Career Lieutenant Dies and Four Firefighters Injured at a 3-Story 

Multi-Family Residential Occupancy–Massachusetts

Page i

F2019-18 • March 25, 2022

Executive Summary

On November 13, 2019, a 39-

year-old career lieutenant 

died, and four other 

firefighters were injured 

while fighting a multi-family 

residential structure fire. At 

01:00:06, Fire Alarm

dispatched Car 4, Engine 15, 

Engine 2, Engine 13, Engine 

12, Ladder 5 Ladder 3, 

Rescue 1, and Ladder 4 

(rapid intervention team

(RIT)) to Box 15-14 for a fire 

with occupants on the 2nd 

floor and a baby on the 3rd 

floor. At 01:02:27, Engine 

15 arrived on scene and

reported a Type V structure 

with heavy fire showing on the 2

nd floor of Side Bravo. At 01:03:37, Car 4 arrived and had assumed 

Command. Engine 2 also arrived at this time and was assigned to stretching a supply line from a 

hydrant to Engine 15. Command reported smoke showing from the roof and 3

rd floor Side Bravo and 

requested a 2

nd alarm. Engine 5, Engine 6, Ladder 1, and Car 3 were dispatched at 01:04:25. Engine 

15 did a quick transitional attack to fire venting on Side Delta from the 2nd floor. Within minutes, 

Engine 15 and Ladder 5 were going to the 2

nd floor on Side Delta. Engine 13 was going to the 2nd floor 

on Side Alpha and Ladder 3 was going to the roof. Engine 13 was knocking down the exterior fire on 

Side Bravo. Engine 12 was assigned to supply Ladder 3 with water. At 01:09:59, Rescue 1 split into 

two teams. Team 1 went to Division 2 and Team 2 went to Division 3. At 01:14:41 Rescue 1-Team 2

encountered heavy fire on the 3

rd floor hallway Side Alpha and Engine 2 knocked down fire in the 

front stairwell on their way to assist Rescue 1. At approximately 01:19:16, Engine 13 made it to the 

doorway of the room of the fire origin which was the bedroom midway on the 2

nd floor in the Side 

Companies operating defensively at Box 15-14 after the Mayday 

occurred and was cleared.

(Photo courtesy of the fire department)
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Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Bravo. Engine 13 knocked down the fire, but it wasn’t completely extinguished. At 01:21:40, Engine 6 

used a yard lay off of Engine 12, which was pumped by Engine 15 and went to the 3rd floor. Engine 5 

also was assigned to the 3rd floor. At 01:23:56, Ladder 5 re-entered the structure and went to the 3

rd

floor. At 01:27:36, the lieutenant from Ladder 5 called a Mayday. The lieutenant stated they were on 

Division 3 with fire all around them, exit blocked, and they did not have a personnel accountability 

report (PAR). Command acknowledged the Mayday and sent in a rapid intervention team (Ladder 4) to 

the 3rd floor. Command advised the lieutenant there was a ladder (Ladder 3 platform) on 2

nd floor Side 

Bravo. At 01:28:37, the lieutenant stated they were trapped, it was very hot, and they needed a hose 

line. The lieutenant and chauffeur of Ladder 5 had temporarily taken shelter in a shed on the porch at 

the Bravo/Charlie corner. At approximately 01:32, the lieutenant of Ladder 5 grabbed the chauffeur of 

Ladder 5 and pushed him out of a window on the 3rd floor of Side Charlie to get him out of the 

hazardous area. He fell approximately 15 feet, hitting an awning over the basement man-door, then 

rolled off and fell about another 10 feet to the ground. At 01:34:03, Car 400 notified Command that a 

civilian stated a firefighter was lying in the backyard (Side Charlie). At 01:34:21, Engine 5 located the

Ladder 5 chauffeur on the ground and requested EMS. Over next 23 minutes, Ladder 4 (RIT), Ladder 

1, Rescue 1-Team 2, Engine 12, Engine 4 and Car 2 encountered heavy fire while trying to get to the 

3

rd floor and locate the lieutenant. Crews struggled to access the 3rd floor due to limited space in the 

enclosed stairwell that had high heat, zero visibility due to smoke, and the added obstruction of a hose 

line that had burned through and was gushing water between the 2nd and 3

rd floors in the Side 

Delta/Charlie stairwell. At 02:07:20, Rescue 2 (Rescue 1-Team 2 and Ladder 4) (Note: This 

designation was assigned by the officer of Ladder 4) reached the 3

rd floor of the Side Delta/Charlie

stairs, but debris blocked the entrance to the porch. A member of Rescue 2 breached the wall to the 

porch. Several minutes later, after crawling across the porch and avoiding holes, Rescue 2 made it to 

the porch shed door where the lieutenant had returned to take shelter. Rescue 2 could hear the 

lieutenant’s personal alert safety system (PASS) sounding. Rescue 2 breached the shed door and found 

the lieutenant. Rescue 2 accompanied by Ladder 1 located grabbed the lieutenant. Crews from Ladder 

4, Ladder 1, and Engine 4 moved the lieutenant from the 3rd floor to the 1st floor down the Side 

Delta/Charlie stairs. The lieutenant was brought out the Side Delta/Charlie rear door where an EMS 

crew was waiting at approximately 02:13. The lieutenant was transported by EMS to the local trauma 

center where he was pronounced deceased. Command advised Fire Alarm that the fire at Box 15-14 

was declared under control at 04:05 and was marked out at 06:31.

Contributing Factors

• Building construction and contents enhanced fire spread

• Wind driven fire

• Lack of scene size-up and risk assessment

• Lack of incident management and command safety

• Lack of a defined incident action plan

• Lack of crew integrity

• Poor survivability profile

• Inadequate company level staffing

• Lack of professional development opportunities 
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• Lack of required sprinkler system

Key Recommendations

• Incident commanders should ensure a detailed size-up and define a strategy and incident action 

plan (IAP) based on the scene size-up and risk assessment. Incident commanders should 

continually reevaluate the strategy and adjust the IAP based on continuous size-up, risk 

assessment, risk management, and the completion of tactical objectives 

• Fire departments should use risk management principles, including occupant survivability 

profiling, at all structure fires 

• Fire departments should develop and implement standard operating procedures/standard 

operating guidelines (SOP/SOG), training programs, and tactics for wind-driven fires

• Fire departments should ensure that all companies are operating based upon the assignment 

given by the incident commander, eliminating freelancing and ensuring tactical priorities are 

met 

• The early establishment of divisions/groups provides an effective incident management 

organizational framework that the IAP can build on and expand. This enhances the 

accountability of resources operating in the hazard zone.

• Fire departments need to ensure that critical incident benchmarks are communicated to the 

incident commander throughout the incident

• Fire departments should ensure that once Command is established at an incident, the incident 

commander maintains control of situation status, resource status, fireground communications, 

and ensures the completion of the tactical objectives

• Fire departments should incorporate the principles of command safety into the incident 

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

safety responsibilities are incorporated into the command functions throughout the incident

• Fire departments should ensure adequate staffing for deployment to urban incidents involving 

high hazard occupancies and a concentrated population.

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) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine 

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

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

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

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

available records to develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s 

recommendations. The NIOSH summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, 

as well as the conclusions and recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.
Page 1

Introduction 

On November 13, 2019, a 39-year-old career lieutenant died, and four other firefighters were injured 

responding to a multi-family residential structure fire. On November 13, 2019, the U.S. Fire 

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

incident. On December 13-20, 2019, a general engineer, an investigator, and a safety specialist from 

the NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) traveled to 

Massachusetts to investigate this incident. The NIOSH investigators met with fire department officials 

including the fire chief, the deputy chief of operations, the deputy chief of services, the chief of safety, 

the chief of training, and members of the department’s fire investigation unit. The NIOSH investigators 

also met with representatives of the International Association of Fire Fighters local and representatives 

from the city buildings and zoning office. The NIOSH investigators visited the city’s dispatch center 

and obtained a copy of the fireground audio; visited the incident site; and conducted interviews with 

the fire department officers and firefighters directly involved in the fatal incident. The NIOSH 

investigators inspected and photographed the victim’s personal protective clothing and the selfcontained breathing apparatus (SCBA). They also reviewed department training records and standard 

operating procedures. On January 14-16, 2020, the general engineer and the investigator returned to 

complete the interview process.

Fire Department 

The career fire department provides fire protection and life safety services to an area encompassing 39 

square miles and a population of 206,000. The daytime population increases to well over 230,000. The 

city encompasses a diverse range of structures from densely populated multi-family dwellings,

residential occupancies, office high rise buildings, and a mixture of manufacturing and industrial

complexes. The city also contains nine universities and colleges. A major east-west interstate highway 

passes through the city, along with multiple rail systems. The fire department provides first responder 

emergency medical care. Basic life support (BLS), advanced life support (ALS) and transportation is 

provided by a private healthcare company. 

The fire department operates 13 engine companies, 7 ladder companies, 1 heavy rescue company, 1 

special operations unit, and 2 self-contained underwater breathing apparatus (SCUBA) (dive rescue 

operations) vehicles from 10 fire stations. Fire operations are divided into North Division (Car 3) and 

South Division (Car 4) with a district chief overseeing operation within each district. Car 3 and Car 4 

are also staffed with an incident command technician. The fire department employs a total of 409

uniformed personnel within the operations, fire prevention, and support services divisions.
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The members assigned to a piece of apparatus are identified as follows:

• Engine 5 or Engine 5 officer

• E501

• E502

• E503

The firefighters’ identification is based upon seniority not by riding position.

Firefighters are assigned to work one of four operations shifts. Firefighters work a 24-hour shift, 

followed by 2 days off, another 24-hour shift, and then 4 days off. A full shift roster includes 91 

firefighters, with the minimum staffing at 69. 

The fire department has a special operations division which includes a technical rescue team and dive 

rescue team. Both teams are available for regional response. Also, the department responds to a 

regional airport in a support role to the aircraft rescue firefighting fire department based at the airport. 

The fire department responded to a total of 29,185 incidents (1,584 fire and 27,601 non-fire) during 

2020. In 2007, the fire department received a Class 2 rating from the Insurance Services Office (ISO). 

In the ISO rating system, Class 1 represents exemplary fire protection, and Class 10 indicates that the 

area’s fire-suppression program does not meet ISO’s minimum criteria. 

The fire department operates a vehicle maintenance facility, which is located at the Fire Department 

Headquarters. 

Fire Department Operations

The personnel accountability system is based on the daily riding list of each company. The list is 

updated in the morning and in the evening of each shift. This process is used for tactical personnel 

accountability reports (PARs) and when the strategy changes from offensive to defensive. The 

department also uses a Pak-Tracker locator system, which is integrated into the department’s SCBA. 

Each district chief vehicle carries one handheld Pak-Tracker locator system devices. 

Training and Experience

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

firefighter, although the fire department in this incident has adopted the Commonwealth of 

Massachusetts civil service system, which requires a candidate to pass the state civil service written 

examination and successfully complete the Candidate Physical Ability Test (CPAT). The 

Commonwealth of Massachusetts Civil Service Commission administers the firefighter written 

examination and physical agility exam for the municipality. 

Once ranked, the results from both examinations are provided to the city’s human resources division. 

The municipality then conducts the following: 

• Background check 

• Drug screen 
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• Medical examination, which meets the requirements of National Fire Protection Association NFPA 

1582, Standard on Comprehensive Occupational Medical Program for Fire Departments (current 

edition) [NFPA 2022b] 

• Psychological examination 

• City residency requirements check. 

Preference is given to veterans, city residents, and family members of any police officer or firefighter 

killed in the line of duty in the Commonwealth of Massachusetts. 

Potential candidates must have a valid driver’s license and a high school diploma or a general 

educational diploma certificate. Selected candidates attend a 16-week recruit training class at the 

department’s training center, regardless of whether they have previous firefighting experience. The 

recruit class curriculum is equivalent to the Fire Fighter I and Fire Fighter II requirements of NFPA

1001, Standard for Fire Fighter Professional Qualifications [NFPA 2019]. 

Recruit training is conducted at the fire training center, except for the flashover simulation training, 

gas-fueled fires and hazardous materials awareness, and operations level training, which are conducted 

at the Massachusetts Fire Academy. Upon completion of the recruit school, the recruit firefighter is 

certified per NFPA 1001, Standard for Fire Fighter Professional Qualifications, to the level of Fire 

Fighter I and Fire Fighter II and per NFPA 472 (as incorporated in NFPA 470, Hazardous 

Materials/Weapons of Mass Destruction (WMD) Standard for Responders [NFPA 2022a]), to the level 

of Operations Level Responder. 

Upon successful completion of recruit school, the recruit firefighter becomes a probationary firefighter 

for 36 weeks. During this time, the probationary firefighter: 

• Receives a task book to complete 

• Must complete a weekly journal, which documents training and emergency responses

• Rotates to an engine company, ladder company, and the heavy rescue company 

• Is evaluated 1 week prior to completion of probation

• Must successfully complete a physical training standard (CPAT) evaluation 

• Must successfully complete Fire Fighter I and Fire Fighter II cognitive skills and live fire 

examinations. 

• Must operate in a company with an officer during probation. 

Recruits must pass the ProBoard Certification requirements prior to receiving a permanent assignment. 

Note: The Pro Board is a non-profit corporation that was incorporated in 1990 as the “National 

Board on Fire Service Professional Qualifications”. The organization is commonly known as the

ProBoard.

This municipal fire department operates its own training center under the supervision of a Chief of 

Training (district chief). The training center includes a burn building, which allows for live fire 

training using Class A fuels. Different configurations of the burn building allow for multiple training 

scenarios, which include incidents simulating residential, commercial, triple-decker, or high-rise 

occupancies.
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Firefighters are required to train at least 1-hour per work shift and must complete eight training drills 

covering eight different topics per month. Companies are required to conduct “Back to Basic Training” 

every Thursday in an effort to ensure that firefighters are familiar with their equipment and basic skills, 

such as, ladder handling and placement, SCBA emergency drills, etc. The company office submits the 

training record forms through their district chief to the Chief of Training. The fire department has 

maintained an electronic training record-keeping system since 2006. The department conducts annual 

mandatory training for recertification for cardiopulmonary resuscitation (CPR), emergency medical 

responder, and hazardous materials operations level responder. Special operations training is also 

handled through the fire training center.

The Division of Training is staffed with:

• 1 district chief

• 1 captain

• 1 lieutenant

• 1 firefighter.

When a recruit school is scheduled, additional staff are assigned to the Training Division.

Promotional Process

Internal promotions to all ranks are handled following the state’s civil service promotional testing 

process. Promotion examinations are given every 2 years. When promotions occur, the fire department 

conducts a 40-hour officer development training program. In addition, company officers can take Fire 

Officer I-IV training and certification at the Massachusetts Fire Academy, although it is not a fire 

department requirement.

• Lieutenant: 80-question examination (state civil service); 3 years in grade as fire

fighter; with bibliography

• Captain: 100-question examination (state civil service); 1 year in grade as a lieutenant; 

with bibliography

• District Chief: 80 question examination (state civil service); 1 year in grade as a captain; with 

bibliography

• Deputy Chief: Assessment center and panel interview; 1 year in grade as a district chief

• Fire Chief: Assessment center; 1 year in grade as a deputy chief.

The fire department established a biannual officer school for all firefighters on the eligible promotional 

list for lieutenant that are anticipated to be promoted. It is 1 week-long. The department does not have 

a position for fire apparatus operator or require certification for fire apparatus operators.

Every firefighter must qualify as a fire apparatus operator for the type of apparatus they are assigned 

to. Driving training is conducted at the Fire Training Center and non-emergency training is on city 
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streets. The fire apparatus operator position rotates weekly. It is the responsibility of the company 

officer to ensure probationary firefighters are provided with driver training.

The lieutenant from Ladder 5 (L500) was hired by the fire department in 2010. As a firefighter, he

served on 2 engine companies and 1 ladder company and was then promoted to lieutenant in October 

2018. He was the lieutenant on ladder 4 before being transferred to Ladder 5 in January 2019. The 

lieutenant took multiple courses in HazMat, EMS, rapid intervention, live burns, special operations 

with 4 gas meters, large area search, thermal imagers, fireground strategy and tactics, and radio 

emergency button/mayday activation. The lieutenant had recent certificates in Fire Prevention OfficerBasic (May 2018), ICS-100: Introduction to Incident Command System (April 2017), ICS-200: ICS 

for Single Resources and Initial Action Incident (April 2017), IS-700: National Incident Management

System (NIMS), An Introduction (May 2017), and IS-800: National Response Framework, An 

Introduction (May 2017).

The district chief (Car 4) was hired by the fire department in 1991. As a firefighter, he served on 4 

engine companies then promoted to lieutenant on February 1, 1998. He was promoted to captain in 

December 2009. He was the captain on engine 16 then later promoted to district chief in December 

2014 where he was assigned to the training division. In December 2015, he was assigned to Car 4. The 

district chief took multiple courses in HazMat, EMS, rapid intervention, live burns, fireground strategy 

and tactics, special operations–dive team training, dive rescue, and IED and Homemade explosives 

familiarization. The District Chief completed training in Responding to Hybrid/Electric Vehicle 

Incidents (August 2015) and had recent certificates in ICS-100: Introduction to Incident Command 

System (April 2017), ICS-200: ICS for Single Resources and Initial Action Incident (April 2017), IS700: National Incident Management System (NIMS), An Introduction (May 2017), IS-800: National 

Response Framework, An Introduction (May 2017), and ICS-300: Intermediate ICS Expanding 

Incidents (October 2019).

Apparatus, Staffing, and Communications

At 01:00:06 hours, Fire Alarm dispatched the following resources for the 1

st Alarm assignment for Box 

15-14 for a report of structure fire. Note: Minimal staffing of most apparatus per NFPA 1500.

Resource Staffing

Car 4 District Chief and ICT

Engine 15 Acting Lieutenant and 2 firefighters

Engine 2 Lieutenant and 2 firefighters

Engine 13 Lieutenant and 3 firefighters

Engine 12 Lieutenant and 2 firefighters

Ladder 5 Lieutenant and 2 firefighters

Ladder 3 (spare apparatus) Lieutenant and 3firefighters

Rescue 1 Lieutenant and 4 firefighters

Ladder 4 Acting Lieutenant and 2 firefighters

TOTAL 30 
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At 01:04:25 hours, Fire Alarm dispatched the following resources for the 2nd Alarm assignment for

Box 15-14.

Resource Staffing

Car 3 Acting District Chief and ICT

Engine 6 Lieutenant and 2 firefighters

Engine 5 Lieutenant and 2 firefighters

Ladder 1 Acting Lieutenant and 2 firefighters

TOTAL 11

At 01:29:27 hours, Fire Alarm dispatched the following resources for the 3rd Alarm assignment for 

Box 15-14.

Resource Staffing

Engine 7 Lieutenant and 3 firefighters

Engine 4 Lieutenant and 3 firefighters

Ladder 7 Lieutenant and 2 firefighters

TOTAL 11

At 02:09:19 hours, Fire Alarm dispatched the following resources for the 4th Alarm assignment for Box 

15-14.

Resource Staffing

Engine 16 Lieutenant and 3 firefighters

Engine 3 Lieutenant and 2 firefighters

TOTAL 7

The fire department operates on a Motorola Association of Public Safety Communications Officials 

(APCO) P-25 Phase 1, Digital, 800-megahertz trunked radio system managed by the city’s Emergency 

Communications Division. The system is tied into the statewide Motorola system managed by the 

Massachusetts State Police. Fire Operations uses a single zone in the radio with 15 talk groups and one 

conventional fireground frequency. The fire department uses Motorola APX6000 XE portable radios. 

All portables are equipped with an emergency call button which, when activated, the emergency radio 

receives priority on that talk group and must be acknowledged by the dispatcher. The radio system was 

installed in 2016 and is a 3-site system each with a repeater system located strategically throughout the 

city. 

The city’s Emergency Communications Division receives all 9-1-1 calls originating within the city. 

Calls are then transferred to the appropriate dispatchers. Call receipt and dispatching are processed by 

a computer-aided-dispatch (CAD) system. These calls for service are dispatched on a designated talk 

group and responding units operate on one of three talk groups assigned by dispatch. All administrative 

functions such as fire prevention, training, and maintenance, operate on separate talk groups from 

those used for dispatch and fireground operations.
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Car 3 (North Division) incidents are dispatched on Alpha channels and Car 4 (South Division) 

incidents are dispatched on Bravo channels. Charlie channels are used primarily for single company 

incidents. Also, the responding EMS provider can utilize Charlie channels. The radio system has one 

direct channel, which is not recorded or routed through the repeater. 

The Emergency Communications Division has 60 positions allotted and had a staffing of 47 personnel

at the time of the incident. Each shift works eight hours. The shifts are 0700 – 1500 hours, 1500 –

2300 hours, and 2300 – 0700 hours. The daytime shifts are staffed with 10 dispatchers and nighttime 

shifts are staffed with 9 dispatchers. The division has Dispatcher II and Dispatcher III positions. The 

Emergency Communications Division also dispatches for the city police department and a neighboring 

city’s fire, police, and EMS. The Emergency Communications Division answers 90,000 calls annually.

The training for new dispatchers is based upon curriculum from APCO. The training program for 

public safety telecommunicators is as follows:

• Assigned a field training officer during probation

• 2-day 9-1-1 telephone training 

• 3 – 5 months on the job training

• Probationary dispatchers do not dispatch fire incidents for the first month.

Each dispatcher must complete a minimum of 16 hours of annual telecommunicator refresher training 

required by the Commonwealth of Massachusetts. The Emergency Communications Division requires 

additional training above the minimum of 16 hours annual refresher training.

Dispatcher Mayday Procedures

Dispatchers have the following procedures in the event of a Mayday.

• If a Mayday is communicated and the incident commander hears and acknowledges the 

Mayday, dispatch adds the time into the incident notes only.

o At the request of the incident commander dispatch will sound a unique tone on the tactical 

channel

• If a Mayday is missed by the incident commander, but the dispatcher acknowledges the 

Mayday, the dispatcher verifies and sounds a unique tone on the tactical channel.

• The incident commander will make the decision whether to switch non-essential members to 

another tactical channel or leave everyone on the fireground tactical channel. 

Dispatcher Fireground Operational Procedures

Dispatchers have the following procedures for fireground operations.

• All fire incidents are dispatched by “Still Box”

• All fire incidents are assigned a box number 

• Dispatcher will broadcast time stamp every 10 minutes for the first 60 minutes during an 

incident, then every 30 minutes thereafter, unless the incident commander (IC) requests 

dispatch to continue broadcasting 10-minute time stamps.
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• On incidents of 3rd alarms or greater, the fire department’s Chief of Special Operations will 

respond to the dispatch center. The chief is responsible for assisting dispatchers with alarm 

assignments, mutual aid response, backfilling empty fire stations, response deployment, and 

any other necessary tasks. 

Building Construction

The multi-family residential structure was built in the 1900s. The 3-story structure had 3 floors plus a 

walkout basement, and each floor was approximately 1,033 square feet (See Diagrams 1- 4 and 

Photos 1- 4). Each floor was a separate apartment with the basement being a small unpermitted 

apartment. The structure was balloon frame construction (this construction method was common in 

the New England area in the 1900s) with vinyl siding on the exterior and was approximately 25 feet 

wide by 41 feet long. The 2

nd and 3rd floors had an enclosed porch on Side Charlie with a large center 

window and an enclosed storage shed on the Bravo/ Charlie corner. The 1

st and 2nd floors had a small 

exterior porch on Side Delta near the Side Charlie corner.

 

Diagram 1. Basement Floor Plan. Note: 

This apartment was not approved for 

occupancy by the city’s Building and 

Zoning Office.

Diagram 2. 1st Floor Plan
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Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

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Diagram 3. 2nd Floor Plan. Note: The 

origin of the fire started in the large 

bedroom.

Diagram 4. 3rd Floor Plan. Note: 

Enclosed porch is where the crew of 

Ladder 5 was trapped.

Photo 1. Side Alpha and Side Delta of the 

structure.

NIOSH Photo

Photo 2. Side Bravo of the structure. 

Note the heavy fire damage from the 

bedroom where the fire originated.

NIOSH Photo
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Timeline

The following timeline is a summary of events that occurred as the incident evolved on November 13, 

2019. Not all incident events are included in this timeline. The times are approximate and were 

obtained by studying the dispatch records, audio recordings, witness statements, and other available 

information. This timeline also lists the changing fire behavior indicators and conditions reported, as 

well as fire department response and fireground operations. All times are approximate and rounded to 

the closest minute. 

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

911 Call. Caller stated fire was on 2nd

floor, people still inside.

0058 

Hours

Photo 3. Side Bravo and Side Charlie of the 

structure. Note: The awning over the 

basement door was where the chauffeur of 

Ladder 5 landed when the lieutenant 

pushed him out the 3rd floor window.

NIOSH Photo

Photo 4. Side Delta of the structure. 

Engine 15 entered the door on Side 

Charlie to attack the fire on the 2nd

floor.

NIOSH Photo
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Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Fire Alarm dispatched Car 4, Engine 

15, Engine 2, Engine 13, Engine 12, 

Ladder 5, Ladder 3, Rescue 1, and 

Ladder 4 (RIT) for a structure fire for 

Box 15-14. Incident Safety Officer 

(Captain) responded.

01:00:06

Hours

Fire Alarm to Car 4: Caller states there 

is a fire on the 2

nd floor with people 

still inside and a baby on the 3

rd floor.

01:00:47 

Hours

Fire Alarm advised Car 4, “We have

reports that the baby is on the 3

rd floor 

and is unconscious. Occupants are 

trying to get him out now. Note: The 

baby was out of the residence prior to 

the arrival of Engine 15, but this 

information was not relayed to Car 4 

or other responding companies.

01:01:27

Hours

“Engine 15 is on arrival. We have a

21⁄2 story, Type V with heavy fire 

showing Bravo Side 2

nd floor.”

01:02:17 

Hours

01:02:36 

Hours

Car 4 to Engine 2, “Secure a hydrant 

for Engine 15.”

“Car 4 is on arrival. We're assuming 

Command. We have smoke showing 

from the roof and the 3

rd floor Bravo 

Side. Fire Alarm, give me a 2

nd

Alarm.” 

01:03:27 

Hours

Engine 2, Engine 13, and Ladder 5 

arrived on-scene.

01:03:42 

to 

01:03:50 

Hours
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Fire Alarm dispatched a 2nd Alarm for 

Box 15-14. Engine 6 (PAR 3), Engine 

5 (Par3), Ladder 1 (PAR 3), and Car 3 

(PAR2) were dispatched. 

01:04:25 

Hours

 01:04:28 

Hours 

Command ordered Engine 13 to stretch 

a hose line off of Engine 15.

01:05:14 

Hours

Ladder 5 entered the structure on Side 

Delta/Charlie and went to the 2nd floor 

for search.

01:06:07 

Hours

Command to Car 400, “I have Engine 

15 and Ladder 5 going to the 2nd floor. 

Engine 13 is going to the 2

nd floor

through the front. Ladder 3 is going to 

the roof in the platform.”

Rescue 1 arrived on-scene. 01:07:11 

Hours

01:07:14

Hours

Command ordered Rescue 1 to the 2nd

floor and 3rd floor. Rescue 1, Team 1 

went to the 2nd floor via Side 

Delta/Charlie and Rescue 1, Team 2 

went to the 3rd floor via Side Alpha.

Engine 12 on scene. 01:07:27 

Hours

Command ordered Engine 12 to lay a 

supply line to supply Ladder 3.

01:07:44 

Hours

Engine 13 knocked down the fire on 

Side Bravo with a hose line off Engine 

15. E13 then moved to enter the front 

door on Side Alpha.
Page 13

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Ladder 4 arrived on-scene. Ladder 4 

assigned as RIT in front of the 

building.

01:08:16 

Hours

Engine 5 arrived on-scene followed by 

Engine 6, Ladder 1, and Car 3.

01:09:39 

Hours 

Command ordered Engine 5 to take a 

handline off Engine 15 and go to the 3rd

floor and meet Rescue 1, Team 2.

01:10:12 

Hours

Command ordered Engine 6 to take a 

handline off Engine 12 and go to the 3rd

floor through Side Alpha. Command 

advised Engine 6 it was a long hose 

lay.

01:11:41

Hours

Engine 13 advised Command that they 

had water on the fire on the 2nd floor. 

01:12:08

Hours

Engine 2 took a hose line to the 3rd

floor via Side Alpha stairs.

Fire Alarm advised Command that he 

was 10 minutes into the incident from 

the first arriving apparatus. Fire Alarm 

advised Command that the power 

company had an ETA of 10 minutes. 

01:13:13 

Hours

01:14:32 

Hours

Rescue 1, Team 2 advised Command 

that there was heavy fire on the 3rd

floor. They needed a hose line. 

01:15:34 

Hours 

Rescue 1, Team 1 advised Command 

they are encountering a large amount of 

debris on the 2nd floor, Side Delta. The 

debris including a mattress was that 

blocking the doorway.
Page 14

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:15:53 

Hours

Rescue 1, Team 2 called Command and 

asked for a hose line to the 3

rd floor. 

Command advised that Engine 2 was 

trying to get to the 3rd floor but there 

was heavy fire on the 2nd floor.

01:16:37 

Hours

Command advised Engine 13 there was 

heavy fire still showing on Side Bravo 

near the Side Charlie corner.

01:18:04 

Hours

Command called Ladder 3 and asked if 

the roof had been vented. Ladder 3 

advised the power saw wouldn’t start 

due the smoke. Ladder 3 was trying to 

vent the roof with an axe.

01:19:07 

Hours

Engine 13 called Command and 

advised that Engine 13 was knocking 

down the fire in the bedroom on the 

Side Bravo/Side Charlie corner.

01:20:03 

Hours

Ladder 5 advised Command they were 

out of the building to change air 

cylinders and had PAR.

01:21:35 

Hours

Engine 6 advised Command that 

Engine 6 and Ladder 1 were at the front 

door (Side Alpha) going to the 3rd

floor.

01:21:55 

Hours

Ladder 3 advised Command the roof 

was vented.

01:22:35 

Hours

Rescue 1, Team 2 out of the building to 

change cylinders.
Page 15

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:22:57 

Hours

Rescue 1 on the 3rd floor needed a hose 

line and was checking for extension.

Command assigned E2 as Division 3.

01:23:38 

Hours

Engine 15 acting lieutenant out of the 

building. E1503 (Engine 15 jumpseat) 

was still on the 2nd floor with Rescue 2, 

Team 1.

01:23:49 

Hours

Incident Commander and Ladder 5 

officer had a face to face; Ladder 5 was 

ordered to the third floor through the 

Delta/Charlie stairwell along with the 

Incident Safety Officer.

Fire Alarm advised Command that he 

was 20 minutes into the incident.

01:24:02 

Hours

Primary search still being conducted.

01:24;25 

Hours

Engine 13 was out of the building.

01:24:43 

Hours

Rescue 1, Team 2 was in the basement 

securing utilities.

01:25:25

Hours

Command called Division 3 for a status 

update.

Division 3 reported that Engine 2 was

advancing further into the kitchen area. 

They were checking for extension, but 

not finding anything.

01:25:41 

Hours

Command called Division 3 and 

advised the 3rd floor room at the Side 

Bravo/Side Charlie corner looks like its 

lighting up a little bit. Engine 6 moved

to that bedroom.
Page 16

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:26:13 

Hours

Command called Ladder 1 and ordered

them to the 3rd floor to pull ceilings.

01:26:44 

Hours

Division 3 to Command, “we're in the 

kitchen area going into the bedroom on 

the Side Bravo/Side Charlie corner. 

We have fire. We only have room for 2 

companies up here. Keep the stairway 

clear.”

01:27:17 

Hours

Rescue 1 to Command, “We have fire 

showing in that 3

rd floor stairwell, the 

rear stairs (Side Delta).

01:27:36 

Hours

Ladder 5 officer called a Mayday. 

“Mayday, Mayday, Mayday.”

01:27:44 

Hours

Ladder 5 officer Division 3, “Fire is all 

around us, we are blocked. We do not 

have PAR. It is very hot up here.”

01:28:08 

Hours 

Command ordered Ladder 4 (RIT) to 

the 3rd floor.

01:28:31 

Hours

Division 3 to Command, “Division 3 is 

at yellow. We're going to be leaving the 

3

rd floor.”

Command to Fire Alarm, “Strike a 

3

rd Alarm for Box 15-14.” Fire 

Alarm acknowledged.

01:28:47 

Hours

Fire Alarm dispatched a 3rd Alarm 

for Box 15-14. Engine 7 (PAR 4), 

Engine 4 (PAR 4), and Ladder 

7(PAR 3). 

01:29:27 

Hours
Page 17

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:30:03 

Hours

Ladder 4 RIT to Command, “They say 

there's one more member. I'm on the 

back porch at the top of the ladder. 

What's their location?”

01:30:13 

Hours

Command to Ladder 4 RIT, “They're 

on the 3

rd floor trying to find an exit. 

Command to Ladder 5, “Get to a 

window. Let us know where you are.”

01:30:20 

Hours

Ladder 4 officer called Ladder 4's 

crew, “Ladder 4, I want the ladder on 

Side Delta on the porch. Heavy fire on 

Side Charlie.

01:30:34 

Hours

Command to Ladder 5, “Get to a 

window. We have Ladder 3 on the Side 

Bravo. We have a ladder there. A 

bucket.”

01:31:10 

Hours

Ladder 5, “We need a line.”. 

Same message transmitted at 01:31:35 

Hours.

01:31:53 

Hours

Engine 6 to Command, “We're on the 

3

rd floor front right now. We made it to 

the front living room, but that is as far 

as we made it with a crew on another 

line.”

01:32:49 

Hours

Ladder 5, “We can’t get out.” 

Note: This was the last radio 

transmission from the Ladder 5 officer.

Incident at 30 minutes. 0133 

Hours
Page 18

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:33:13 

Hours

Ladder 1 to Command, “Chief we're on 

the 3

rd floor at the top of the stairs. We 

have heavy fire over our head. We have 

a line.”

01:34:03 

Hours

Car 400 to Command, “I'm getting a 

report at the truck that a firefighter fell 

out the back of building and he's on the 

ground.”

01:34:13 

Hours

Command to Car 400, “Engine 5 is 

checking Side Charlie.” Note: The 

chauffeur of Ladder 5 was pushed out a 

3

rd floor window by the officer of 

Ladder 5. The chauffeur landed on an 

awning for the entrance to the 

basement apartment on Side Charlie. 

The chauffeur eventually rolled off the 

awning and landed on the ground, 

which was witnessed by a civilian. The 

civilian relayed this information to Car 

400.

01:35:01 

Hours

Engine 5 to Command, “We have one 

firefighter from Ladder 5 on Side 

Charlie.” Note: The chauffeur was 

conscious and alert. He was treated 

and transported by EMS to the local 

trauma center.

01:36:06 

Hours

Engine 6 to Command, “We got heavy 

fire. We're knocking it down in the 

front room. I'm up here with Ladder 1. 

My crew's outside, but we're knocking 

it down with Ladder 1. We've started 

advancing the line in.”
Page 19

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:37:08 

Hours

Car 400 conducted a (PAR). Only 6 

companies were contacted when the 

PAR was stopped. This was due to 

trying to locate the officer from Ladder 

5.

01:39:09 

Hours

Ladder 4 to Command, “Negative. 

Negative. We're in the stairway on the 

3

rd floor. We bypassed the fire. We 

stopped in front of it. We're in the 

stairwell. Come up with a 13⁄4- inch.”

0140 

Hours

Engine 6 is out of the building

changing air cylinders, PAR 3.

01:41:48 

Hours

Ladder 1 is out of the building

changing air cylinders, PAR 3.

01:42:22 

Hours

Ladder 4 to Command, “We're stuck. 

We got fire behind us on the 2

nd floor

stairwell. We're on the 3

rd floor 

stairway. Fire on the still on the 2nd.

01:43:15 

Hours

Ladder 4 to Command, “Ladder 4 is 

making our way down the stairs. The 

rear 3

rd floor stairs on the porch, trying 

get out now. Trying to get down the 

stairs.”

Fire Alarm advised Command that he 

was 40 minutes into the incident.

01:44:04 

Hours

01:44:29 

Hours

Ladder 4 is out of the building, PAR 3.

01:45:57 

Hours

Engine 4 to Command, “We are on the 

2

nd floor. We have the line. We have 

never been able to advance the line to 

the 3

rd floor.
Page 20

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:48:08 

Hours

Command advised that Engine 2 and 

Engine 13 were heading to the 3

rd floor 

from Side Alpha. Engine 4 was going 

from the rear side (Side Delta/Charlie)

trying to make progress.

01:51:31

Hours

Engine 4 to Command, “We are on the 

back stairs, we’re hitting the fire. We're 

not making progress, any progress, but 

we're hitting the fire. Heavy fire still on 

the 3

rd

floor. Engine 5, give me some

more line.”

01:52:08 

Hours

Engine 13 to Command, “We knocked 

down the fire in the 3

rd floor. The fire is 

coming up from the 2

nd floor on the 

Side Delta, in the front of the building, 

where the closets are.”

Incident at 50 minutes. 0153 

Hours

01:54:17 

Hours

Engine 2 to Command, “Engine 2 and 

Engine 13 are in the first room in on 

Side Alpha, 3rd floor and we are getting 

fire from the closet. Engine 13 is about 

to start backing out. They're getting 

low on air.”

01:54:35 

Hours

Engine 4 and Engine 7 are out of the 

building. Both companies had PAR. 

01:55:46 

Hours

Command to all companies, “No one 

go in the building without direction 

from Command.”

01:56:10 

Hours

Command advised the Ladder 4 officer 

and Rescue 1-Team 1 were heading to 

the 3

rd floor rear.
Page 21

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

01:57:10 

Hours

Car 400 to Command, “I got that. I still 

have Engine 6, Engine 2, and Ladder 7 

on the 3rd floor.”

01:57:20 

Hours

Ladder 4 to Command, “I got a PASS

alarm going off about 20 feet in front 

of me. ”

01:58:29 

Hours

Engine 2 to Command, “We got fire in 

the kitchen on the 3

rd floor. We don't 

need any more guys up on the 3

rd floor 

with us. It's too tight up here.”

01:59:22 

Hours

Engine 2 to Command, “We are in the 

3rd floor kitchen area. We have fire 

coming above and below. We're 

knocking it down. Engine 2 should be 

the only company on the 3rd floor Side 

Alpha wing. It's getting tight up here.”

02:00:48 

Hours

Ladder 4 to Command, “We just lost 

the stairs. We just lost the stairs. They

are collapsing.”

02:01:02 

Hours

Ladder 4 to Command, “The stairs 

collapsed. That PASS alarm is right in 

there. Going off the whole time.”

Incident at 60 minutes. 02:03:13 

Hours

Rescue 1 to Command, “That line that's 

going in from the 1

st floor rear 

stairwell. It's burst. It's dumping out. 

Can we shut down that 1

st floor rear 

stairwell line?” Note: The wrong hose 

line was shutdown leaving Ladder 4 on 

the 3rd floor with no water. Eventually, 

Ladder 4’s hose line was charged 

again.
Page 22

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:06:11 

Hours 

Engine 2 to Command, “We're in the 

back bedroom, Side Bravo/Side Charlie 

on the 3rd floor with heavy fire.”

02:07:20 

Hours

Ladder 4 to Command, “Alright, we’re

going to be, our designation is Rescue 

2, alright? Our designation is Rescue 2. 

We're trying to make our way back up. 

We got a good location; We got a line. 

We need another working crew to 

follow that line to the 3

rd floor over the 

porch.”

02:08:03 

Hours

Ladder 4 to Command, “We're in the 

Side Charlie/Side Delta corner on the 

stairs. The doorway, like everything 

around the doorway has collapsed, but 

the stairs are intact. We have a PASS

alarm going off. We have a large 

amount of fire right over that area.”

Car 1 to Fire Alarm, “Strike a 4th

Alarm for Box 15-14.” 

02:08:39 

Hours

Fire Alarm dispatched Engine 16 and 

Engine 3 for the 4th Alarm for Box 15-14. 02:09:19 

Hours

02:09:55 

Hours

Rescue 2 to Command, “We're 

breaching the stairway wall. We're 

breaching the stairway wall. That 

doorway's impassable. We're at the top 

of the stairs. We're getting closer. 

We're getting closer.”

02:11:43 

Hours

Rescue 2 to Command, “We got him.”
Page 23

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

02:11:50 

Hours

Rescue 2 to Command, “We're just 

getting to him now. He is stuck behind 

the doorway. 

Incident at 70 minutes. 02:13:15 

Hours

Rescue 2 to Command, “We're at the 

stairway. We're trying to make our way 

out. Clear the stairway except, Ladder 

1.”

02:13:55 

Hours

Rescue 2 to Command, “Clear that 

stairwell. We're coming out on 

vibralert. One member on vibralert.”

Command changes the strategy to 

defensive

02:14:22 

Hours

Rescue 2 has the officer of Ladder 5 

out of the building.

Command to Fire Alarm, “The fire at 

Box 15-14 is under control.”

0405 

Hours

Command to Fire Alarm, “The fire at 

Box 15-14 is out.”

0435 

Hours

Command to Fire Alarm, “Command 

is dissolved, and all units are clear 

from Box 15-14.”

0631 

Hours

Personal Protective Equipment

At the time of the incident, the Lieutenant was wearing his station uniform, turnout coat and pants, 

gloves, hood, helmet, boots, and self-contained breathing apparatus. The Lieutenant carried a portable 

radio and flashlight assigned by the fire department. The NIOSH investigators inspected and 

photographed the personal protective clothing and equipment at the fire department’s headquarters

facility. As part of this investigation, the self-contained breathing apparatus (SCBA) worn and used by 

the Lieutenant was shipped to the NIOSH National Personal Protective Technology Laboratory 

(NPPTL) in Morgantown, West Virginia, for evaluation and testing. A summary of the NIOSH 

evaluation is included in Appendix One. 

The full evaluation and report can also be downloaded from the NIOSH NPPTL PPE website. 
Page 24

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

The lieutenant’s turnout gear and equipment were not considered to be a contributing factor in this 

incident. 

Weather

At 0054 hours on December 13, 2019, the weather was fair with an approximate temperature of 17° F. 

The dew point was 0o F, the relative humidity was 47%, the winds were 17 miles an hour (MPH) 

gusting to 26 mph from the west northwest (WNW). The barometric pressure was 28.90 inches and 

there had been no precipitation in the past 24 hours [Weather Underground 2019].

Investigation

On November 13, 2019, a 39-year-old career lieutenant died and four other firefighters were injured 

while responding to a multi-family residential structure fire with heavy fire showing (See Photo 5). At 

01:00:06, Fire Alarm dispatched Car 4, Engine 15, Engine 2, Engine 13, Engine 12, Ladder 5, Ladder 

3, Rescue 1, and Ladder 4 (Rapid Intervention Team), to a fire with a report of people on the 2

nd floor 

and a baby on the 3rd floor. The Safety Officer (one of four Captains) on duty responded as well. At 

approximately 01:02:17, Engine 15 arrived on scene and reported a Type V structure with heavy fire 

showing on the 2

nd floor on Side Bravo. At 01:03:37, Car 4 arrived and assumed Command. Engine 2 

also arrived at this time and was assigned to stretching a supply line from a hydrant to Engine 15. 

Command reported smoke showing from the roof and 3rd floor Side Bravo and struck a 2nd Alarm for 

Box 15-14. Engine 5, Engine 6, Ladder 1, and Car 3 were dispatched at 01:04:25. Engine 15 did a 

quick transitional attack on fire venting on Side Delta from the 2nd floor. Command ordered Engine 13 

to hit the fire venting from the exterior on Side Bravo of the 2

nd floor. Within minutes, Engine 15 and 

Ladder 5 were going to the 2nd floor on Side Delta. Engine 13 was going to the 2nd floor on Side Alpha 

and Ladder 3 was going to the roof. 
Page 25

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Prior to entering the building, Engine 13 was knocking down the fire on the 2nd floor on Side Bravo 

near the Side Charlie Corner. Command ordered Engine 13 to get water on the fire on Side Alpha and 

the fire that re-ignited on Side Bravo. Engine 15 was down to less than a half tank of water. A 

firefighter from Engine 2 charged the hydrant and provided Engine 15 with water (See Diagram 5). 

Rescue 1 informed Command that they were splitting into 2 teams. Rescue 1-Team 1 went to the 2

nd

floor and Rescue 1-Team 2 went to the 3rd floor. Rescue 1-Team 2 encountered heavy fire on the 3rd

floor hallway on Side Alpha. Engine 2 brought a hose line to assist Rescue 1-Team 2.

At approximately 01:10:42, the 2nd Alarm companies arrived on scene. Engine 5 and Engine 6 were 

assigned to the 3rd floor on Side Alpha. Ladder 1 was assigned to get Ladder 3 another power saw. 

Ladder 14 was ordered to assist Engine 2 at the front door on Side Alpha to get a hose line to the 3rd

floor. At approximately 01:13, Fire Alarm informed Command they were 10 minutes into the incident 

and the power company had been contacted per standard procedure for a working fire and had an 

arrival time of 10 minutes. Engine 13 requested more water pressure on their hose line as Side Bravo 

still had heavy fire showing. 

Photo 5. The fire building. There was access to all three floors by Side Alpha and Side Delta 

stairs.

(Courtesy of Google Earth)
Page 26

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Rescue 1-Team 1 informed Command that there was a huge pile of debris in the doorway to the 2nd

floor on Side Delta. Rescue 1-Team 2 was still conducting a primary search on the 3rd floor, Side 

Alpha. Ladder 3 was trying to ventilate the roof, but their power saw would not run due to the smoke. 

Ladder 3 started using an axe while Command ordered Ladder 1 to get Ladder 3 another power saw. 

At approximately 01:19, Engine 13 made it to the origin of the fire, the bedroom on the 2nd floor in the 

Bravo-Charlie corner, Engine 13 temporarily knocked down the fire, but it continued to re-ignite (See 

Photo 6). At 01:20:03, Ladder 5 informed Command they were out of the building to change air 

cylinders, Command acknowledged and requested to see the Ladder 5 Lieutenant out front for an 

update (See Diagram 6). Command requested a report from Engine 13, then Rescue 1-Team 2 notified 

Command they were coming out for new air cylinders. At 01:22:35 Engine 6 and Ladder 1 entered side 

Alpha to go to 3rd floor. Command advised E2 that he was now Division 3. Ladder 3 reported the roof 

was vented (See Photo 7). At 0123 hours, Engine 15 exited the building and Ladder 5 re-entered to 

head to the 3

rd floor. Command was notified by Fire Alarm that he was 20 minutes into the incident. 

Engine 13 notified Command they were out of the building and the fire was knocked down. They left 

the hose line at the doorway for the next crew. Engine 13 stated they had another hose line that was 

operating from Side Charlie. At 01:24:43, Rescue 1-Team 1 was in the basement securing the utilities. 

Command requested a report on the 3rd floor. At 01:25:25, Division 3 reported that Engine 2 was 

advancing further into the kitchen area. They were checking for extension, but not finding anything. 

Command ordered Ladder 1 to hook the 3rd floor ceiling to check for extension in the attic. At 

approximately 01:26:44, Division 3 called Command and advised that Engine 2 was in the kitchen area 

going into the bedroom on the Side Bravo/Side Charlie corner with Engine 6. They noted that there 

was only room for 2 companies and asked that the stairway be kept clear.

Diagram 5. The location and accountability of the 1st Alarm companies at Box 15-14. 

The time was approximately 0110 hours
Page 27

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Diagram 6. The location and accountability of the 1st and 2nd Alarm companies at Box 

15-14. The time was approximately 0120 hours.
Page 28

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

 

At 01:27:17, Rescue 1 reported fire in 3rd floor stairwell on Side Delta. While Ladder 5 and Safety 2 

were advancing to floor 3 they were overcome by fire. The safety officer who was behind Ladder 5 

grabbed Ladder 503 and pulled him through fire to the Floor 2 landing. Ladder 503 exited the building 

through the interior stairway while the safety officer exited the Side Charlie porch via a ground ladder. 

At 01:27:36, the lieutenant of Ladder 5 called a Mayday and stated Ladder 5 was on Division 3 with 

fire all around them, and Ladder 5 did not have a PAR. Note: The chauffeur of Ladder 5 that was with 

the officer of Ladder 5 and stated they were near the porch window on the 3rd floor on Side Delta with 

fire all around them. The chauffeur stated his hands were getting hot through his gloves when the 

lieutenant called the Mayday. Command acknowledged, sent in Ladder 4, the Rapid Intervention 

Team, and stated there was a ladder on 2nd floor side Bravo. Engine 2 was on the 3rd floor but was 

unable to locate where Ladder 5 might be. They thought perhaps Ladder 5 meant 2nd floor. The Ladder 

5 Lieutenant radioed an immediate need for a hose line. Note: The Ladder 5 chauffeur was with the 

lieutenant from Ladder 5 on the 3rd floor. The chauffeur stated that they had looked for an exit, saw the 

porch shed, and ran into the cluttered shed for protection from the fire.

At 01:28:47 Command ordered a 3rd Alarm for Box 15-14. At 01:29:47, Engine 7, Engine 4, and 

Ladder 7 were dispatched on the 3rd Alarm. At 01:31:10 hours, the lieutenant from Ladder 5 radioed 

that they needed a hose line. Command instructed Ladder 5 to move towards Side Alpha or find a 

window. At approximately 01:32, the lieutenant of Ladder 5 transmitted his final message, “Can’t get 

out”. Note: The chauffeur from Ladder 5 stated his hands were getting burnt holding the shed door 

and his mask was turning black. They decided to run for the stairs. The chauffeur stated the next thing 

he knew the lieutenant grabbed him and threw him out the window which was at approximately 0133

(See Photos 8 and Photo 9). The lieutenant took shelter back in the storage shed on the porch on the 

Side Bravo/Side Charlie corner. 

Approximately five minutes after the Mayday, Ladder 1 with the officer of Engine 6 was on Floor 3 

Side Alpha, reporting heavy fire above them and operating a hose line. At 01:34:03, Car 400 informed

Photo 6. 2

nd floor bedroom that was on the 

Side Bravo/Side Charlie corner.

NIOSH Photo

Photo 7. Roof vented by Ladder 3 on Side 

Bravo.

NIOSH Photo
Page 29

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Command that a civilian had advised him that a firefighter was lying on the ground on Side Charlie.

Engine 5 was sent to locate the firefighter on Side Charlie and requested EMS who treated and 

transported the chauffeur to the local trauma center.

 

Ladder 4 placed a ground ladder to the Side Delta porch 2nd floor. Ladder 4 took the stairs to the 3rd

floor before running into heavy fire. Engine 6 was on the 3rd floor with Engine 2 on their way out. 

 

Ladder 4 reported to Command that Ladder 4 was in the stairwell trying to make it to the 3rd floor, but 

it was fully involved in heavy fire. Ladder 4 needed a back-up hose line. Command sent Engine 7 to 

the 2nd floor on Side Alpha to operate a line that was already in place. At approximately 01:35, Ladder 

4 reported the first hose line from Engine 15 had burned through and burst right inside the door to the 

2

nd floor at the side Delta stairway (See Photo 10). Engine 6 and Ladder 1 were on the 3rd floor 

knocking down heavy fire in the front room on Side Alpha. At 01:37:08, Command called an 

emergency PAR, but it was never completed due to the strain on communications from heavy radio 

traffic trying to locate the missing lieutenant.

Photo 8. 3

rd floor porch 

window Ladder 5 firefighter 

went out of and initially landed 

on awning over basement door.

NIOSH Photo

Photo 9. View of awning which reduced 

the impact when the Ladder 5 firefighter 

hit the concrete pad on the ground. 

NIOSH Photo
Page 30

Career Lieutenant Dies and Four Firefighters Injured at a 3-Story MultiFamily Residential Occupancy–Massachusetts

Report # F2019-18

Ladder 4 reported to Command they were in the Side Delta/Charlie stairway going to the 3rd floor, and

they had fire behind them and needed an additional hose line. Ladder 4 repeated the first hose line had 

burned through and burst in the stairway on the 2nd floor. Engine 6 and Ladder 1 (out of the building 

changing air cylinders), and Rescue 1 reported a PAR. Command radioed Ladder 4 that a hose line was 

coming up the rear stairwell to them. Also, Command asked if Ladder 4 could get out and if they had a 

PAR. The Ladder 4 officer responded that he had 2 members outside and there were 2 members inside 

with a member of Rescue 1 on a landing with fire below them in the 2

nd floor stairwell. Ladder 7 was 

headed to Side Delta/Charlie stairwell from Side Alpha with a hose line. At 01:43:15, Ladder 4 

reported they were on low air and coming down the stairs. Ladder 4 reported they were out of the 

building and reported a PAR. Engine 4 was on the 2nd floor Side Delta/Charlie stairs and advised that

they couldn’t advance to the 3rd floor. Command ordered Engine 4 to keep trying. At 01:44:14, Fire 

Alarm radioed Command that he was 40 minutes into the incident (see Diagram 7).

Photo 10. Side Delta stairwell second floor where first entry 

hose line burst.

NIOSH photo
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At approximately 01:47, Engine 13 was being assisted by Ladder 7 on the Side Alpha stairs between 

the 2nd and 3rd floors, trying to get to the 3rd floor. Engine 12 and Engine 4 were on the 2nd floor Side

Charlie, and Engine 7 was on the 2nd floor near the Side Bravo/Side Charlie corner fighting fire and 

opening walls. All crews reported having PAR. Engine 13 reported knocking down the fire on the 2nd

floor and requesting hooks to open the ceiling. At 0153 hours, Fire Alarm notified Command that the 

incident was at 50 minutes. At approximately 0154 hours, Engine 2 was on Side Alpha 3rd floor 

attacking the fire in the Side Alpha/Side Delta corner closet area. The fire was coming up from the 2nd

floor. Engine 13 had been assisting Engine 2 but had to head towards 3rd floor stairs to exit as they 

were getting low on air. Engine 4 and Engine 7 were out of the building to change cylinders. Ladder 4,

with a member from Rescue 1, informed Command they were going to make entry on the Side 

Delta/Charlie stairs and try to get to the 3rd floor. At 01:55:46, Command announced no one was to

enter the building without direction from Command. Engine 13 exited the building and Command 

replaced them with Engine 6. Ladder 7 was on the 2

nd floor and had knocked down the fire in the 

kitchen and was overhauling this area.

At 01:57:20, Ladder 4 heard a PASS alarm sounding and advised Command, “I got a PASS alarm 

going off about 20 feet in front of me.” Engine 2 was on Side Alpha of the 3rd floor and reported they 

had fire coming from below and above them. Engine 2 advised Command not to send any more crews 

to the 3rd floor on Side Alpha due to lack of room. Command had Engine 6 on the 2nd floor stairway 

landing backing up Engine 2. Car 2 informed Command that fire had been knocked down on the 

exterior of side Charlie and the hose line was shut down.

At 02:00:48, Ladder 4 radioed “We just lost the stairs - We just lost the stairs; They’re collapsing”. 

Command ordered a ground ladder to 3rd floor Side Charlie. Ladder 4 reported they could hear a PASS

(see Diagram 8). 

Diagram 7. The location and accountability of all companies operating at Box 15-14 

at approximately 0145 hours.
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Ladder 4 requested another company and hose line on the 3rd floor and advised that the hose line had

burst on the landing. Ladder 7 and Rescue 1 called Command and requested the burst hose line be shut 

down. Command had Engine 15 shut down the hose line. Ladder 4 started exiting the 3rd floor via the 

stairway and assumed there were enough stairs left to get to the 1st floor. At 02:03:13, Rescue 1 called 

Command, “The hose line that's going in from the 1st floor rear stairwell. It's burst. It's dumping out. 

Can we shut down that 1st floor rear stairwell line?” Note: The wrong hose line was shut down, leaving 

Ladder 4 on the 3rd floor with no water. Eventually, Ladder 4’s hose line was charged again. Also, Fire 

Alarm advised Command that the incident was at 60 minutes. At 02:07:20. Ladder 4 called Command, 

“Alright, we’re going to be, our designation is Rescue 2, alright? Our designation is Rescue 2. We're 

trying to make our way back up to the 3rd floor. We got a good location; We got a line. We need 

another working crew to follow that line to the 3rd floor over the porch.” Note: Rescue 2 consisted of 

Ladder 4, Ladder 1, and a firefighter from Rescue 1. Rescue 2 confirmed that the Side Delta/Charlie

stairs were intact and that the wall around the 3rd floor door had collapsed on the stairs. Engine 2 

reported they were in the back bedroom on the Side Bravo/Side Charlie corner and trying to knock 

Diagram 8. The location and accountability of all companies operating at Box 15-14 at 

approximately 0200 hours.
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down the fire, which was on the other side of the wall from the shed where the lieutenant from Ladder 

5 was located.

At 02:08:03, Rescue 2 advised Command that they had a good location on the lieutenant. They 

reached the top of the Side Delta/Charlie stairwell, but wall debris had blocked the entrance to the Side 

Charlie porch. Rescue 2 breached the wall onto the porch. At 02:08:39 Command struck a 4

th alarm for 

Box 15-14. 

Engine 6 had relieved Engine 2 on the 3rd floor near the Side Bravo/Side Charlie corner and requested 

hooks be brought up to pull ceiling. Engine 2 exited the building with a member of Ladder 3. Engine 5 

made entry and headed to the 3rd floor with hooks to assist Engine 6.

At 02:09:55, Rescue 2 crawled across the porch avoiding holes in the floor that were covered by a 

ground ladder. Rescue 2 and made it to the porch shed door and they could hear the lieutenant’s PASS 

alarm. (See Photo 11). At 02:11:43, Rescue 2 breached the porch shed door. The lieutenant was stuck 

behind the shed door (See Photo 12 and Diagram 9). Rescue 2 navigated the holes in the porch floor 

with the lieutenant. Most of Rescue 2 was low on air, so they requested the stairwell be cleared. 

Rescue 2 handed off the lieutenant to Ladder 1. Crews brought the lieutenant out the Side 

Delta/Charlie rear door where an EMS crew was waiting at 02:14:22. The lieutenant was transferred to 

a stretcher and transported to the local trauma center where he was pronounced deceased. 

At 02:15, Command evacuated the structure and changed the strategy to defensive. The fire was 

declared under control at 04:05 by Command. 

Photo 11. Holes in 3rd floor porch shown from 2nd floor.

NIOSH Photo
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Photo 12. Third floor porch shed breached by Rescue 2 where Ladder 5 Lieutenant 

took shelter.

NIOSH Photo
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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:

• Building construction and contents enhanced fire spread

Diagram 9. Rescue 2 advanced to porch shed trying to locate the officer of 

Ladder 5. A ground ladder was used to avoid holes in the porch floor.
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• Wind driven fire

• Lack of scene size-up and risk assessment

• Lack of incident management and Command Safety

• Lack of a defined incident action plan

• Lack of crew integrity

• Survivability profile

• Company level staffing

• Lack of professional development opportunities

• Lack of required sprinkler system

Cause of Death

According to the death certificate, the state medical examiner listed the lieutenant’s cause of death as

thermal injuries and the inhalation of products of combustion. The carboxyhemoglobin was less than

12%. The manner of death was accidental.

Recommendations

Recommendation #1: Incident commanders should define a strategy and an Incident Action Plan 

based on the scene size-up and risk assessment. Incident commanders should continually reevaluate 

the strategy and adjust the IAP based on the continuous size-up, risk assessment, risk management, 

and the completion of tactical objectives.

Discussion: Standard conditions are identified as the incident’s critical factors. Fire Officers/Command 

should identify the incident’s critical factors before taking any action. An initial size-up produces the 

information that becomes the basis for the incident strategy and the corresponding incident action plan 

(IAP). Investing a small amount of time evaluating the critical factors is extremely important to 

beginning and on-going command, operational success, and firefighter safety. The incident 

commander (IC) needs a simple system to deal with all basic incident information. Critical factors 

offer such a system. There 8 basic critical factor categories: 

• Building Type 

• Occupancy 

• Arrangement 

• Life safety 

• Fire 

• Resources

• Action

• Special circumstances 

Standard conditions are identified as the incident’s current and forecasted critical factors. The IC 

should:

• Identify the incident’s critical factors before taking any action

• The initial and ongoing size-up of the incident’s critical factors should produce the information 

that becomes the basis for the current incident strategy and IAP
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• Current, accurate and relevant information provides the informational foundation for effective 

initial and ongoing action.

This systematic evaluation process continually produces standard, safe, well-managed incident 

outcomes [Blue Card 2018].

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

priority, and property conservation as the 3rd priority. The task of ensuring the safety of firefighters is a 

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

evaluated and matched with appropriate actions and conditions. The following risk management 

principles should be used during fireground operations:

• Limit activities that present a significant risk to the safety of members to situations where there 

is a potential to save endangered lives

• Recognize activities that are routinely employed to protect property as inherent risks to the 

safety of members and take actions to reduce or avoid these risks

• Do not risk the safety of members when it is not possible to save lives or property

• Limit activities to defensive operations in situations where the risk to fire department members 

is excessive [NFPA 2021].

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

tactical channel to the IC and the dispatch center. The transmission should include the following: 

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

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

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

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

operating procedure (SOP) to implement.

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

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

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

alternative actions to fulfill identified operational goals. 

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

Alpha and Side Charlie). 

• Basement access and type. 

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

Another issue to consider are red flags. Red flags are pieces of information that should be addressed 

because these are situations or conditions that can result in a line of duty death or serious injury. The 

IC should always take a pessimistic approach when sizing-up, assuming the worst until determining 

otherwise. A red flag will not necessarily change the overall incident strategy or incident action plan, 

but it should be identified and addressed by the IC and the rest of the hazard zone team. Some 

examples of red flags include:

• Fire in an attic space

• Fire in a basement

• Operating above a fire (basements, floor above the fire)

• Zero visibility
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• Encountering high heat

• Reports of, “We can’t find the fire”, beyond the normal discovery time

• More than one request to back up an attack position

• A report that states the fire is “under control,” but you can still see active fire conditions from 

the command post

• Victim(s) located

• Wind-driven fires

• Smoke/fire showing from cracks in walls [Blue Card 2018].

The first arriving fire department unit initiates the command process by giving an initial radio report, 

which includes:

• Clear alarm

• Unit designation/on the scene

• Building/area description

o Occupancy

o Size (large, medium, small)

o Height (assumed 1 story unless reported otherwise)

• Obvious problem/conditions

o Nothing showing (indicates checking)

o Smoke showing (amount and location)

▪ Working fire

o Fire showing (amount and location)

▪ Working fire

o Fully involved

• Action taken

o Assuming Command

o Laying a line

o Attacking with...etc.

• Declaration of Strategy

o Offensive or defensive

• Command confirmation with name [PRSOPs 2018].

Fireground operations are very dynamic and fast-paced. Incident commanders should determine a 

strategy and then develop the incident action plan (IAP) to ensure that the proper actions are 

implemented to take control of the incident. Incident commanders should follow the decision-making

model that includes identifying incident critical factors (through a situational evaluation or size up), 

define the acceptable level of risk using the standard risk management plan, declare a strategy 

(offensive or defensive), and then establish the tactical objectives. This model will lead to the 

development of the IAP, which serves as the tactical road map to effectively manage the incident. The 

IAP defines where and when resources will be assigned throughout the incident, along with tasks and 

objectives [Blue Card 2018, NFPA 2021] (See Diagram 10).

During the initial stage of an incident, the IAP should be communicated verbally to all staged and 

assigned resources at an incident. For Type IV (heavy timber) and Type V (wood-framed) incidents, 
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the IC should verbally communicate the IAP during the initial stages and throughout the incident as 

benchmarks are met or not met [NFPA 2020a].

To ensure a standard outcome of each incident, the incident commander should match the standard 

conditions to standard actions. This is the core of the incident command system and is the basis for all 

operations. Standard conditions are identified as the incident’s current critical factors: 

• Identify the incident’s critical factors before taking any action. 

• Initial and ongoing size-up of the incident’s critical factors must produce the information that 

becomes the basis for the current incident strategy and IAP. 

• Current, accurate, and relevant information provides the foundation for effective initial and 

ongoing action. 

• The goal of this systematic evaluation process continually produces standard, safe, wellmanaged incident outcomes [Blue Card 2018]. 

The IAP should match the defined strategy established by an incident commander for a particular 

incident. The defined strategy describes the overall approach to incident operations and drives the IAP. 

Diagram 10. The components of the Strategic Decision-Making Model. This model 

conforms the decision-making process into a standard sequence. The incident 

commander identifies the incident’s significant critical factors and develops a risk 

management plan. The incident commander then bases the strategy and IAP on the 

evaluation of those factors. This leads to the tactical priorities for the incident.

(Courtesy of Blue Card 2018)
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The IAP provides the tactical assignments required to achieve the offensive/defensive objective. The 

order of occurrence is key—the strategic goals are developed first and then the tactical objectives. At 

each incident, the incident commander should start with a standard placement-oriented operational 

plan that develops a strong, dependable beginning for command and control of the incident. While 

developing the strategic goal for the incident is the first component, the incident commander needs to 

produce detailed tactical objectives that can be assigned to responding companies. This is the purpose 

of the IAP [Brunacini 2002; Fire and Rescue Departments of Northern Virginia 2013]. 

The initial incident commander, most often, is a company officer who arrives on-scene prior to a 

command officer. The company officer should provide a detailed size-up, which is communicated to 

all responding resources including the dispatch center. The company officer assumes command and 

decides a strategy and develops the IAP. The company officer may not have the ability or time to 

record the IAP on paper and provide documentation when transferring command. In this case, a verbal 

IAP is appropriate. As with this or any incident, events can occur very quickly before a detailed 

tactical worksheet or written IAP is developed [Brunacini 2002; Harms, 2010].

The IAP can be as simple as a verbal transmission to all units assigned to an incident. Once an officer 

assumes command, the overall strategy – either offensive or defensive – is communicated. Command 

can make specific assignments to arriving companies along with tactical objectives such as search, 

rescue, fire attack, ventilation, utility control, and exposure protection. The responding command 

officer should be monitoring radio communications and documenting tactical objectives on a tactical 

worksheet if possible. When the command officer arrives on-scene, an update from the initial incident 

commander can occur (face-to-face or by radio). The command officer will then assume command at a 

stationary location. By following this process, the initial and second IC will be in a stronger position to 

manage an incident should an emergency event occur [NFPA 2020a; NFPA 2021].

NFPA 1561 defines an IAP as a verbal plan, tactical worksheet, written plan, or combinations thereof 

that reflects the overall incident strategy, tactics, risk management, and member safety that are 

developed by an incident commander. NFPA 1561, Standard on Emergency Services Incident 

Management System and Command Safety [NFPA 2020a] requires the following regarding an incident 

action plan: 

• 5.3.16.1 The incident commander shall be responsible for developing and/or approving an 

incident action plan (IAP). 

• 5.3.16.2 This IAP shall be communicated to all staged and assigned members at an incident.

• 5.3.24 The incident commander shall be responsible for reviewing, evaluating, and revising the 

IAP and overall strategy of the incident (See Diagram 11). 

Offensive Incident Action Planning 

When an incident’s critical factors and the risk management plan indicate an offensive strategy, 

Command will define the tactical objectives for entering the structure (hazard zone) to attempt to 

control the incident hazards. An offensive IAP is based on the standard offensive tactical priorities.

Offensive strategy tactical priorities and their corresponding completion benchmarks are: 

• Water on the fire 
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• Life Safety—Primary and Secondary “All Clear” 

• Fire Control— “Under Control

• Property Conservation— “Loss Stopped” 

• Customer Stabilization— Short term 

The offensive tactical priorities establish the major operational activities required for a complete, 

integrated effort, and they identify the three major functions needed to establish the overall incident 

response [Blue Card 2018]. 

Diagram 11. Guide for developing an incident action plan at Type V and Type IV 

incidents. For these types of incidents, the incident action plan is most often 

communicated verbally.

(Courtesy of FireFighterCloseCalls.com.)
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Defensive Incident Action Planning 

A defensive situation is where the incident problem has evolved to the point that lives and property are 

no longer savable and offensive tactics are no longer effective or safe. The entire defensive strategy is 

based on protecting firefighters. 

Firefighter safety is the Number 1 defensive priority. 

Defensive strategy tactical priorities and their corresponding completion benchmarks include: 

• Define the hazard zone and keep fire fighters out of the potential collapse zone(s) 

• Establish cut-offs—Forward progress stopped 

• Search exposures—Primary and Secondary “All Clear” 

• Protect exposures— “Fire Control”—Loss Stopped.

Defensive operations represent a standard organizational response to situations that cannot be 

controlled with offensive tactics. When conditions go beyond the safety systems required for interior 

operations, Command should conduct defensive operations from outside the hazard area. Command 

should write off lost property and decide where the cut-off will take place. If defensive operations are 

conducted from the onset of the incident, a primary search will not be completed for the involved 

structure(s). During defensive campaign operations, Command will coordinate the rotation of crews for 

rest and rehydration. 

A basic defensive IAP includes the following tasks: 

• Scene size-up 

• Identify critical fireground factors

• Determine the need for additional resources

• Evaluate fire spread/write-off lost property

• Determine collapse zones and ensures no entry

• Search exposures

• Protect exposures

• Prioritize master streams; provide big, well-placed streams

• Surround and drown [Blue Card 2018]. 

As an incident progresses, Command should continually review and update the IAP. The following list 

serves as a guide for Command to consider. Continuous review and evaluation should occur when 

benchmarks are met, or conditions change, and benchmarks have not been achieved. 

• Firefighter safety 

• Consider changing operational modes – go defensive 

• Does the current strategy match the current conditions 

• Location(s) of fire attack 

• Effect of the fire attack 

• All affected areas searched (“All clear”) 

• Timing and support 

• Adequate back-up 

• Adequate staffing and resources 

• Develop “Plan B” 
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• Corrective actions to the current conditions (Fire Control, All Clear, Loss Stopped) [Blue Card 

2018]. 

Recommendation #2: Fire departments should use risk management principles, including occupant 

survivability profiling, at all structure fires. 

Discussion: While it is recognized that firefighting is an inherently hazardous occupation, established 

fire service risk management principles are based on the philosophy that greater risks will be assumed 

when there are lives to be saved and the level of acceptable risk to firefighters is much lower when 

only property is at stake. Interior (inside a structure) offensive firefighting operation can increase the 

risk of traumatic injury and death to firefighters from structural collapse, burns, and asphyxiation. 

Established risk management principles suggest that more caution should be exercised in abandoned, 

vacant, and unoccupied structures and in situations where there is no clear evidence indicating that 

people are trapped inside a structure and can be saved. More importantly, the fire department should 

establish a standardized method or approach to assess the risks encountered at each incident, especially 

structure fires. Structure fires are very dynamic and fast paced operations with little room for error, or 

miscalculations of the significance of the risk encountered.

The IC is specifically responsible for managing risk at the incident. However, one person cannot be 

expected to apply these principles to an incident if the organization has not integrated a standard 

approach to risk management into its SOPs/SOGs and its organizational culture. To be effective, risk 

management principles should be integrated into the entire operational approach of the fire department 

organization. They should be incorporated within the duties and responsibilities of every officer and 

member. The single most important reason to establish an effective incident management system is to 

ensure that operations are conducted safely. Every individual assigned to the incident is responsible for 

monitoring and evaluating risks and for keeping the IC informed of any factor that causes the system to 

become unbalanced. Continuous risk assessment should be reprocessed with every benchmark or task 

completed until the incident is ended.

A standardized evaluation of the situation should occur at each incident starting with the first arriving 

officer or member of the department arriving on scene of the incident. This process starts with the 

scene size-up. This responsibility starts with the first arriving unit that should look at the entire 

incident scene versus focusing on a small part of the situation. During the initial size-up, incident 

commanders should consider the following incident priorities: 

• Life Safety 

• Incident Stabilization 

• Property Conservation 

• Continuous – firefighter safety 

Situations where there is clear evidence or indication that there is a life safety (imminent rescue or 

trapped occupants) changes the focus of the strategy and incident action plan. Established risk 

management principles dictate that more caution is exercised in abandoned, vacant, and unoccupied 

structures.
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In general terms, the risk management plan should consider the following:

• risk nothing for what is already lost—choose defensive operations 

• extend limited risk in a calculated way to protect savable property—consider offensive 

operations

• and, extend very calculated risk to protect savable lives—consider offensive operations.

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness Program, 

Section 8.4 addresses the use of risk management principles at emergency operations. Subsection 8.4.4 

states, “Risk management principles shall be routinely employed by supervisory personnel at all levels 

of the incident management system to define the limits of acceptable and unacceptable positions and 

functions for all members at the incident scene.” [NFPA 2021]

If occupant survival isn’t possible, the IC should evaluate conditions based upon the risk to firefighters 

and revise the strategy and IAP. The IC should take a more cautious approach to fireground 

operations. Fire control should be obtained before proceeding with the primary and secondary search 

efforts [Morris 2020].

A fire in a building today is not what it was 50 years ago. Yet, fireground tactics have not changed to 

be consistent with the effects of fire conditions in today’s modern furnishings. As a result of the 

increased use of plastics in our buildings, today’s fires are hotter and flashover occurs more quickly 

than in the past, releasing extreme levels of toxins. Fire models reflect that flashover can occur in less 

than five minutes and reach a temperature of more than 1,100°F. When exposed to fire, plastics burn 

hotter and produce highly toxic gases. For example, a pound of wood when burned produces 8,000 

British thermal units (BTUs). On the other hand, a pound of plastic can produce 19,900 BTUs when 

burned. The human limit for temperature tenability is 212 degrees. On many occasions, flashover can 

occur as the first fire companies are arriving on the scene. In such circumstances, the survivability of 

any victims in the affected compartment can be very limited or nonexistent [Marsar 2010]. Firefighter 

fatality reports reflect what can happen without a thorough size-up that includes a survivability profile

[Morris 2020]. 

The effects of carbon monoxide poisoning on a victim are well known to the fire service. Due to the 

increased use of plastics and synthetic materials, carbon monoxide is produced in very high 

concentrations and very quickly in structure fires. As a result, victims die sooner than in the past. 

What’s not as well-known but is evolving as a killer for both the victim and firefighters, is cyanide 

poisoning. Hydrogen cyanide (HCN) is formed when natural fibers and common synthetic materials 

are not completely consumed during a structure fire. HCN can enter the body by adsorption, inhalation, 

or ingestion and targets the major organs of the body. Where carbon monoxide kills by blocking 

oxygen absorption in the blood, cyanide kills the body’s organs. Literature reflects that a low 

concentration of 135 PPM of cyanide and carbon monoxide will kill a person in 30 minutes. At 3,400 

PPM, it can kill in less than one minute. It’s not uncommon for a fire in today’s buildings to routinely

produce 3,400 PPM of cyanide. Where a victim may be resuscitated from the effects of carbon 

monoxide poisoning, the victim may not survive the organ damage caused by cyanide poisoning

[Marsar 2010].
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Research findings by the Underwriters Laboratories (UL) show that modern furnishings in a fire 

environment can contribute to flashover occurring up to 8 times faster than with legacy furnishings. An 

experiment was conducted by UL with two side by side living room fires. The purpose was to gain 

knowledge on the difference between modern and legacy furnishings and how they contribute to fire 

growth. Both rooms contained similar amounts of like furnishings. Both rooms were ignited by placing 

a lit stick candle on the right side of the sofa. The fires were allowed to grow until flashover. The 

modern room transitioned to flashover in 3 minutes and 30 seconds and the legacy room at 29 minutes 

and 30 seconds [Underwriters Laboratories Firefighter Safety Research Institute 2020]. For these 

reasons, the conditions within a fire compartment are becoming untenable much sooner than in the 

past. The bottom line: victims die quicker today than in the past. 

The International Association of Fire Chiefs (IAFC) recently revised and updated their Rules of 

Engagement for Firefighter Survival and the Incident Commander’s Rules of Engagement for 

Firefighter Safety as a recommended best practice model which fire departments can adopt and apply 

to enhance fire ground safety. Both documents stress the need to determine the occupant survival 

profile ranking as the second most important action to take on the fireground, behind only the initial 

size-up [IAFC 2012] (See Diagram 12).

Diagram 12. The IAFC’s Rules of Engagement for Firefighter Survival and the IC’s 

Rules of Engagement for Firefighter Safety
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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 results from current research and field studies, adjusting 

firefighting tactics to account for wind conditions in structural firefighting is critical to enhancing the 

safety and the effectiveness of firefighters. A wind-driven fire may be one of the most dangerous 

operations firefighters 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 firefighters 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 hose line 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 hose lines proved ineffective and 

ultimately led to firefighters incurring serious injuries [FDNY 2013]. 

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

include wind conditions and their potential effect on the fire. The key to successfully operating at 

wind-impacted fires in a structure depends on recognizing that a seemingly routine fire may change 

into a “blowtorching” fire when the fire is 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 a window 

fails. 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 

should 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 2013]. 

Fire departments should develop a SOP/SOG for incidents with high-wind conditions and for areas 

where high-wind conditions are likely. It is important that fire officers and firefighters develop an 

understanding of how wind conditions influence fire behavior and 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 firefighters should use caution and take wind direction and speed 

into account when selecting a strategy and developing tactical objectives. 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]. A NIST 

study showed 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 
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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 SOP/SOG 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, considering 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 of 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 firefighting operations should not commence until a report from Side 

Charlie is received [Fire and Rescue Departments of Northern Virginia 2013].

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 be 

monitored and reported throughout the fire incident. It is critical that firefighters are not 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 need to 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 firefighters, 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). 
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• Ensure that firefighters 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 firefighters 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 firefighters are trained to check for fire in overhead voids upon entry and as 

charged hose lines are advanced. 

• Develop, implement, and enforce a comprehensive Mayday standard operating procedure and 

train and educate firefighters to ensure they understand the process and know how to initiate a 

Mayday. 

• Ensure firefighters 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 2014].

In this incident, the wind, building construction, roof ventilation completed 22 min into the incident all 

compounded to create an untenable environment at 01:27:36.

Recommendation #4: Fire departments should ensure that all companies are operating based upon 

the assignments given by the incident commander and ensuring that tactical priorities are met. 

Discussion: The first arriving fire department resource initiates the incident command process by 

giving a brief initial report. It is the responsibility of every firefighter to stay connected with crew 

members. The company officer should maintain constant contact with their assigned members by 

visual observation, voice, or touch while operating in a hazard zone. The company officer should 

ensure they stay together as a company or crew. If any of these elements are not adhered to, crew 

integrity is lost, and firefighters are placed at great risk. A company officer can track personnel in 

smoky conditions by calling out to crew members. This becomes necessary when conducting a PAR. 

Because it is possible to have crew members with the same first name, it is best to use the member’s 

last name.

The IAP is a methodical process that ensures life safety, incident stabilization, and property 

conservation. Assigning the tactics in the order of accomplishment will aid in the coordination of the 

fireground activities. Companies need to periodically communicate their progress on the tactical 

objectives given to them by Command. This keeps the operation focused on making sure everyone is 

out and okay, managing the incident problem, and reducing the damage to the property. Incident 

operations are conducted around the completion of the tactical priorities. Incident communications 

should mirror this simple concept. This will help keep communications short and effective. It also 

maximizes the available free airtime. Incident commanders should structure unit assignments around:

• Addressing the incident’s critical factors

• Completing the tactical priorities 
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• Having tactical reserve (On Deck) [Blue Card 2018]. 

The incident commander has a choice of available methods to implement the IAP. One option is 

assigning tactics. It is necessary to assign tactics in order of accomplishment, which will aid in the 

coordination of the fireground activities [USFA 2009]. Assigning tactics also limits the amount of 

radio traffic needed to implement the IAP, allows companies to react immediately to unforeseen or 

changing conditions, and reduces the demands placed on the incident commander.

An assigned tactic provides a direction to a company, which serves as the basis for feedback to the 

incident commander as to whether the tactic is completed. If a company is unable to complete the

assignment, the incident commander needs to know as soon as possible in order to adjust the IAP. The

incident commander also needs to understand why the company is not capable of completing its

assigned tactic, such as no water, unanticipated conditions, or conditions that have deteriorated since 

the original assignment [USFA 2009].

When units arrive on the scene, they should announce that they are staged. Dispatch should not 

acknowledge any staged units over the tactical channel. Command should contact the staged units and 

assign them based on the IAP.

Orders to 1

st Alarm-staged units should follow a Task-Location-Objective format: 

• Tasks 

• Location of the tasks 

• Objectives of the tasks.

Location of those tasks should include: 

• What floor to operate on 

• What occupancy/exposure to operate in 

• What side to make entry on

• What side to operate on (defensive).

When assigning a unit to deploy a hose line, the incident commander should designate the following: 

• What the company needs to do with their apparatus 

o Lay a supply line 

o Pump a supply line

o Park the apparatus out of the way (manpower only).

• Where the company will get the handline from: 

o Their own company 

o Another forward pumper designated by Command.

The task objectives should focus on the completion of the tactical priorities (objective = completion 

benchmark): 

• Search/rescue = primary and secondary “all clear” 

• Fire control = “under control” 

• Loss control = “loss stopped” [Blue Card 2018].
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When assigning companies to areas that already have units assigned, the incident commander should

inform the newly assigned unit to whom it will report to/work under. The incident commander also 

should inform the division/group supervisor of the newly assigned companies(s).

Recommendation #5: Fire department should establish divisions/groups early on in an incident 

which provides an effective incident management organizational framework that the IAP can build

on and expand. This enhances the accountability of resources operating in the hazard zone.

Discussion: The incident command system (ICS) organization should develop at a pace that stays 

ahead of the tactical deployment of resources. For the incident commander to manage the incident, 

they must first be able to direct, control, and track the position and function of all resources. Building 

an ICS organization is the best support mechanism incident commanders can utilize to achieve the 

balance between managing personnel and incident needs.

The basic configuration of command includes three levels:

• Strategic level – Overall direction of the incident 

• Tactical level – Assigns operational objectives 

• Task level – Specific tasks assigned to companies.

The strategic level involves the overall command of the incident. The incident commander is 

responsible for the strategic level of the ICS organization. The IAP should cover all strategic 

responsibilities, all tactical objectives, and all support activities needed during the entire operational 

period. The IAP defines where and when resources will be assigned to the incident to control the 

situation. This plan is the basis for developing an incident’s organization, assigning resources, and 

establishing tactical objectives. The tactical level directs operational activities towards specific 

objectives. Tactical level officers include branch directors and division/group supervisors, who are in 

charge of specific resources. Tactical level officers are responsible for specific geographic areas or 

functions and supervising assigned personnel. A tactical level assignment comes with the authority to 

make decisions and assignments, within the boundaries of the overall IAP and safety conditions. The 

accumulated achievements of tactical objectives should accomplish the strategy as outlined in the IAP. 

The task level refers to those activities normally accomplished by individual companies or specific 

personnel. The task level is where the work is done. Task level activities are routinely supervised by 

company officers [FIRESCOPE 2015].

The incident commander should begin to assign divisions/groups based on the following factors:

• When situations eventually involve several companies or functions, beyond the capability of 

the incident commander to directly control. 

• When the incident commander can no longer effectively manage the number of companies 

currently involved in the operation.

• When companies are involved in complex operations (large interior or geographic area, 

hazardous materials, technical rescues, etc.).

• When companies are operating from tactical positions that the incident commander has little or 

no direct control over (e.g., out of sight).
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• When the situation presents special hazards and close control is required over operating 

companies (i.e., unstable structural conditions, hazardous materials, heavy fire load, marginal 

offensive situations, etc.) [Blue Card 2018].

Incident commandera should initially assign division/group responsibilities to a second company 

officer since the first due officer has an assignment and is operating on the task level. This allows the 

first company officer to work with his company and focus on the assigned task and more importantly 

prevents task saturation. The second company officer assigned as the division/group supervisor can 

operate on the tactical level, which ensures a broader view of the operations. Another benefit, if 

companies are operating with limited staffing, the company officer assigned to the position of 

division/group supervisor can assign his/her crew to the initial crew to improve company operations. 

When assigning resources to a division/group that is already established with a company officer, the IC 

must include:

• The location of the assignment

• The tasks required

• The tactical objectives to be addressed

• The division/group supervisor that they will be reporting to/working under. 

Command should then contact the division/group supervisor and inform them of the additional 

resources assigned to them. Company officer division/group supervisors have the same set of 

challenges as the fast-attacking company officer incident commander. The challenges are:

• communication difficulties wearing full PPE

• working in a hazard zone with high heat and low visibility

• supervising and accounting for their own crew members

• engaging and focusing in on task level activities.

The IC should consider assigning a chief officer as a division/group supervisor when two or more 

companies are assigned to the division/group.

If the division/group supervisor is operating in or must go into the IDLH atmosphere (hazard zone), the 

division/group supervisor should operate with another firefighter. The primary function of company 

officers working within a division/group is to direct the operations of their individual crews in 

performing assigned tasks. Company officers will advise their division/group supervisor of work 

progress, preferably face-to-face. All requests for additional resources or assistance within a 

division/group needs to be directed to the division/group supervisor. Division/group supervisors will 

communicate with the incident commander. When additional chief officers arrive, they should be 

assigned to a division or group to provide the best assessment for the incident commander and provide 

ongoing conditions, actions, and needs (CAN) reports. It is important to have visual observation of all 

four sides and the interior to develop and monitor the IAP. Without the observations and CAN reports, 

the incident commander’s knowledge of vital information will be limited. 

The early establishment of division/group provides an effective incident management organization 

framework on which the operation can be built and expanded. One of the most important benefits of 
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establishing divisions/groups early in the incident is that accountability is shifted to each 

division/group supervisor, which greatly improves the ability to track resources on the fireground.

Subdividing the incident provides tactical supervision, direction and support to units assigned when 

operating in the hazard zone. This delegated management also helps the incident commander to 

achieve the incidents tactical objectives much more safely and effectively. Utilizing the appropriate 

divisions/groups:

• Reduces the incident commander’s span of control

• Streamlines and creates more effective incident scene communication

• Allows the incident commander to focus on the strategic elements of the incident from a 

stationary command post

• Gives the incident commander an array of functions to choose from and match the needs to the 

incident

• Improves personnel accountability 

• Places strong tactical direction and leadership where the work is taking place

• Improves firefighter safety by having dedicated officers directly manage and control the 

position and function of the operating companies assigned to them [Blue Card 2018].

When establishing a division/group, the incident commander will assign each division/group:

• A supervisor

• Tactical objectives

• Communications

• A radio designation (Roof Division, Division A, Rescue Group)

• The identity of resources assigned to the Division/Group.

The safety of firefighting personnel is the major reason for establishing divisions/groups. Each 

division/group supervisor needs to maintain communication with assigned companies to control both 

their position and function. The division/group supervisor needs to constantly monitor all hazardous 

situations and risks to members and make sure all companies are operating in a safe and effective 

manner.

Recommendation #6: Fire departments should ensure that critical incident benchmarks are 

communicated to the incident commander throughout the incident.

Discussion: Company officers should communicate with Command when benchmarks are met or not 

met. This is an essential element of the IAP because this process allows Command to consider and 

account for changing fireground conditions. Moreover, Command must be able to forecast the 

direction of the incident to stay ahead of the fire. Without this information, the IAP becomes out of 

sequence with the phase of the fire.

Fire departments should consider incident management system training and a certification program for 

company officers and chief officers that prepares members for the dynamic events they will encounter.

This program benefits officers who serve in the role of incident commander, as well as those who 

supervise and manage emergency and hazard zone operations for everyday local National Incident 

Management System (NIMS) Type V and Type IV incidents [NFPA 2021].
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Fireground benchmarks are an essential element for accomplishing successful and safe outcomes. To 

ensure that the proper benchmarks are communicated at fireground incidents, fire departments should 

develop and maintain SOPs/SOGs for communicating critical benchmarks. The SOPs/SOGs should 

include effective hands-on classroom and practical training programs with annual live fire training, a 

defined department deployment model, an effective incident management system, assurance of 

adequate radio equipment (mobile and portable radios), and assurance of adequate radio channels 

(dispatch, tactical, and command channels) [NIOSH 2014a, NIOSH 2014b, NIOSH 2015].

Because the IC is located at the Command Post (outside the hazard zone), interior crews should 

communicate the interior conditions to the IC as soon as possible. Interior conditions can change the 

incident commander’s strategy and IAP. Interior crews can aid the IC in this process by providing 

reports of the interior conditions as soon as they enter the fire building and by providing regular 

updates, especially when benchmarks are met (e.g., “primary search complete, all clear” and “the fire 

has been knocked down”).

A fire department’s communications SOP/SOG should include communications necessary to gather 

and analyze information to plan, issue orders, and manage operations. For example: 

• Additional resources required

• Status of water on the fire

• Assignment completed

• Unable to complete an assignment

• Special information 

• Emergency traffic or Mayday [FIRESCOPE 2015].

Communication of critical incident factors and their possible consequences offers the basis for a 

standard incident management approach. A standard information approach is the launching pad for 

effective incident decision making and successful operational performance. An IC should use the 

critical factors in their order of importance as the basis for making the specific assignments that make 

up the IAP. Incident Commanders should not assume the action-oriented responders engaged in 

operational activities will stop what they are doing so they can feed the IC with a continuous supply of 

top-grade, objective information. It is an IC’s responsibility to do whatever is required to stay 

effectively informed [Brunacini 2002].

For all members operating at an incident scene, radio discipline is essential. All members on the 

fireground should receive training on and use the thought process of “is my transmission necessary” as 

a part of fireground behavior. Members should refrain from transmissions that add little information to 

the IAP. As the incident progresses, the following relevant information needs to be exchanged between 

Command and companies operating on the fireground:

• Follow-up radio report—A CAN Report

• Safety concerns

• Status of water on the fire

• Additional detailed report of fire/smoke conditions and location(s)

• Status of personnel accountability (announce the initial accountability location)

• Disposition of resources
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• Rapid intervention crew in place and location

• Any notable results of the initial fire attack [Blue Card 2018].

Recommendation #7: Fire departments should ensure that once Command is established at an 

incident, incident commanders maintain control of situation status, resource status, fireground 

communications, and ensures the completion of the tactical objectives. 

Discussion: Fireground SOPs/SOGs define the strategic goals and tactical objectives for the 

coordinated deployment of departmental resources for specific incidents and occupancies. SOPs/SOGs 

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

competencies; apparatus, tools, and equipment; community risk assessment and building information, 

including height, area, construction class, and type of occupancy; and potential life hazard.

The first arriving resource will establish command of an incident. The initial scene size-up is 

communicated to the initial responding units with or without a command officer on the scene. The 

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

and tactics for an incident are dictated by the size-up, initial risk assessment, and situational report 

from 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 unit to Side Charlie of the structure. 

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 IC and the dispatch center.

The goal of effective fireground procedures is to increase the safety of the fire fighters, eliminate 

confusion, and prevent the loss of life [Fire and Rescue Departments of Northern Virginia 2013; 

NIOSH 2015]. This will ensure a strong command structure is developed and essential strategic-, 

tactical-, and task-level functions are performed by the incident commander, division/group 

supervisors, company officers, and firefighters.

Strategic Level. This organizational level is designed around the incident commander and incident 

advisory team operating in the command mode. The strategic level involves the activities necessary for 

overall operational control, considering critical fireground factors and the risk management plan in 

establishing objectives, determining the strategy, and developing an IAP, continuous review of the 

strategy, setting priorities, and allocating resources.

Strategic-level responsibilities include the following:

• Determining the appropriate strategy: offensive or defensive

• Establishing a strategic plan for the incident

• Setting priorities

• Obtaining and allocating resources

• Predicting outcomes and planning

• Assigning specific objectives to tactical-level units.
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Tactical Level. The first management “subdivision” of incident scene organization is accomplished by 

assigning division/group responsibilities. Officers operating at this level are responsible for the tactical 

deployment of assigned resources, evaluation, and communication with the IC. They are assigned by 

the IC and are supervised directly at the site of the assigned activity to meet the operational objectives 

given to them by the IC.

When Command appoints division supervisors, one of the most critical functions of Command is to 

ensure the division supervisor is accountable for all resources assigned under their span of control and 

for coordination with Command, the operations section chief, or other supervisory personnel at the 

same level. The division supervisor has the following responsibilities:

• Implement and manage the division IAP, which matches incident commander’s IAP

• Implement a risk management plan in the division

• Complete tactical priorities in the division

• Ensure positions always match conditions in the division

• Coordinate with other division supervisors as needed

• Manage the passport accountability system within the division

• Assist with division air management

• Manage work-rest cycles within the division

• Manage recycle & rehab within the division [Blue Card 2018].

Task Level. The task level of the organization is where the work is performed by assigned companies 

and other resources. The strategic and tactical levels are in place to support the task level. Company 

officers routinely supervise task-level activities [NFPA 2020a].

Additionally, this process compliments the defined knowledge, skills, abilities, competencies, and 

fireground experience to assist:

• The IC in how to plan and implement an effective strategy and IAP

• Division/group supervisors to formulate and follow tactics and maintain accountability of 

assigned resources 

• Company officers to successfully carry out assigned tasks,

• Individual members to effectively perform their duties [FDNY 2011b; FIRESCOPE 2015].

There are necessary tasks that need to occur at any fire regardless of the occupancy, such as the initial 

on-scene report upon arrival, initial risk assessment, situational report, water supply, deployment of 

hose lines and back-up hose lines, search and rescue, ventilation, initial rapid intervention crews, 

ground and aerial ladder placement, fire attack and extinguishment, and salvage and overhaul. 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 [FDNY 2011b; TSFRS 2014]. Command is then obligated to re-broadcast and receive 

acknowledgement from all operating companies. 

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

any of the following issues occur or are present: 

• Life hazard (must be given first priority)
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• 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, the intensity, and the duration of the fire [ISFSI 2013]. 

Recommendation #8: Fire departments should incorporate the principles of command safety into 

the incident management system during the initial assumption of command. This ensures that 

strategic-level safety responsibilities are incorporated into the command functions throughout the 

incident.

Discussion: The purpose of command safety is to provide the incident commander with the necessary 

guidance on how to use, follow, and incorporate safety into the incident management system at all 

incidents. Command safety is incorporated into the eight functions of Command. The principles of 

command safety describe how the incident commander must use regular, everyday command functions 

to complete the strategic-level safety responsibilities during incident operations. Using the command 

functions creates an effective way to ensure a close connection between incident safety and incident 

management. 

The eight functions of Command are:

• Deployment

• Assume, Confirm, and the Positioning of Command 

• Situation Evaluation

• Strategy/Incident Action Planning

• Communications

• Organization

• Review, Evaluate, Revise 

• Continue, Support, and Terminate Command [Brunacini 2002; NFPA 2020a].

These eight functions of Command serve as the foundation for addressing command safety issues. The 

incident commander should follow each of these functions in order without skipping or missing any 

function. Automatically connecting and integrating safety with Command becomes a simple and 

essential way that the incident management system protects assigned resources at an incident. These 

functions serve as a practical performance foundation for how the incident commander fulfills the 

responsibility as the strategic-level incident manager and the overall incident safety manager 

[Brunacini and Brunacini 2004].

A vital command function involves the incident commander using the initial scene size-up, 

consideration of critical factors (building type, occupancy, life safety, fire conditions, and available 

resources), the standard risk management plan, the forecast of incident conditions, and a standardized 

decision-making process. The choice of strategy (offensive or defensive) is independent of location 
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(inside or outside) as it relates to the hazard area or hazard zone. The strategy may change over the 

course of an incident, but only one of the two strategies is used at any one time [Blue Card 2018]. 

Any strategy should include a simple understandable plan that describes in basic terms how close the 

emergency responders will get to the incident’s hazards. The incident’s overall strategic decision is 

based on the incident’s critical factors weighed against the risk management plan. 

Declaring the incident strategy up front, as part of the initial radio report will: 

• Announce to everybody the overall incident strategy 

• Eliminate any question on where firefighters will operate on the incident scene inside the 

structure [Blue Card 2018].

Once the overall incident strategy is determined and the IAP developed, the incident commander 

should manage the completion of the tactical priorities for the chosen strategy. Each strategy has a 

different set of tactical priorities to complete. Tactical priorities provide the incident commander with a 

simple short list of major categories that are designed to act as a practical guideline during the difficult 

initial stages of fireground planning. The IAP is short and simple. A complicated IAP tends to break 

down during this critical time. 

In general, the IC tries to achieve the same basic objectives from one incident to the next. Tactical 

priorities offer a regular set of tools which the incident commander can utilize for tactical activities in 

order to develop a standard approach to solving incident problems. With this standard approach, the 

incident commander can manage the basic work sequence at every incident in the same manner.

Dispatch Centers should contact the incident commander every 10–15 minutes on the assigned 

fireground tactical channel with elapsed-time reminders. These 10–15-minute notification reminders 

serve as cues for the IC to re-evaluate conditions, restate the current strategy, and consider the length 

of time firefighters operate in the hazard zone. The incident commander develops the strategy and the 

IAP based on the initial size-up of the incident’s critical factors. These critical factors are very 

dynamic. Incident operations are either getting better or they are getting worse, but they never stay the 

same. The incident conditions drive the strategy, IAP, and risk management plan [Blue Card 2018; 

NFPA 2021].

An integral part of the personnel accountability system is to make sure that all assigned resources 

working in the hazard zone are initially accounted for. Throughout the incident, it is necessary to 

conduct a PAR periodically to ensure that all assigned resources are accounted for by the 

accountability officer or resource status officer. 

The accountability officer also should request a PAR from each division or group supervisor whenever 

a change in conditions occurs that could cause unsafe operation, such as an “emergency traffic” 

announcement to “all companies evacuate the building.” When a division or group supervisor is 

requested to conduct a PAR, this supervisor is responsible for reporting on the accountability of all 

companies or members working within their area of responsibility [NFPA 2020a]. With a strategic 

mode change, a PAR should occur to ensure that all assigned resources are accounted for and are out 
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of the hazard zone. Defensive operations should not start until the PAR is completed and all members 

are accounted for by resource status. 

At this incident, the incident commanders experienced several command safety issues. The fire 

department is addressing these issues as part of its recovery process. This process includes improving

fireground communications, establishing a stationary Command Post, improving personnel 

accountability, implementing use of a tactical worksheet that compliments personnel accountability 

and crew integrity, and establishing a continuous scene size-up and risk assessment process.

Recommendation #9: Fire departments should ensure adequate staffing for deployment to urban 

incidents involving high hazard occupancies and a concentrated population.

Discussion: Fire departments should ensure adequate staffing and a deployment strategy to ensure 

adequate resources are on-scene to conduct fire suppression operations for the likely hazards in their 

jurisdiction. The deployment strategy should allow for mutual aid for large fires and maintain adequate 

coverage for smaller incidents in their jurisdiction in cooperation with neighboring departments.

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 2020b]. 

NFPA 1710 states: “On-duty fire suppression personnel shall be comprised of the numbers necessary 

for firefighting performance relative to the expected firefighting conditions.” These numbers shall be 

determined through task analyses that consider the following factors: 

• Life hazard to the populace being protected

• Provisions of safe and effective fire-fighting performance conditions for the firefighters

• 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 

2020b]. 

Following a community hazard/risk assessment, fire service leaders need to 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 written 

policies and procedures that establish the distribution and concentration of fixed and mobile resources 

of an organization [NIST 2013].

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 2020b]. Concentration is also about geography and arranging the 

timing of multiple resources 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 
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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 drive response time 

performance of all responding resources and the assembly of effective on-scene firefighting (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. Other 

considerations by fire service leaders should include an assessment of the probability or likelihood that 

a particular event will occur.

Many cities struggle with staffing and deployment challenges. However, NFPA and best practices have 

suggested a minimum of 18 fire fighters (3 engines, a ladder, and a battalion chief with an incident 

command technician (ICT)) for a single-family residential structure fire. This deployment model 

example may or may not meet some fire departments’ needs. Rapid intervention teams and 

rehabilitation also need to be taken into consideration in the deployment model.

NFPA 1710 states that both engine companies and truck companies shall be staffed with a minimum of 

four on-duty personnel. The standard also states that companies shall be staffed with a minimum of 

five or six on-duty members in jurisdictions with tactical hazards, high-hazard occupancies, highincident frequencies, geographical restrictions, or other pertinent factors identified by the authority 

having jurisdiction. [NFPA 2020b]

Staffing studies have concluded that four-person crews were more effective than three-person crews 

once a water supply from an external source is established. Tasks that may be accomplished by a fourperson crew include:

• two-person interior search and rescue with no hand-held back-up line

• two-person interior structural firefighting with no rescue component and no hand-held back-up 

line

• limited roof-level ventilation operations

• laddering operations

• salvage operations.

Four-person crews, depending on the circumstances, may also be capable of completing the following:

• use of a 21⁄2-inch hose line

• establishment of a water supply from a static source

• establishment of a second point of entry and approach to the fire location in the structure

• preparing for search and rescue for person(s) in need of rescue.

NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, 

Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments

requires a minimum full alarm assignment of 15 firefighters and 1 command officer, for a total of 16

members on the scene of a residential structure fire in a typical 2,000-foot, two-story single-family 
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dwelling without a basement and with no exposures within 8 minutes of travel time [NFPA 2020b]. If 

the aerial or platform is in operation, an additional member is required. This staffing allows for one 

attack line to be placed in operation on the 1st floor or 2nd floor, with one back-up line, one search and 

rescue crew, one ventilation crew, and a rapid intervention crew.

However, best practices suggest that residential structures that exceed these characteristics, but do not 

fit a high-rise or high-hazard occupancy, should receive a minimum full-alarm assignment of 25

firefighters, 1 command officer, and 1 incident command technician for a total of 27 personnel on the 

scene of a structure fire within 8 minutes of travel time [NFPA 2020b]. If the aerial or platform is in 

operation, an additional member is required. This staffing allows for two attack lines to be stretched to 

an upper floor, one back-up hose line, two search and rescue crews, one interior forcible 

entry/ventilation crew, one exterior ventilation crew, and a rapid intervention crew. The standard also 

requires staffing of engine companies and truck companies with a minimum of four on-duty personnel. 

To better match resources to service demands and address risk, the standard also states that companies 

shall have a minimum of five on-duty members in jurisdictions with high numbers of incidents or 

geographical restrictions or six on-duty members in jurisdictions with tactical hazards, high-hazard 

occupancies, or dense urban areas as identified by the authority having jurisdiction [NFPA 2020b].

The effectiveness of increasing staffing from 3 firefighters to 4 firefighters was more pronounced when 

measured for a larger building than the one assumed by NFPA 1710 that was used to justify a 15-

member response in 8 minutes [NFPA 2020b] (See Diagram 13). The community served by the fire 

department in this investigation was comprised of buildings with basements, close exposures, and 

more than two floors, and indicated that the increase in efficiency would be greater than that calculated 

by National Institute for Standards and Technology (NIST) for smaller structures.

At the scene of a structure fire, the driver/operator of the first engine company on the scene should 

remain with the apparatus to operate the pump. This leaves one firefighter to assist the operator in 

securing a water source from a hydrant and two firefighters to deploy a hose line and stretch it to the 

fire. After assisting the operator, the third firefighter should begin to assist the other two firefighters 

with advancing the hose line into the building and to the location of the fire. Before initiating 

firefighting operations, the officer of the first arriving engine company conducts a complete walk 

around of the structure to assess the situation, determine the extent of the fire, request any additional 

resources, and assume Command. The driver/operator of the first arriving ladder company should 

remain with the apparatus to operate and position the aerial device, while the other three firefighters 

perform critical fireground tasks, such as ventilation and search and rescue.

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 hose lines, 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. 
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However, officers will assist in conducting searches and removing victims when necessary. These 

officer tasks are essential to firefighter and civilian life safety, since studies show that situational 

Diagram 13. Initial full alarm assignment for a 2,000 square-foot, two-story 

single-family dwelling capability deployed within 8 minutes per NFPA 1710.

(NFPA 1710)
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awareness and human error are contributing factors in nearly 20% of the fireground line-of-duty 

deaths, and that 40% of firefighter injuries are attributed to situational awareness [NIST 2013]. 

Urban fire departments should staff companies commensurate with the tactical hazards, high-hazard 

occupancies, high incident frequencies, geographic restrictions, and other pertinent factors that are 

common in urban environments. 

At this incident, engine and ladder companies operated with an officer and two firefighters. The 

staffing levels are consistent throughout the city. Based upon the workload of the fire department (call 

volume, working fires, and deployment criteria), this staffing allows for tasks to be completed based 

upon the capabilities of the company. 

Recommendation #10: Fire departments should ensure that all firefighters and fire officers are 

trained in managing a Mayday.

Discussion: The ability of a firefighter to call a Mayday is a complicated behavior that includes the 

affective, cognitive, and psychomotor domains of learning and performance. Any delay in calling a 

Mayday reduces the chance of survival and increases the risk to other firefighters trying to rescue the 

“downed” firefighter. Firefighters should have 100% confidence in their competency to declare a 

Mayday. Fire departments should ensure that any personnel who enter a hazard zone meet the 

department standards for Mayday competency throughout their active-duty service. A Rapid 

Intervention Crew (RIC) typically is not activated until a Mayday is declared. Any delay in calling a 

Mayday reduces the window of survivability and increases the risk to the RIC [NFPA 2021].

The National Fire Academy has a 1-hour course addressing the firefighter Mayday Doctrine, Q133 

Firefighter Safety: Calling the Mayday, which covers the cognitive and affective learning domains of 

the firefighter Mayday Doctrine. As with any training, practical training should supplement the 

classroom training. The important factor is to ensure fire departments understand the true magnitude of 

a Mayday. When a firefighter calls a Mayday, the response must include effective incident 

management, proper fireground and radio communications plus dispatcher support, adequate resources 

(staffing), tools and equipment, and emergency medical services support [NIOSH 2011].

One important point is that every firefighter should be equipped with a portable radio when operating 

in the hazard zone. If a firefighter becomes lost or trapped in the hazard zone, the firefighter should 

activate the emergency button (orange) on the portable radio prior to transmitting a Mayday. This 

action will give the member in distress priority on the radio channel and will provide the best chance

for the dispatcher and/or IC to acknowledge the Mayday. This ensures the Mayday will be addressed in 

a timely manner. This process should be supported by a SOP/SOG and practical training.

The rescue of a lost, missing, trapped, or injured firefighter is time sensitive. A very narrow window of 

survivability exists for a firefighter who is out of air or trapped in a hazardous environment. 

Firefighters must not delay in communicating a Mayday, ensuring the incident commander is notified. 

It is important to remember that the safest way to remove a downed firefighter from an upper level of a 

building is by using stairs if feasible.
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When it comes to rapid egress or removing a downed firefighter, the most appropriate action to take 

due to conditions may be to use a window in the immediate area. A task such as this can be 

challenging if it is not trained on or practiced regularly. Firefighters may be forced to use windows for 

removal for a variety of reasons. The route taken into the structure may have been altered or changed 

during operations by collapse, deteriorating fire conditions, the malfunction of a self-contained 

breathing apparatus (SCBA), an air-supply issue or disorientation. Factors such as surroundings, fire 

conditions, collapse or building construction can further increase the challenges that must be 

overcome. A constricted-space window removal requires at least three rescuers. These maneuvers are 

labor intensive and will require a RIC to be operating on the exterior as well as the interior. 

Communication between these crews is of highest priority. The exterior RIC will need to know the 

specific equipment and exact location necessary to affect the rescue. This will normally take place after 

the initial RIC locates the downed firefighter. Two of the most common ways to perform removal 

through a window are the "Denver" and "Fulcrum" techniques [Pindelski, J. 2010].

The IC is required to revise the strategy and IAP (tactics) to incorporate a priority rescue. This will 

impact fireground communications. A Mayday condition is transmitted on the radio, using distinctive 

emergency traffic alert tones. Then the IC and/or dispatch center is responsible for taking action to 

clear the radio channel and to determine the member’s location, situation, and resources needed to 

remedy the situation. In the event of a Mayday, a rescue group supervisor will take responsibility for 

the resolution of the Mayday. It is necessary for the IC to support the rapid intervention group 

supervisor with appropriate and adequate resources to manage the Mayday. At the same time, the IC

should reinforce the surrounding groups and division to continue the incident mitigation. Projecting 

resource requirements for the rescue group operations has the potential to increase the survivability of 

a Mayday situation. 

The IC should ensure that firefighting operations are continued in conjunction with the rescue 

operations, especially in the area around the Mayday, by assigning this responsibility to a division or 

group supervisor. This allows the availability of adequate resources to hold or extinguish the fire while 

the rapid intervention group operations are conducted [Blue Card 2018]. The two most important 

Mayday rescue tasks that must occur are protecting the “downed” firefighter from fire and getting air 

to the “downed” firefighter. The incident commander has the responsibility for ensuring these two 

tasks are assigned and occurring.

Responsibilities of the rapid intervention group include: 

• Responding to the Mayday from the inside out 

• Managing communications with the “downed” firefighter 

• Managing the search and rescue efforts for the “downed” firefighter if necessary 

• Increasing and maintaining resources assigned to the rapid intervention group 

• Managing the logistical support well 

• Improving survivability and tenability 

• Improving ventilation 

• Increasing exterior access for the rapid intervention group 

• Utilizing the RIC bag and requesting additional RIC bags if necessary 

• Recognizing and supporting the help order of a Mayday 
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• Positioning or staging crews in an on‐deck position or outside of the rapid intervention group as 

a tactical reserve 

• Requesting additional resources from the IC

• Overseeing crews from other groups or divisions 

• Requesting additional staged resources 

• Communicating with surrounding divisions and groups. 

Mayday Operational Procedures (Task, Tactical, and Strategic Levels) 

Task/company/firefighter level Mayday responsibilities 

The affected firefighter must:

• Call for a Mayday after realizing that it is not possible to safely exit the hazard zone

• Declare a Mayday (three times) to ensure priority radio traffic, unkey the microphone, and wait 

for Command to acknowledge the Mayday

• Give a CAN (conditions, actions, and needs) report that includes: 

o Who—identity (unit, unit riding position, or entire name)

o What caused the condition(s) of the Mayday—what was the assignment

o Where—identify current location/surroundings or the last known location 

o Needs—the needs that will help resolve the Mayday (critical) 

• Calm down and begin self-help/self-rescue techniques 

• Conserve air 

• Activate PASS alarm if appropriate

• Maintain radio contact with the incident commander or division supervisor as required [Blue 

Card 2018]. 

Other companies operating in the hazard zone during a Mayday must: 

• Maintain radio silence 

• Transmit Mayday announcements and priority traffic and status reports only

• Prepare to assist with the rescue if able to do so

• Continue with interior fire control efforts when a Mayday occurs [Blue Card 2018]. 

Tactical level Mayday responsibilities (if in place) 

A division supervisor who is in place at the entry point when a Mayday occurs in the supervisor’s

division must perform the following: 

• Take strong control of entry point

• Assess resources available in the division

• Request resources 

• Support the firefighting when necessary 

• Consider the critical factors in the division 

• Develop the Division’s rescue IAP 

• Refrain from flooding the interior with resources

• Organize, properly equip, and brief on-deck units before deployment

o Note: “on-deck” is defined as a forward staging position located just outside the immediate 

hazard zone, safely distanced from the entrance of a tactical position/ division/group 

supervisor; on-deck crews are supervised either by the division/group supervisor or the 
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company officer; the on-deck company remains on-deck until assigned by the IC or 

division/group supervisor.

• Provide clear, realistic objectives to the rescue teams

• Implement, react to, and reinforce the rescue efforts as required in the division [Blue Card

2018]. 

Strategic level Mayday responsibilities

When a Mayday is declared on the fireground, the IC must: 

• Confirm the critical factors, the risk management plan, and the overall strategy 

• Take strong control of the communications process 

• Follow the Mayday communication algorithm

• Change the IAP to a high-priority rescue effort 

• Implement a no PARs policy 

• Assign officers into divisions, if not already assigned

• Coordinate and support the rescue efforts with the divisions as required 

• Expand the command organization and verify with the dispatch center that the next alarm level 

and EMS strike team were dispatched 

• Support the firefighting when necessary

• Establish a treatment group

• Consider the medical and technical requirements for the rescue [Blue Card 2018]. 

If a division supervisor is in place where the Mayday is declared and Command has completed the 

Mayday communication algorithm, Command should assign the division supervisor to manage the 

Mayday. The division supervisor is in the best position to manage the rescue activities that need to take 

place in the division to resolve the Mayday. The IC is then in the best position to coordinate and 

support the rescue, firefighting, and treatment efforts with the other divisions and companies as 

required by the incident’s critical factors. 

If no division supervisor is in place when a Mayday is declared on the incident scene, the IC should 

continue to manage all tactical rescue efforts required to resolve the Mayday after completing the 

Mayday communication algorithm procedure. 

Recommendation #11: Fire departments should provide a Mayday tactical worksheet for incident 

commanders in the event of a Mayday.

Discussion: A checklist can assist the incident commander in ensuring the necessary steps are taken to 

clear the Mayday as quickly and safely possible. A structured checklist serves as a guide, and it is 

possible to tailor the checklist to any fire department’s Mayday procedures. 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 firefighter who is missing, trapped, or injured.

Some departments have adopted the term LUNAR—location, unit assigned, name, assistance needed, 

and resources needed—to gain additional information in identifying a firefighter who is in trouble and 
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in need of assistance. The incident commander, division/group supervisors, company officers, and 

firefighters 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 [Brunacini and Brunacini 2004; 

NFPA 2020a]. Note: A checklist is provided in Appendix Two, Incident Commander’s Tactical 

Worksheet for Mayday.

Recommendation #12: Fire departments should ensure that firefighters are trained in fireground

survival procedures.

Discussion: Training is frequently limited to breathing apparatus emergencies, egress through small 

openings, emergency window egress, etc. It is necessary to place additional emphasis on appropriate 

procedures for tactical withdrawal under worsening fire conditions and structural collapse situations.

As part of emergency procedures training, firefighters need to understand that their PPE and SCBA do 

not provide unlimited protection. PPE that are not properly donned, worn, or activated may provide 

reduced protection or no protection at all. The IAFF and the IAFC have developed the IAFF Fire 

Ground Survival Program to ensure that training for Mayday prevention and Mayday operations is 

consistent between all firefighters, company officers, and chief officers [IAFF 2010].

Firefighters must act promptly when they become lost, disoriented, injured, low on air, or trapped 

[FIRESCOPE 2015; IAFF 2010; LAFD 2016; TFRD 2012]. After quickly assessing the tenability of 

their location, a fire fighter should transmit a Mayday following these procedures:

• Activate the emergency alert button (EAB) on the portable radio pushing the button for 1 to 3 

seconds to activate

• Declare the Mayday announced on the radio as “MAYDAY, MAYDAY, MAYDAY” followed 

by the unit designation, then a brief and concise statement of essential information

• Ensure the message is acknowledged by Command and/or the dispatcher

• Ensure that the PASS device is activated. 

Firefighters should survey their surroundings to get their bearings and determine potential escape 

routes, such as windows, doors, hallways, changes in flooring surfaces, etc., and stay in radio contact 

with the incident commander and other rescuers. In addition, firefighters can attract attention by 

maximizing the sound of their PASS device (e.g., by pointing it in an open direction), pointing their 

flashlight toward the ceiling or moving it around or using a tool to make tapping noises on the floor or 

wall. A crew member who initiates a Mayday call for another person should quickly try to 

communicate with the missing member via radio and, if unsuccessful, initiate another Mayday 

providing relevant information on the missing firefighter’s last known location. Training should 

include situations dealing with uncontrolled SCBA emergencies, egress through small openings, 

emergency window egress, building collapse, and other situations that are possibly encountered during 

a Mayday situation.

Emphasis on appropriate procedures for tactical withdrawal under worsening fire conditions and/or 

pending building collapse is necessary. An operational retreat is designed to quickly remove 

firefighters from operations in an unsafe or potentially unsafe environment. Per the IAFF Fire Ground 
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Survival Training Program, the incident commander shall initiate an operational retreat whenever the 

operational area is deemed unsafe for emergency personnel. All personnel operating in the unsafe area 

shall evacuate as the operational retreat procedures are initiated. Operational retreat shall begin with 

radio traffic announcing “emergency traffic” with directions for all emergency personnel to evacuate 

the operational area. An emergency egress signal shall sound [IAFF 2010; LAFD 2016]. For example:

• Repeated short air horn blasts of approximately 10 seconds, followed by 10 seconds of silence

• The sequence of the air horn blast for 10 seconds, followed by 10 seconds of silence, repeated

three times.

Upon hearing the operational retreat signal, all firefighters should immediately withdraw from any

operations they are performing and leave the operational area. All company officers should 

immediately perform a PAR of all personnel they are responsible for and report the results to the 

incident commander.

Firefighters need to understand the psychological and physiological effects of the extreme

level of stress encountered when they become lost, disoriented, injured, run low on air, or become

trapped. Most fire training curriculums do not discuss the psychological and physiological effects of 

extreme stress encountered in an imminently life-threatening situation, nor do they address key 

survival skills necessary for effective response. Understanding the psychology and physiology 

involved is an essential step in developing appropriate responses to life threatening situations. Reaction 

to the extreme stress of a life-threatening situation, such as becoming trapped by extreme fire behavior 

or building collapse, can result in sensory distortions and decreased cognitive processing capability.

Recommendation #13: Fire departments should ensure that company officers are trained to operate 

with limited staffing, to ensure the essential task level functions are performed. 

Discussion: Most fire departments face or struggle with budget shortages which impact their staffing 

capabilities, training needs, equipment upkeep, and policy compliance which ultimately effects the 

safety of their firefighters. Fire departments should ensure that company officers are trained to operate 

in a hazard zone with 2-person or 3-person staffing to function on the task level properly and safely. 

Crew integrity means firefighters stay together as a team of two or more. Crew integrity becomes even 

more critical when a company enters a structure to perform interior firefighting operations. Crew 

integrity starts with the company officer ensuring that all members of the company understand their 

assignment and have the proper PPE, tools, and equipment. Fire departments that operate three-person 

company level staffing (chauffeur/engineer, company officer, and firefighter) proves difficult for the 

company officer. The company officer should supervise but also participate in critical fire ground tasks 

such as back-up firefighter, nozzleman, or division/group supervisor [TSFRS 2013, FIRESCOPE 

2015, Blue Card 2018]. All members should be educated and trained to understand the consequences 

of reduced staffing and company effectiveness. 

Task level operations may take longer and be less efficient. The incident commander needs to 

understand that two companies may have to be assigned to perform the same tactical objective that a 

heavier staffed company may be able to accomplish on its own. In addition, SOPs/SOGs must be 

written in a realistic manner that recognizes that not all tactical objectives may be able to be addressed 
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immediately with reduced staffing. Tactical objectives should be prioritized by the incident 

commander, so that the most critical tactical objectives (e.g., search and rescue, extinguishment) can

be initiated as soon as possible.

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

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

with the members of their companies directly in the hazard zone. The task level is the most important 

level on the incident site because it solves the incident problems taking place in a hazard zone, which 

could result in firefighter injuries or deaths. Companies working on the task level have the greatest 

stake in the personnel accountability system because they operate inside a hazard zone. No hazard zone 

management system can outperform unsafe behaviors on the task level. Task level responsibilities 

include: 

• Following all staging procedures

• Making sure that everyone is assigned properly into the hazard zone 

• Using the personnel accountability system properly

• Staying together as a company 

• Attaching all members to a hose line

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

• Entering no more than 175 feet into a structure, based on air supply

• Refraining from freelancing [Blue Card 2018]. 

Training with limited staffing can be beneficial to properly prepare for actual fireground operations, 

especially for an engine company in which deploying hose lines and flowing water are essential skill 

sets. While training with limited staffing is difficult and time consuming, it needs to take place. In 

order to maximize time, fire departments should focus on individual skill work (stretching hose lines, 

throwing ground ladders, establishing a water supply) while in service. This allows the company to 

focus on one skill at a time to achieve competency, then utilize complex evolutions to put all of the 

skills together. No matter what method is used, training with the actual company staffing level has to 

occur. 

If the company officer is first-due on the alarm or box, the company officer should assume Command. 

In conjunction with assuming Command, a scene size-up and risk assessment must occur. While this 

may seem like an everyday task for a company officer with limited staffing, every second counts. The 

initial size-up and strategic decision made on the initial radio report of the overall incident conditions

provide the necessary direction for the incident. Whenever possible, prior to making entry into a 

structure fire, a fast-attacking company office/incident commander shall perform a 360-degree 

assessment of the fire building/area to:

• Determine the fire’s size, location, and extent

• Verify the basement type (if present) and the stories/floors from Side Charlie

• Determine the ventilation profile of the structure (the identification of flow paths – or potential 

flow paths)

• Identify the safest, most appropriate attack position

• Establish the life safety profile of the incident

• Confirm the initial strategy and IAP [Blue Card 2018]. 
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With a limited crew, the company officer must decide what size hose line to use. Offensive attack hose 

line evolutions/stretches must be highly mobile—as mobility is slowed, attack activities begin to 

become more defensive in nature and effect. The selection of the hose line must match the conditions 

encountered. 

If the company officer arrives before a command officer, the company officer should assume 

Command for a finite period, but no more than 5 – 6 minutes. The first arriving unit or officer will 

establish command until arrival of a higher-ranking officer (command officer). Many times, the 

strength of the incident command system is the fast-attacking incident commander, who directly 

supervises the use of quick force at the beginning of the event. That action is reinforced and upgraded 

by response chiefs who come in behind the initial fast attacking IC to quickly establish a stationary, 

exterior command post that supports and expands on the fast-attacking IC’s initial actions. The fastattacking command position provides the front-end command structure for that capability. A fastattacking company officer incident commander will also directly supervise and assist their crew 

members with the tasks required to bring the incident’s problems under control. The company 

officer/incident commander may find it necessary to assign additional companies in order to complete 

the necessary task functions such as hose line stretch, or search. In this situation, another company 

officer can move up to manage this combined company [Blue Card 2018].

Upon arrival of a higher-ranking officer, they will be briefed by the on-scene incident commander. The 

higher-ranking officer will then assume Command. This transfer of command is to be announced. The 

officer being relieved of command responsibilities will be reassigned by the new Incident Commander, 

most often as a division/group supervisor. This establishes tactical level operations in the hazard zone. 

Each division/group supervisor is responsible for the tactical deployment of the resources at their 

disposal, to complete the objectives assigned by the incident commander. Division/group supervisors 

are also responsible for communicating needs and progress to the incident commander. The company 

officer is now responsible for the companies assigned (span of control) and to manage tactical level 

accountability [FIRESCOPE 2015, Blue Card 2018]. 

Conditions dictate actions, but planning, training, and SOPs/SOGs are essential to ensure that company 

operations with limited staffing provide the essential job tasks when responding to residential structure

fires. It is imperative for company officers and their crews to train for any potential staffing scenarios. 

The best scenario is for the engine company is to make a search a priority along with fire attack. It is

important to establish these procedures; train on what will work for the department in a variety of 

scenarios; and train all your members at all three positions. Also, fire departments should consider 

combining companies to operate as a 4-person or 5-person crew, which will make accomplishing task 

level operations easier and safer.

Recommendation #14: Fire departments should ensure that all unassigned resources are dispatched 

to a designated staging area or base per standard operating procedures. 

Discussion: During fireground operations, the incident commander may need resources beyond those 

that are already operating on the fireground. When Command identifies a task that is needed, 

Command chooses the proper resources, confirms availability, and then orders the resources into 
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action. Managing incident operations in this fashion is how the incident management system 

coordinates and incorporates all the efforts of multiple units into a single, cohesive operation [Blue 

Card 2018].

Staging is the function and location designated at the incident that is used to position uncommitted 

resources so that they are immediately available for assignment (within 3 minutes) [NFPA 2020a]. The 

incident scene can quickly become congested with personnel and equipment if not managed 

effectively. During incidents when companies are involved in investigative operations or when 

companies have not yet received assignment, additional responding equipment normally will stage one 

block from the incident in the direction of travel. This will provide more flexibility in the use or 

clearing of resources at an incident. When additional resources or alarms are requested, the incident 

commander should establish a staging area and designate a location as soon as possible. Requesting a

separate tactical channel for staging ensures that the tactical channel used by on scene resources is not

overrun with radio traffic. The first uncommitted company arriving at the staging area is responsible 

for staging (staging area manager). Staging reports to the incident commander until operations are

established. In the expanded organizational structure, all resources within staging are under the direct 

control of the operations section chief [Virginia Beach Fire Department (VBFD) 2015]. 

The staging area manager has the following major responsibilities: 

• Establish layout of staging area 

• Post areas for identification and traffic control 

• Provide check-in for incoming resources

• Determine required resource reserve levels from the incident commander or the operations 

section chief

• Contact the operations section chief or incident commander when reserve levels reach 

minimums 

• Maintain and provide status of all resources in staging area to the resource unit

• Respond to the incident commander or operations section chief requests for resources 

• Request logistical support for personnel and/or equipment as needed 

• Maintain staging area in an orderly condition 

• Demobilize or move staging area as required 

• Maintain a unit log (ICS Form 214—Unit Log) [NFPA 2020a]. 

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

Paragraph 5.10.1.8.1 states, “The incident management system shall provide a standard system to 

manage reserves of responders and other resources at or near the scene of the incident.” In addition, 

NFPA 1561, Paragraph 5.10.1.8.2 states, “When emergency activities are being conducted in a 

location where there would be a delay in activating staged resources, the incident commander shall 

establish staging areas close to the area where the need for those resources is anticipated” [NFPA 

2020a]. 

Staging provides a standard method to keep reserves of responders, apparatus, and other resources 

ready for action close to the scene of an incident. Staging also provides a standard method to control, 

record, and account for the arrival of such resources and their assignment to specific activities. When 
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resources are dispatched to assist at working incidents, dispatch should assign them to a designated 

staging or base area, where they can stay ready for assignment when required by the incident 

commander. This process helps the incident commander track the resources that are on the scene and 

know which are available for assignment, where they are located, and where specific units already are 

assigned. 

The incident commander should attempt to keep reserves of responders, equipment, and supplies 

available to rotate assignments with fatigued crews. It is good to anticipate equipment failures and 

have supplies ordered to the scene in time and in sufficient quantities to provide a safe margin for 

unanticipated needs. The ability to provide these reserves is dependent on available resources. Every 

fire department should have plans to maximize its use of available resources and contingency plans to 

obtain resources from other departments that are possibly available [NFPA 2021].

The term Base often is used to refer to a more remote location where standby resources are gathered 

but are not available for immediate action. As needed, resources can move up to a staging location 

where they are ready for immediate action. An example is a high-rise building where apparatus are 

parked at a safe distance from the building and responders and equipment are moved to stand by in 

Staging on a safe floor below the fire level. Base is the location at which primary support activities are 

performed, including all equipment and personnel support operations. It also is designated as the initial 

gathering point for resources not immediately available for assignment. Base most commonly is used 

during incidents involving high-rise structures, hazardous materials, and wildland incidents. The fire 

officer or firefighter managing Base reports to Command unless a Logistics Section is established. The 

term Base is used for its radio designation [VBFD 2015].

It generally is desirable to keep staged resources in locations where they are ready for action within 3

minutes. In some cases, particularly where imminent hazards exist, it is advisable to keep an immediate 

response capability in a state of readiness in a safe location with immediate access to the area [NFPA 

2020a]. 

Recommendation #15: Fire departments should develop and implement a professional development 

plan for firefighters to ensure for career enhancement and maintain knowledge, skills, abilities, and 

competencies for emergency response. 

Discussion: 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 duties 

and responsibilities, the department should ensure the introduction of the necessary knowledge, skills, 

and abilities to members who are new in their position as well as ongoing development of existing 

skills. To build a successful training plan, it is critical to develop the plan in a systematic and 

functional manner. Training occurs in the fire service to improve the skills of firefighters as well as the 

overall response capabilities of the department while meeting national standards. Therefore, it is 

critical to build a structured plan that meets all these criteria [Clark 2017]. 

Each fire department should develop an annual training plan that will be a combination of minimum 

company standards, special operations training, and opportunity training. This process should consist 
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of fire suppression, EMS, hazardous materials, technical rescue, water rescue, and various firefighter 

safety topics. The annual training plan should serve as the training calendar for the given year but is 

also the basis for multi-year planning. Classes should be rotated on a minimum three-year basis to 

ensure a variety of opportunities are offered. Classes such as Instructor I and II, Fire Officer I and II, 

National Fire Academy classes, and others will be offered on a rotating basis. Live fire training 

evolutions should be conducted at least once every year. All training should be delivered in varying 

formats. Classroom presentations, quick drills, practical evolutions, or web-based training should be 

utilized throughout the course of the year [Springfield Fire Department 2014].

When developing a formal training plan, the first step is to evaluate and build upon existing training 

standards, such as NFPA professional qualifications standards. Each fire department is structured 

differently to meet the needs of their community. Therefore, training plans must be designed based on 

services provided by a fire department and the department’s mission statement. NFPA 1500, Standard 

on Fire Department Occupational Safety, Health, and Wellness Program, Chapter 4, “Fire Department 

Administration,” states in paragraph 4.1.2, “The fire department shall prepare and maintain written 

policies and standard operating procedures that document the organization structure, membership, 

roles and responsibilities, expected functions, emergency operations. and training requirements,

including the following: 

• The types of standard evolutions that are expected to be performed and the evolutions that must 

be performed simultaneously or in sequence for different types of situations 

• The minimum number of members who are required to perform each function or evolution and 

the manner in which the function is to be performed in accordance with NFPA 1710 [NFPA 

2020b] or NFPA 1720 [NFPA 2020c]

• The number and types of apparatus and the number of personnel that will be dispatched to 

different types of incidents in accordance with NFPA 1710 [NFPA 2020b] or NFPA 1720

[NFPA 2020c]

• The procedures that will be employed to initiate and manage operations at the scene of an 

emergency incident

• Post-incident control and mitigation of emergency scene contaminants” [NFPA 2021]

These programs should include information to ensure that members are trained prior to performing 

individual duties, as well as ongoing professional development to ensure competency. The training 

plan continues to serve as a comprehensive all-hazards approach that meets or exceeds federal, state, 

and local regulations as well as the needs of fire department personnel. This approach allows the 

department to maintain operational and response capabilities to the customers they serve. The plan is 

designed to be specific yet allows for flexibility in the event of training that is made available or as 

departmental needs dictate. The plan includes a detailed calendar for the year, which allows the 

company officers and command staff to balance other duties and priorities throughout the course of the 

year [Maness 2013]. 

Training programs should include but not be limited to the following: 

• Community risk reduction (fire prevention, public education, investigation, etc.) 

• Safety, health, and wellness 

• Fire suppression 

• Emergency medical services
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• Human resources (leadership, supervision, interpersonal dynamics, equal employment 

opportunity, etc.) 

• Incident management system 

• Hazardous materials

• Technical rescue 

• Information systems and computer technology 

• Position-specific development (fire fighter, company officer, chief officer, telecommunicator, 

investigator, inspector, driver/operator, etc.) [NFPA 2021]. 

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness Program, 

Chapter 5, “Training, Education and Professional Development,” states in paragraph 5.1.9, “As a duty 

function, members shall be responsible to maintain proficiency in their skills and knowledge, and to 

avail themselves of the professional development provided to the members through department 

training and education programs” [NFPA 2021]. 

Finally, the responsibility of the fire service is to save lives, stabilize incidents, and conserve property. 

This is accomplished through effective and structured training prior to an emergency response. A welldeveloped annual training plan will ensure continuity across a fire department and will maintain and 

improve knowledge, skills, and abilities in all members. All members must take it upon themselves to 

continually improve and train new fire service members so the department can respond effectively to 

any emergency incident.

Recommendation #16: States and municipalities should consider adopting and enforcing 

regulations for interventions to reduce or eliminate the spread of fire in renovated multi-family

structures, including automatic sprinkler systems and self-closing doors.

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 

firefighter 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 is one of the greatest hazards that firefighters face in 

today’s combustible environment. This exposure and risk to firefighters can be dramatically reduced 

when fires are controlled or extinguished by automatic sprinkler systems. NFPA statistics show that 

most fires in sprinklered buildings are controlled prior to fire department arrival by the activation of 
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one or two sprinkler heads. The presence of automatic fire sprinklers also reduces the exposure risk to 

firefighters in rescue situations by allowing the safe egress of building occupants before the fire 

department arrives on-scene. Finally, the exposure to hazards such as building collapse and overhaul 

operations are greatly reduced, if not eliminated, when fire development is arrested and controlled.

The Commonwealth of Massachusetts requires the installation of a sprinkler system in renovated 3-

family occupancies. It is unclear when this occupancy was last renovated from 3-family to 4-family 

occupancy and whether the resonation occurred after this code was enacted.

Another important factor is requiring self-closing apartment exit doors to ensure that a fire does not 

spread due to an open apartment door. Closed doors can reduce the flow path of a fire, prevent fire 

spread, and protect other building occupants from smoke and fire. Self-closing doors are an effective 

method for slowing down the spread of a fire providing sometimes critical, life-saving time for fire and 

rescue personnel to do their job and allow individuals to escape the fire or be rescued. It is imperative 

that where such doors are in place or required that they are unobstructed and that the self-closing 

mechanisms are always fully operational. Such self-closing mechanisms should be included as a 

routine inspection item to ensure proper operation of the mechanism. In situations where the 

mechanism is not functioning due to resident action, management should treat this as a violation of the 

lease and take appropriate action on a case-by-case basis. The importance of the proper functioning of 

self-closing doors should be addressed during regular, on-going resident education programs on fire 

safety. 

Finally, emergency egress doors in residential properties should never be locked from the inside 

barring emergency egress. There are some exceptions to this in certain types of facilities, but where

this is necessary there are specific procedures that must be followed in accordance with local/state 

requirements [USDHUD 1999].

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Association of Firefighters. 

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

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2019

Investigator Information

This incident was investigated by Matt Bowyer, General Engineer, Murrey Loflin, Investigator, and 

Jeff Funke, Occupational Health and Safety Specialist with the Fire Fighter Fatality Investigation and 

Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, 

NIOSH located in Morgantown, WV. An expert technical review was provided by Vincent P. Mulray, 

Deputy Chief, Philadelphia Fire Department. A technical review was also provided by the National 

Fire Protection Association, Emergency Response & Responder Safety Division.

Additional Information

National Institute for Standards and Technology (NIST) and Underwriters Laboratories (UL)

These two agencies provide information, including training videos, reviewing the findings from NIST 

and UL research for the development of more effective tactics conducted in cooperation with the Fire 

Department of New York on Governor’s Island in 2012. 

Underwriters Laboratory (UL), Firefighter Safety Research Institute (FSRI) UL FSRI Director Steve 

Kerber, Fire Protection Engineer Dan Madrzykowski and Los Angeles County Fire Department,

Assistant Chief Derek Alkonis team up to present a 7-part video lecture series titled NIST and UL 

Research on Fire Behavior and Fireground Tactics. The presentations were filmed at the 2013 IAFF 

Redmond Symposium and these slides and videos have been integrated into the presentations for a 

better learning experience. Part 4: Case Studies is most relevant to this investigation. 

International Association of Firefighters (IAFF) Fire Ground Survival Program

The purpose of the IAFF Fire Ground Survival Program is to ensure that training for Mayday

prevention and Mayday operations is consistent among all firefighters, company officers, and chief 

officers. Firefighters must receive training to perform potentially life-saving actions if they become 

lost, disoriented, injured, low on air, or trapped. Funded by the IAFF and assisted by a grant from the 

U.S. Department of Homeland Security through the Assistance to Firefighters (FIRE Act) grant 

program, this comprehensive fireground survival training program applies the lessons learned from 

firefighter fatality investigations conducted by NIOSH FFFIPP. It was developed by a committee of 

subject matter experts from IAFF, IAFC, and NIOSH.

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

Safety (2020 edition)

The primary focus of the revision to NFPA 1561 in the 2020 edition, the standard has mostly been 

refined to reflect the latest information and best practices in incident management. New requirements 

for positional best colors have been added to the mandatory section of the standard. This will make 

incident management team members universally identifiable based on the color of vest they don for 
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their assigned role. Language was added to prevent the “incident within an incident” practice of 

managing emergencies or Maydays at large-scale incidents. It is imperative that the incident 

commander stay in control of the entire incident and not become overly committed to the emergency. 

This can be accomplished by assigning a supervisor to the rapid intervention group to the emergency. 

Annex C: Use the Planning “P” When Developing an Initial Incident Action Plan has been completely 

revised to reflect the latest “Planning P” diagram and the best practices for creating an incident action

Plan.

The chapter Command Safety clearly defines the requirements for the incident commander, including 

establishing a fixed Command Post, maintaining personnel accountability, using staff aides, using 

rapid intervention crews, and appointing a safety officer and assistant safety officer(s) as needed. It 

also defines the expectations and authority of the safety officer. Annexes cover topics such as 

functional assignments for high-rise building incidents, development of subordinate officers or 

implementing a more efficient management system, incident management for the fire service on Type 

V or Type IV incidents, and structural firefighting—risk assessment and operational expectation. 

It is possible to purchase NFPA 1561, Standard on Emergency Services Incident Management System 

and Command Safety (2020 edition), from NFPA. 

Disclaimer

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

Occupational Safety and Health, Centers for Disease Control and Prevention. In addition, citations to 

websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or 

their programs or products. Furthermore, NIOSH is not responsible for the content of these websites. 

All web addresses referenced in this document were accessible as of the publication date.
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Appendix One

SCBA Evaluation and Testing Report 

Summary of Personal Protective Equipment Evaluation

Status Investigation Report of Two

Self-Contained Breathing Apparatus

Submitted by the

NIOSH Division of Safety Research

for the Fire Department

NIOSH Task Number 23616

Note: The full report is available at is at:

PPE Case Report TN-23616 Fire Department, Massachusetts – Status Investigation Report (cdc.gov)

Background

As part of the National Institute for Occupational Safety and Health (NIOSH), Fire Fighter Fatality

Investigation and Prevention Program (FFFIPP), the National Personal Protective Technology 

Laboratory (NPPTL) agreed to inspect, evaluate, one self-contained breathing apparatus (SCBA) unit 

identified as Scott Safety Air-Pak Model 75 4.5, 45-minute, 4500 pounds per square inch (psi) units. 

This report provides a summary of NPPTL’s inspection and evaluation methods, and findings for a 

SCBA that was used by the fire department lieutenant during a fatal event. The SCBA was the Scott® 

Safety Air-Pak® Model 4.5, 45-minute, 4500 psi unit. The NIOSH Division of Safety Research, 

Surveillance and Field Investigation Branch, Fire Fighter Fatality Investigation and Prevention 

Program (NIOSH/DSR/SFIB/FFFIPP) investigators and the fire department were advised that NIOSH 

NPPTL would provide a written report of the evaluation and any applicable test results.

NIOSH/DSR/SFIB/FFFIPP investigators submitted fire department SCBA unit to NIOSH NPPTL for 

evaluation and testing. The SCBA unit was delivered via FedEx in a plastic box to Lab H1513 in the 

NIOSH facility in Morgantown, West Virginia on December 18, 2019. 

On December 31, 2019, NPPTL employees Jay Tarley and Angie Andrews inspected the SCBA unit. 

The SCBA unit remained in Lab H1513 throughout the inspection and testing process. The SCBA was 

identified as belonging to the fire department and was visually examined, component by component, in 

the condition received to determine the conformance of the unit to the NIOSH-approved configuration. 

The unit was identified as the Scott® Safety Air-Pak® Model 4.5, 45-minute, 4500 psi unit, with 

NIOSH Approval Number TC-13F-212CBRN.

SCBA Inspection

On December 31, 2019, NPPTL employees Jay Tarley and Angie Andrews inspected the SCBA unit. 

The SCBA unit remained in Lab H1513 throughout the inspection and testing process. The SCBA was 

identified as belonging to the fire department and was visually examined, component by component, in 

the condition received to determine the conformance of the unit to the NIOSH-approved configuration. 

The unit was identified as the Scott® Safety Air-Pak® Model 4.5, 45-minute, 4500 psi unit, with 

NIOSH Approval Number TC-13F-212CBRN.
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SCBA Testing

The SCBA unit inspected and evaluated by NPPTL was a Scott® Safety Air-Pak® Model 4.5, 45-

minute, 4500 psi unit with NIOSH Approval Number TC-13F-212CBRN. The firefighter was wearing 

the unit when the event occurred. A corresponding facepiece was provided with the unit. The provided 

cylinder was not suitable for testing: therefore, we used one of NPPTL’s cylinders for testing. 

Overall, the SCBA was in fair condition. The NFPA approval label was present and readable. The 

PASS, HUD, and Vibralert all functioned. The SCBA unit leaked air from the high-pressure hose until 

approximately 3500 pounds per square in gauge (psig) during the NIOSH Positive Pressure Test and 

still met the test requirements, as the SCBA maintained a positive pressure for the 45-minute minimum 

duration of the test. The unit passed all the other NIOSH tests, as well as met the requirements for the 

NFPA “Airflow Performance” test. The information obtained during this investigation does not 

suggest that the components tested contributed to the fatality. The SCBA was returned to the shipping 

container to be shipped back to the fire department.

Summary and Conclusions

No evidence was identified to suggest that the SCBA unit inspected and components evaluated 

contributed to the fire fighter fatality. NIOSH determined that there was no need for corrective action 

with regards to the approval holder or end user of the SCBA manufactured under the approval number 

granted to this product. 

Actions to be taken by the fire department with SCBAs involved in an incident:

• Any SCBA unit involved in an incident may not be placed back in service until the SCBA has 

been repaired, tested, cleaned, and any damaged components replaced and inspected by a 

qualified service technician, including such testing and other maintenance activities as 

prescribed by the schedule from the SCBA manufacturer.

• All SCBA units, even those not involved in an incident, must undergo a flow test on at least an 

annual basis.

• Sign up for NPPTL’s Listserv to receive email notifications relevant to PPE.
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Appendix Two

Incident Commander’s Tactical Worksheet for a Mayday

Diagram 14. Mayday Tactical Worksheet 

(Diagram courtesy of the Los Angeles Fire Department)