted a personnel accountability report to determine if any companies were lost or 

missing. The intent of a Mayday worksheet, like the tactical worksheet, is to assist the incident 

commander during a very difficult and stressful time on the fireground.
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Recommendation #8: Fire departments should ensure that the incident commander incorporates 

Command Safety into the incident management system.

Discussion: The purpose of Command Safety is to provide the incident commander with the necessary 

resources on how to use, follow, and incorporate safety into the incident management system at all 

incidents. Command Safety is used as part of the eight functions of command developed by Fire Chief 

Alan V. Brunacini (retired). Command Safety defines how the incident commander must use the 

regular, everyday command functions to complete the strategic-level safety responsibilities during 

incident operations. Using the command functions creates an effective way and a close connection 

between the safety officer and the incident command. The eight functions of command are:

• Assumption/confirmation/positioning

• Situation evaluation, which includes risk management

• Communications

• Deployment

• Strategy/incident action planning

• Organization

• Review/revision

• Transfer/continuation/termination [Brunacini 2002; Brunacini and Brunacini 2004]

A major objective of the incident management system is to create, support, and integrate an incident 

commander into this process. The incident commander will direct the geographical and functional 

needs of the entire incident on the task, tactical, and strategic level. Issues develop for the incident 

commander when these three standard levels are not in place, operating, and effectively connected.

One of the most important components is to ensure the incident commander operates on the strategic 

level from the very beginning of the incident and stays on the strategic level as long as fire fighters are 

operating in an immediately dangerous-to-life-and-health (IDLH) environment [Brunacini 2002; 

Brunacini and Brunacini 2004].

The incident commander uses the incident management system as the basic foundation for managing 

the strategic-level safety function. Command Safety ensures the highest level of safety for fire 

department members operating at emergency incidents. The incident commander completes the 

operational and safety responsibility to the fire fighters by performing the eight command functions.

These functions serve as a very practical performance foundation for how the incident commander

completes the responsibility as the strategic-level incident manager and the overall incident safety 

manager [NFPA 2014a].

Following this incident, several Command Safety issues were addressed by the fire department as part 

of their recovery process. These issues included fireground communications personnel accountability, 

use of a tactical worksheet (which complements personnel accountability and crew integrity), and a 

continuous scene size-up and evaluation.
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Recommendation #9: Fire departments should develop a training program for staff assistants or 

incident command technicians.

Discussion: The function of a staff aide (e.g., chief’s aide, emergency incident technician, field 

incident technician, or staff assistant) is an essential component of the incident management system 

[Brunacini 2002]. Functions of the staff aide include maintaining the tactical worksheet; maintaining 

personnel accountability of all members operating at the incident (resource status and situation status); 

monitoring radio communications on the dispatch, command, and fireground channels; control 

information flow by computer, fax, or telephone; and accessing reference material and pre-incident 

plans [Ciarrocca and Harms 2011; Los Angeles Fire Department 2011; Phoenix Fire Department 

2010]. NFPA 1561 Standard on Emergency Services Incident Management System and Command 

Safety states in Chapter 8, “Command Safety,” that the staff aide is assigned to facilitate the tracking 

and accountability (resource status) of the assigned companies or crews [NFPA 2014a].

Some fire departments use fire fighters as staff aides and other fire departments use fire officers to 

serve as a staff aide for a command officer. Regardless of the rank of the staff aide, the staff aide has to 

be trained in the duties and responsibilities in order to proficiently function and meet the expectations 

of the incident commander. These job functions include: 

• Size up of the incident 

Address of incident

Type of incident

Name of incident 

Resources assigned and responding to the incident 

Life hazard

Additional resources needed

Exposure problems

Location of the command post

• Maintaining communications with the dispatch center or fire department communications center 

Dispatch channel 

Command channel

Tactical channels

• Situation status (what is the incident doing) 

Are we making progress on this incident?

• Resource status (what are they doing) 

Personnel accountability system (e.g. PASSPORT System)—accountability board or tactical 

worksheet 

How, what, and where are companies operating?

Who is in staging?

• Staging 

Staging area manager(s)

Separate tactical channel

• Tactical worksheet 
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Teletype printout can be used as initial Incident Briefing (ICS Form 201).

Transfer information immediately upon arrival to the department’s tactical worksheet and 

document companies by assignment or location (personnel accountability system).

Diagram the incident starting with Side Alpha.

Document divisions and groups with assigned supervisor.

Document response of other resources on scene (e.g., law enforcement, other fire departments).

As the incident expands, officers could be assigned as a division supervisor or group supervisor. The 

assigned officer will proceed to the division or group and evaluate and report conditions to the incident 

commander. If directed by the incident commander, the assigned officer will assume responsibility for 

directing resources and operations within their assigned area of responsibility. Division/group 

supervisors assigned to operate within the hazard zone must be with a second individual, which would 

be the staff aide. The staff aide can assist the division/group supervisor by maintaining accountability 

of the resources assigned that particular division/group. The division/group supervisor and the staff 

assistant will be required to be equipped with the appropriate protective clothing and equipment for 

their area of responsibility [Los Angeles Fire Department 2011].

At a structure fire, an incident command technician (ICT) is initially assigned to Side Charlie to report 

conditions to Command. The ICT then goes inside with the first-alarm companies. In order to ensure 

that personnel accountability is started during initial fireground operations, the ICT should assist the 

incident commander with the tactical worksheet as needed. Then the ICT starts the personnel 

accountability system process as defined by the department’s SOP. At this incident, due to the 

immediate issues of life safety, the ICT assisted with the rescue of the building occupants.

Recommendation #10: Fire departments should integrate current fire behavior research findings 

developed by the National Institute of Standards and Technology (NIST) and Underwriter’s 

Laboratories (UL) into operational procedures by developing standard operating procedures, 

conducting live fire training, and revising fireground tactics.

Discussion: The National Institute of Standards and Technology (NIST) and Underwriters Laboratories 

(UL) have conducted a series of live burn experiments designed to replicate conditions in modern 

homes and residential structures and to validate previous testing done in laboratory settings. The 

results of these experiments will enable fire fighters to better predict and react to effects of new 

materials and construction on fire. The fire research experiments were conducted in cooperation with 

the Fire Department of New York, Chicago Fire Department, Spartanburg, South Carolina Fire and 

Rescue, and other agencies. The live burn tests are aimed at quantifying emerging theories about how 

fires are different today, largely due to new building construction and the composition of home 

furnishings and products. In the past, these products were mainly composed of natural materials, such 

as wood and cotton, but now contain large quantities of petroleum-based products and synthetic

materials that burn faster and hotter and generate large volumes of fuel-rich smoke. Where a fire in a 

room once took approximately 20 minutes to “flashover”—igniting all the contents—this can happen 

with today’s furnishings in as little as 4 to 5 minutes [NIST and UL 2013; Madrzykowski and Kerber

2009].
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In addition, modern living spaces tend to be more open, less compartmentalized, and better insulated 

than homes built years ago. As a result, interior residential fires can generate oxygen-depleted, fuelrich environment within minutes. This fire condition of hot, fuel-rich smoke is highly reactive to the 

introduction of oxygen. Introducing oxygen to this environment by opening a door or venting a 

window may result in a rapid transition to flashover. These same conditions can occur in commercial 

structures as seen in the Charleston, South Carolina, Sofa Super Store fire [NIOSH 2009].

The NIST and UL experiments evaluated individual and combinations of methods for strategically 

ventilating and isolating fires to prevent flashover—or at least delay it. In contrast, forcing a door open 

or breaking a window without knowledge of conditions inside could create a portal for air that can 

literally fan the flames by introducing oxygen into an oxygen-limited fire environment.

Fire suppression operations are frequently conducted from the interior of the structure as a means of

introducing fire fighters into the building to locate occupants, reducing water damage, and limiting fire 

damage to structures. These operations must be coordinated with the ventilation operations. Previous 

research and examinations of line-of-duty deaths have shown that ventilation events occurring with fire 

fighters in the structure prior to suppression have led to tragic results [NIOSH 2009; NIOSH 2012, 

NFPA 2013]. One means of eliminating the possibilities of this occurrence would be a transitional 

attack in which water is directed into the structure from the exterior onto the known fire location in 

order to cool the fire gases and reduce the heat-release rate of the fire, prior to the fire fighters entering 

the building. The major concern with this type of operation is the potential harm that might occur to 

people trapped in the structure.

Based upon the NIST and UL research, NIOSH [2012] suggests the following fireground operations 

should be considered for implementation.

• Size-Up. Size-up must occur at every fire. Consideration must be given to the resources available 

and situational conditions, such as weather, fire location, size of the fire and building, and the 

construction features. Ensure a 360-degree size-up is conducted whenever possible. A tactical plan 

for each fire must be developed, communicated, and implemented.

• Ventilation. Fire departments should manage and control the openings to the structure to limit fire 

growth and spread and to control the flow path of inlet air and exiting fire gases during tactical 

operations. All ventilation must be coordinated with suppression activities. Uncontrolled 

ventilation allows additional oxygen into the structure that may result in a rapid increase in the fire 

development and increased risk to fire fighters due to increased heat-release rates.

• Fire-fighting Operations. Given the fuel-rich environment that the fire service operates in today, 

water should be applied to the fire as soon as possible. In many cases, water application through an 

exterior opening into a fire compartment may be the best first action. Fire departments should cool 

the interior spaces of a fire building with water from the safest location possible, prior to 

committing personnel into spaces with, or adjacent to, fully developed or ventilation-limited fire 

conditions.
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• Rapid Intervention. Fire department rapid intervention procedures should be updated to ensure 

that during fire fighter Mayday incidents, water is put on the fire as soon as possible and ventilation 

openings are controlled.

The fire service has recently been introduced to (and many fire departments have adopted) the acronym 

SLICE-RS by the International Society of Fire Service Instructors, which has been specifically 

designed to help first-arriving company officers apply recent research on modern fuels and fire 

dynamics to their early strategic and tactical decisions on the fire ground. 

• Size up all scenes.

• Locate the fire.

• Identify and control the flow path. 

• Cool the heated space from a safe location.

• Extinguish the fire.

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

operations, but throughout the incident) [Modern Fire Behavior, 2014].

Identifying and controlling the flow path is about knowing where the air comes from and where it’s 

headed. The importance of identifying and using flow path information cannot be underestimated and 

should find its way into every after-action review. The intent is to locate the fire, cool the heated space 

from a safe location, and ensure for the safety of the fire fighters. Once the fire is under control, the fire 

can be completely extinguished. The rescue and salvage operations are self-explanatory—if anything 

can be saved, save it. These two actions are always active, from initial scene size-up to extinguishment. 

This information is presented to educate the fire service and to ensure that fire departments consider a 

change in fireground tactics based upon the current research presented by NIST and UL. Much of this 

research has been directed toward developing a better understanding of the characteristics of the 

modern fire. This modern research provides members of the fire service with the information and 

knowledge needed to modify essential fire-fighting tactics. While fire-fighting will never be without 

risk, this research represents a vital contribution to overall efforts to reduce risks and increase fire 

fighter effectiveness and to save lives of civilians and fire fighters. 

Recommendation #11: Fire departments should ensure that fire fighters use structural fire-fighting 

protective hoods on all structure fires. 

Discussion: NFPA 1500 Standard on Fire Department Occupational Safety and Health Program states 

that members should be provided and use a protective ensemble that meets the requirements in NFPA 

1971 Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting

[NFPA 2013h]. Protective hoods are an integral part of the overall protective ensemble. They are 

included as an interface device to protect the areas of the fire fighter’s head, face, and neck that are not 

covered by the protective helmet, SCBA facepiece, and protective coat collar and collar closure. These

hoods are typically constructed of knitted material with a face opening to fit around the SCBA 

facepiece and "bib" extensions of the material to remain tucked under the fire fighter's coat. NFPA 

1971 states that protective hoods have a lower thermal insulation requirement than garments (a TPP 
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rating of 20 for protective hoods, compared to the minimum 35 required for garments). Protective 

hoods still have to meet all of the flame and heat resistance requirements typically associated with 

garment materials. As a consequence, protective hoods are heavy, single-ply or double-ply materials 

using Nomex®, PBI®, P84®, Basofil®, Kevlar®, and FR rayon fibers. The lower TPP rating for the 

hoods is justified on the basis that as an interface device, other ensemble components (mainly the 

helmet ear covers, which are also required to have a minimum TPP rating of 20) work together to 

afford the needed thermal insulation [Stull and Stull 2014; NFPA 2013h].

Owing to their knit constructions, hoods are typically "one size fits all" but should be carefully selected 

to fit properly with the other equipment, primarily the SCBA facepiece. Because hoods are repeatedly 

stretched over the facepiece and the wearer's head, some hoods quickly lose their shape and can fail to 

properly protect the fire fighter [Stull and Stull 2014]. NFPA 1971 has attempted to address this 

requirement with a test for measuring the hood face opening size after repeated donning and doffing of 

the hood on a manikin head form [NFPA 2013h, 2014b].

Features for hoods are relatively simple. These usually consist of: 

• The type of face opening (some hoods are designed to accommodate specific respirator facepieces).

• The length of the sides, front, and back (sometimes referred to as "bibs").

Some of the reluctance to using protective hoods has been due to resistance by some fire fighters to the 

idea of total encapsulation of the body. Many more traditional fire fighters claim that they use their 

ears as "early warning" sensors to detect excessive heat and know when to leave. Unfortunately, the 

sensitivity of ears to heat also makes them very vulnerable to high heat. Protective hoods have 

repeatedly demonstrated their effectiveness in covering those exposed portions of the face not covered 

by other elements of the ensemble [Stull and Stull 2014].

At this incident, protective hoods were not worn by the individual fire fighters. While the lack of 

protective hoods were not found to be a contributory cause to the fatalities as determined in this 

investigation, the fire service should consider using complete protective ensembles, including 

protective hoods, for structural fire-fighting.

Recommendation #12: Fire departments should ensure that all members engaged in emergency 

operations receive annual proficiency training and evaluation on fireground operations.

Discussion: In order to ensure for the proficiency and competency of fire department members, the fire 

department should conduct annual skills evaluation to verify minimum professional qualifications. 

This annual evaluation should address the qualifications specific to the member’s assignment and job 

description. This process should be structured in a manner where skills are evaluated on a recurring 

cycle with the goal of preventing the degradation of skills and abilities and ensuring for the safety of 

members. Proficiency evaluation and training provides an opportunity to ensure that all fire officers 

and fire fighters are competent in the knowledge, skills, and abilities in fireground operations. NFPA 

1500 Standard on Fire Department Occupational Safety and Health Program requires a fire 

department to establish and maintain a training, education, and professional development program with 
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the goal of preventing occupational deaths, injuries, and illnesses. This ensures members are trained 

and competencies are maintained in order to effectively, efficiently, and safely execute all 

responsibilities [NFPA 2013d].

This process is consistent with the organizational statement that establishes the existence of the fire 

department. The services the fire department is authorized and expected to perform, the organizational 

structure, and the job descriptions and functions of fire department members are essential in 

formulating a structured training program [NFPA 2013d]. The primary goal of all training, education 

and professional development programs is the reduction of occupational injuries, illnesses, and 

fatalities. As members progress through various job duties and responsibilities, the department should 

ensure the introduction of necessary knowledge, skills, and abilities to members who are new in their 

job titles as well as ongoing development of existing skills [NFPA 2015].

NFPA 1410 Standard on Training for Emergency Scene Operations defines basic evolutions that can 

be adapted to local conditions and serves as a method for the evaluation of minimum acceptable 

performance during initial fireground operations [NFPA 2015]. Proficiency training for fireground 

operations and emergency incidents should be conducted annually. This training should include, but 

not be limited to, scene size-up, situational awareness, use of the incident management system, 

personnel accountability system, strategy and tactics, search and rescue, hoseline operations, ladder 

operations, ventilation, thermal imaging cameras, fireground communications, use of rapid 

intervention teams, and Mayday operations. 

As part of the department’s analysis process of this incident, the commissioner has initiated a “back to 

basics” training program for the department. This process involves a structured training program that 

consists of company-level training conducted at the fire academy. All companies will be required to 

participate in live-fire training evolutions annually at the fire academy. This training will be completed 

by each district on each shift. The training will be conducted by companies who are dispatched as part 

of a first-alarm assignment in their first-due area.

Recommendation #13: Fire departments should consider using large-volume SCBA cylinders for 

operations in medium- and high-risk occupancies.

Discussion: A typical 30-minute (1200-liter) SCBA cylinder may not provide an adequate quantity of 

breathing air for fire fighters working in multi-family, commercial, or high-rise occupancies. The 

1200-liter cylinder will last an average fire fighter actively engaged in suppression activities about 15–

18 minutes [Gagliano et al. 2008]. NFPA 1852 Standard on Selection, Care and Maintenance of Opencircuit Self-contained Breathing Apparatus, A.5.1.5, states, “During extreme exertion, for example, 

actual service time can be reduced by 50 percent or more” [NFPA 2013f]. In addition to the degree of 

user exertion, other conditions that effect the SCBA service time include: 

• Physical condition of the fire fighter.

• Emotional conditions, such as fear or excitement, which can increase the user’s breathing rate.

• Degree of training or experience the user has had with such equipment.
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• Amount of air in the cylinder at the beginning of use; the cylinder should be fully charged at the 

beginning of use.

• Facepiece fit.

• Use in a pressurized tunnel or caisson.

• Condition of the SCBA.

• The SCBA effective dead air space.

SCBAs that are certified by NIOSH include a rated service time based on laboratory tests required by 

NIOSH. The SCBA is tested using a specified breathing machine with a breathing rate of 40 

liters/minute. NIOSH uses the 40 liters/minute rate because it represents a moderate work rate that an 

average user can sustain for a period of time. To attain a rated service time of 30 minutes, during this 

40 liter/minute test, the typical SCBA cylinder has to contain 1200 liters or more of compressed 

breathable air. A 45-cubic-foot cylinder has a capacity of 1273.5 liters, based on 28.3 cubic feet.

Because actual work performed by fire fighters often results in a ventilation rate that exceeds 40 

liters/minute, these fire fighters frequently do not attain the rated service time of 30 minutes [NFPA 

2013f].

Fire departments should ensure that fire fighters have enough air in their cylinder to complete the 

mission of their work assignment. A 30-minute (1200 liter) SCBA might be sufficient for fire fighters 

operating in a 3000-square-foot, single-family dwelling. For fire fighters operating in a multi-family, 

commercial, or high-rise occupancy, a 1200-liter cylinder might not be sufficient. Fire fighters must 

have enough air by volume to effectively provide a work period inside an IDLH atmosphere and still 

contain enough air volume to exit the IDLH with their reserve air intact. The primary benefit of an 

1800-liter cylinder is the substantial increase in reserve air if an emergency occurs. The intent of the 

additional breathing air is to keep the same work period but also increase the amount of emergency 

reserve air.

In conjunction with the department’s community risk assessment program, a risk assessment should 

include, but not be limited to:

• The expected hazards that can be encountered by fire fighters using SCBA.

• The type of duties to be performed, frequency of use, and the organization’s experiences.

• The organization’s geographic location and climatic conditions.

An assessment can identify various occupancies in a jurisdiction that require additional breathing air.

The companies assigned to the areas or occupancies can be equipped with 1800-liter cylinders. 

Cylinders are made of significantly lighter materials and contain higher pressure, greater volume, and 

smaller profile. All SCBA manufacturers are now offering these cylinders. Some manufacturers are 

offering higher pressure (5500 psi) cylinders, which reduce the weight and increase the volume over 

existing cylinders. The most important part of the needs assessment is to identify the areas of the 

jurisdiction that need the increased air volumes and then provide the equipment and training to those 

companies that respond or could be called upon to respond to incidents in those areas. NFPA 1852 

Standard on Selection, Care and Maintenance of Open-circuit Self-contained Breathing Apparatus
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provides fire departments with basic criteria for evaluation and selecting open-circuit SCBA [NFPA 

2013f].

In this incident the fire department provided current edition, certified SCBA with 4500-psi composite 

1200-liter (30-minute) cylinders to all fire fighters. Many fire fighters reported that end-of-service-time 

indicators (EOSTIs) were sounding inside the fire building in the IDLH atmospheres in less than 20 

minutes. With a change to 1800-liter cylinders, this would allow a true 20-minute work period with 

emergency reserve air capacity.

Recommendation #14: Fire service research organizations, standards making organizations,

equipment manufacturers, and fire departments should consider the effects of thermal degradation 

on fire attack hose.

Discussion: During this incident, the 13⁄4-inch attack hoseline used by Engine 33 was burned through 

during the initial fire-fighting operations. Engine 33 had stretched the hoseline down the stairs from the 

first floor to the basement. This placed the hoseline in the flow path of the fire and super-heated gases 

coming up the stairs. The 13⁄4-inch hoseline was burned completely in two. The 21⁄2-inch hoseline that 

Engine 7 stretched to the first floor was severely damaged as well.

During the investigation of this incident, NIOSH Fire Fighter Fatality Investigation and Prevention 

Program (FFFIPP) investigators reviewed previous cases and identified several instances in which 

hoselines had been burned through during structural fire-fighting operations. Current hoseline 

standards do not address the thermal performance of attack hoselines, and technical information 

published by manufacturers does not include thermal performance data. Attack hose is defined by 

NFPA 1961 Standard on Fire Hose [NFPA 2013g] as “hose designed to be used by trained fire 

fighters and fire brigade members to combat fires beyond the incipient stage. Attack hose is designed 

to convey water to hoseline nozzles, distributor nozzles, master stream appliances, portable hydrants, 

manifolds, standpipe and sprinkler systems and pumps used by fire departments.” The hoseline serves 

not only as a tool to help extinguish the fire but also provides a measure of safety to the hoseline crew.

Attack hose can be used as a means to locate an escape route in the event of Mayday or other 

emergency.

In an effort to better understand the thermal performance of attack hose, NIOSH FFFIPP investigators

contacted the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) for assistance. In response, 

the ATF Fire Research Laboratory began a series of tests to explore the impact of radiant heat on 

attack hose. The ATF Research Laboratory established heat flux values and developed full-scale tests 

to replicate fireground conditions. To date, the testing has included full-scale burns and bench testing 

using samples of new and used 13⁄4-inch attack hose of varying grades and construction. Tests are being 

conducted with hose samples dry and charged at both high and low heat flux levels. Hose similar to 

that used in this incident was incorporated in the test samples and continued testing will include 

samples of 21⁄2-inch hose of varying styles and manufacturer. The results, including documentation of 

the test methods, will be made available to NFPA and the fire service at the completion of the test 

series. 
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The NFPA Technical Committee on Fire Hose has discussed two issues, but no final action has been 

taken yet. First is to develop a registry on reported hose failures. Second is to develop a safety alert 

about fire hose and thermal degradation.

It is hoped that this information will prompt further research, discussion, a review of fireground tactics 

by fire departments, and action on the part of fire service research organizations, equipment 

manufacturers, standard-making organizations, and fire departments. 

Additionally, 

Recommendation #15: Code-setting organizations and municipalities should consider requiring the 

use of sprinkler systems in residential structures. Especially residential occupancies having high 

fuel loads, other unique life-safety hazards, and to establish retroactive requirements for the 

installation of fire sprinkler systems.

Discussion: This recommendation focuses on fire prevention and minimizing the impact of a fire if one 

does occur. The National Fire Protection Association (NFPA) Fire Protection Handbook states,

“Throughout history there have been building regulations for preventing fire and restricting its spread. 

Over the years these regulations have evolved into the codes and standards developed by committees 

concerned with fire protection. The requirements contained in building codes are generally based upon 

the known properties of materials, the hazards presented by various occupancies, and the lessons 

learned from previous experiences, such as fire and natural disasters” [NFPA 2008]. Although 

municipalities have adopted specific codes and standards for the design and construction of buildings, 

structures erected prior to the enactment of these building codes may not be compliant. Such new and 

improved codes can improve the safety of existing structures [NFPA 2008]. Sprinkler systems are one 

example of a safety feature that can be retrofitted into older structures. Sprinkler systems can reduce 

fire fighter and civilian fatalities since such systems can contain and may even extinguish fires prior to 

the arrival of the fire department. 

Fire development beyond the incipient stage presents one of the greatest risks fire fighters are exposed 

to during fireground operations. This risk exposure to fire fighters can be dramatically reduced when 

fires are controlled or extinguished by automatic sprinkler systems. 

NFPA statistics show that most fires large enough to activate a sprinkler system are controlled by just 

one or two sprinkler heads [NFPA 2008]. An automatic fire sprinkler system also reduces the exposure 

risk to fire fighters during all phases of fireground operation and allows the safe egress of building 

occupants before the fire department arrives on scene. Finally, by controlling fire development, the 

risks associated with the potential for structural collapse and during overhaul operations are greatly 

reduced, if not eliminated.

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9. 

Investigator Information

This incident was investigated by Murrey Loflin, Matt Bowyer, Steve Miles, and Stacy Wertman with 

the Fire Fighter Fatality Investigation and Prevention Program, Surveillance and Field Investigations 

Branch, Division of Safety Research, NIOSH located in Morgantown, WV. The report was authored 

by Murrey Loflin. Two subject matter experts who assisted with the investigation and provided the

technical review were Deputy Chief Michael McPartland of the Fire Department of New York and 

Peter Van Dorpe, Chief at Algonquin-Lake in the Hills Fire Protection District and retired Director of 

Training for the Chicago Fire Department. Additionally, Adam St. John, Fire Protection Engineer with 

the Bureau of Alcohol, Tobacco, Firearms, and Explosives, Stephen Kerber, Director, UL Fire Fighter 

Safety Research Institute, and Dan Madrzykowski, fire protection engineer in the Fire Fighting 

Technology Group of the Fire Research Division (FRD) of the Engineering Laboratory (EL) at NIST
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served as a subject matter experts due to their expertise with modern fire behavior and wind-driven 

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

Protection Division.

Additional Information

Modern Fire Behavior

This site is meant to serve as a clearinghouse of news and training information related to Modern Fire 

Behavior and Modern Building Construction Research, Tactics, and Practices along with actual street 

experiences. http://modernfirebehavior.com/

National Institute for Standards and Technology and Underwriters Laboratories

These two agencies provide information including training videos showing the findings from NIST and 

UL research conducted in cooperation with the Fire Department of New York on Governor’s Island in 

2012. http://www.firecompanies.com/modernfirebehavior/governorsislandonlinecourse/story.html.

Flashover TV sponsored by FireRescue.com includes a series of training presentations by NIST 

researcher Dan Madrzykowski.

http://flashovertv.firerescue1.com/videos/1875870-nist-and-ul-research-on-fire-dynamic-case-studiespart-4/

Information on completed fire-fighting research studies available at the National institute of Standards 

and Technology website at http://www.nist.gov/el/fire_research/firetech/index.cfm.

The information on completed fire-fighting research studies available at the UL Firefighter Safety 

Research Institute website at www.ULfirefightersafety.com. 

IAFC Rules of Engagement for Firefighter Survival 

The International Association of Fire Chiefs (IAFC) is committed to reducing fire fighter fatalities and 

injuries. As part of that effort the nearly 1,000 member Safety, Health and Survival Section of the 

IAFC has developed DRAFT “Rules of Engagement for Structural Firefighting” to provide guidance 

to individual fire fighters, and incident commanders, regarding risk and safety issues when operating 

on the fireground. The intent is to provide a set of “model procedures” for structural fire-fighting to be 

made available by the IAFC to fire departments as a guide for their own standard operating procedure 

development. http://www.iafcsafety.org/downloads/Rules_of_Engagement.

IAFF Fire Ground Survival Program 

The purpose of the International Association of Fire Fighters (IAFF) Fire Ground Survival Program is 

to ensure that training for Mayday prevention and Mayday operations are consistent between all fire 

fighters, company officers and chief officers. Fire fighters must be trained to perform potentially lifesaving actions if they become lost, disoriented, injured, low on air or trapped. Funded by the IAFF and 

assisted by a grant from the U.S. Department of Homeland Security through the Assistance to 

Firefighters (FIRE Act) grant program, this comprehensive fire ground survival training program 

applies the lessons learned from fire fighter fatality investigations conducted by the National Institute 
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for Occupational Safety and Health (NIOSH) and has been developed by a committee of subject matter 

experts from the IAFF, the International Association of Fire Chiefs (IAFC) and NIOSH. 

http://www.iaff.org/HS/FGS/FGSIndex.htm

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

(2014 edition)

The primary focus of the revision to NFPA 1561 in the 2014 edition is develop requirements directly 

aimed at reducing and eliminating fireground injuries and fireground deaths of fire department 

members. The most apparent change addition to this edition has been the document title to include 

“Command Safety” and the creation of a new chapter, Command Safety. This chapter is intended to 

provide a foundation on how to incorporate the incident management system at all emergency

incidents especially Type V and Type IV incidents.

The chapter on “Command Safety” clearly defines the requirements for the incident commander to 

meet including establishing a fixed Command Post, personnel accountability, the use of staff aides, 

rapid intervention crews, and the appointment of a safety officer and assistant safety officer(s)(as 

needed) plus the expectations and authority of the safety officer. There are annexes that cover 

Functional Assignments for High-Rise Building Incidents, Development of Subordinate Officers or

Implementing a More Efficient Management System, Incident Management for the Fire Service on 

Type 5 or Type 4 Incidents, and Structural Fire Fighting — Risk Assessment and Operational 

Expectation.

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

(2014 edition) can be purchased from the National Fire Protection Association at http://www.nfpa.org

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 Web sites external to NIOSH do not 

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

Furthermore, NIOSH is not responsible for the content of these Web sites. All web addresses

referenced in this report were accessible as of the publication date.
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Appendix One

Status Investigation Report of Two

Self-Contained Breathing Apparatus

Submitted By:

The NIOSH Division of Safety Research

NIOSH Task Number 19925

(Note: Full report is available upon request)

Background

As part of the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality 

Investigation and Prevention Program, the Technology Evaluation Branch agreed to examine and 

evaluate two SCBA identified as Scott Health and Safety model AirPak 4.5, 4500 psi, 30-minute, selfcontained breathing apparatus (SCBA).

This SCBA status investigation was assigned NIOSH Task Number 19925. The NIOSH Division of 

Safety Research (NIOSH/DSR) and fire department were advised that NIOSH would provide a written 

report of the inspections and any applicable test results.

The SCBA units, contained within cardboard boxes, were delivered to the NIOSH facility in Bruceton, 

Pennsylvania on November 6, 2014. After their arrival, the packages were taken to building 20 and 

stored under lock until the time of the evaluations.

SCBA Inspection

The packages were opened initially in the General Respirator Inspection Area (Building 20) on 

November 14, 2014 and an initial visual inspection was conducted by Tom Pouchot, Certification 

Coordinator NPPTL. A reference SCBA was included by the fire department. On November 17, 2014, 

the SCBA data logger for Unit #2 was down loaded by personnel from Scott Health and Safety with 

NIOSH personnel present. The SCBAs were inspected extensively on November 14 and 17, 2014. The 

SCBA identified as the fire department SCBA, was labeled by NPPTL as SCBA Unit #1, and was 

inspected on November 14, 2014. The SCBA identified as fire department SCBA was labeled by 

NPPTL as SCBA Unit #2, and was inspected on November 17, 2014. A third SCBA was included as a 

reference unit and was labeled Unit Reference. The SCBA units involved in the incident were 

extensively examined, component by component, in the condition they were received to determine the 

conformance of the unit to the NIOSH-approved configuration. The units were identified as the Scott 

Health and Safety Company model AirPak 4.5, 30 minute, 4500 psi units, NIOSH approval numbers 

TC-13F-0076CBRN. The visual inspection process was documented photographically.
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Also on November 17, 2014 Scott Health and Safety conducted a down-loading of the data logger for 

SCBA Unit #2. The SCBA Unit #1 data logger could not be down loaded due as the unit was 

extensively damage. Once all inspections were completed, the SCBA units were repackaged and 

placed back in Building 20 in a secured and locked room.

The condition of each major component of each of the SCBA’s that were photographed with a digital 

camera.

It was judged that only Unit #2 could be safely pressurized and tested using a substitute cylinder and 

facepiece provided by the fire department. Unit #2 and the Unit Reference were tested on February 27, 

2015.

SCBA Testing

The purpose of the testing was to determine the conformance of each SCBA to the approval 

performance requirements of Title 42, Code of Federal Regulations, Part 84 (42 CFR 84). Further 

testing was conducted to provide an indication of the conformance of each SCBA to the National Fire 

Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, Standard on 

Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition.

NIOSH SCBA Certification Tests (in accordance with the performance requirements of 42 

CFR 84):

Positive Pressure Test [§ 84.70(a)(2)(ii)]

1. Rated Service Time Test (duration) [§ 84.95]

2. Static Pressure Test [§ 84.91(d)]

3. Gas Flow Test [§ 84.93]

4. Exhalation Resistance Test [§ 84.91(c)]

5. Remaining Service Life Indicator Test (low-air alarm) [§ 84.83(f)]

National Fire Protection Association (NFPA) Tests (in accordance with NFPA 1981, 1997 

Edition):

6. Air Flow Performance Test [Chapter 5, 5-1.1]

Unit #2 was the only unit in a condition to be tested along with the Unit Reference. These units were 

tested on February 27, 2015 using a substitute cylinder and facepiece.

Summary and Conclusions

Two SCBA units along with a reference SCBA unit were submitted to NIOSH by the NIOSH Division 

of Safety Research for the fire department for evaluation. The SCBA units were delivered to NIOSH 

on November 6, 2014 and initially inspected on November 14, 2014. The units were identified as a 

Scott Health and Safety model AirPak 4.5, 4500 psi, 30-minute, SCBA (NIOSH approval number 
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TC-13F-0076CBRN). Scott Health and Safety performed a downloading of the Unit #2 data logger on 

November 17, 2014. The complete inspections of the SCBA units were conducted on November 14, 

2014 for Unit #1 and on November 17, 2014 for Unit #2. The Unit #1 was extensively damaged while 

Unit #2 suffered only slight levels of heat damage, exhibited other signs of wear and tear and both 

units were covered generally with dirt and grime. The cylinder valve as received on Unit #2 was in the 

closed position. The cylinder gauge on Units #2 read 0 psig. The cylinder valve hand-wheel could be 

turned. No cylinder was included with Unit #1. The regulator and facepiece mating and sealing areas 

on the Unit #2 were relatively clean but for Unit #1 the facepiece and regulator were locked together 

due to the damage of both components. There was some dirt on the inside of the facepiece of Unit #2.

Unit #1 facepiece was extensively damaged. Unit #2 had some scratches present on the lens. The lens 

on Unit #1 extensively damaged. Visibility through the facepiece lenses of Units #2 was fair as the lens 

had scratches and dirt present heat damage. 

The facepiece head harness webbing on the Unit #2 was in fair condition with dirt present and some 

evidence of wear. Unit #1 facepiece head harness was missing. Only the PASS on the Unit #2 

functioned. The NFPA approval label was only on present on Unit #2 and readable.

The air cylinder on the Unit #2 had a manufactured date of 10/2011. Under the applicable DOT

exemption, the air cylinder is required to be hydro tested every 5 years. For the air cylinder on Unit #2, 

a retest date before the last day of 10/2016 is required. Therefore the cylinder was within the hydro 

certification when last used. The cylinder on Unit #2 was partially black. No air was remaining in the 

cylinder. 

Replacement air cylinders with a current hydrostatic re-test qualification were supplied by the fire 

department. These cylinders were substituted for all Units #2 and Unit Reference tests. In addition, the 

facepieces were replaced by a facepiece supplied the fire department. No other maintenance or repair 

work was performed on the units at any time.

SCBA Unit #2 did meet the requirements of the NIOSH Positive Pressure Test, as the unit did maintain 

a positive pressure, minimum 0.1 inches of water, for the 30 minute minimum duration of the unit.

Unit #2 did meet the requirements of all of the other NIOSH tests.

SCBA Unit Reference met the requirements of the NIOSH Positive Pressure Test, with a minimum 

pressure of 0.00 inches of water. The Unit Reference did meet the requirements of all of the other 

NIOSH tests.

In light of the information obtained during this investigation, NIOSH has proposed no further action on 

its part at this time. The SCBAs were returned to storage pending return to the fire department.

If Unit #2 is to be placed back in service, the SCBA must be repaired, tested, cleaned, damaged 

components replaced, and inspected by a qualified service technician, including such testing and other 
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maintenance activities as prescribed by the schedule from the SCBA manufacturer. Typically a flow 

test is required on at least an annual basis.
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Appendix Two

Personal Protective Equipment Evaluation

Examination of Fire Fighter Protective Ensemble Items

An examination was made of the selected personal protective equipment worn by the lieutenant and fire 

fighter from Engine 33, who sustained fatal injuries in a Brownstone on March 26, 2014. These items 

included the protective coat and protective pants worn by the lieutenant and fire fighter and the station/work 

uniform worn by the lieutenant.

The lieutenant and fire fighter from E33 entered the structure on the first floor and proceeded down the 

stairs with a 13⁄4 inch hose to the basement. Shortly after being in the basement, the fire conditions 

deteriorated significantly trapping both fire fighters in the basement. Following a Mayday from the 

lieutenant, radio communications indicated that there was no water to their hoseline. Approximately 30 

minutes after entering the structure, a rapid intervention team was were able to remove the fire fighter from 

E33 from the basement. The lieutenant was not recovered until several hours later.

The protective coat and protective pants worn by fire fighter showed low to moderate thermal damage. Due 

to the extended time for which he was exposed to the thermal conditions, the protective capabilities of this 

clothing had been exceeded. In contrast, the protective coat, protective pants, and station/work uniform 

pants worn by the lieutenant exhibited extreme degradation with burn through of several areas of his turnout 

gear. The degradation extended to his station/work uniform pants as well.

It was the general conclusion that the protective clothing worn by both fire fighters were not contributory 

to their fatal injuries. This is given the severe fireground conditions that existed during their entrapment in 

the basement before they could be located and recovered. Both fire fighters were exposed to extended high 

heat conditions. The lieutenant had a much long exposure given the extreme conditions that prevented other 

fire fighters from entering the area where he was trapped. 

Although not contributory to this incident, several general recommendations to department regarding 

personal protective equipment: 

• transitioning all of its turnout gear to the current edition of NFPA 1971, Protective Ensembles for 

Structural Fire Fighting and Proximity Fire Fighting;

• provide structural fire-fighting protective hoods for all members;

• instruct all members in the proper wearing of these clothing items;

• retain the personal protective equipment for a period of at least two years or otherwise deemed necessary 

by the fire department.
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Appendix Three

Incident Commander’s Tactical Worksheet for Mayday