REPORT 2019-03 • November 1, 2023

Brick Gable End Collapses at a Residential Fire Killing a Fire 

Captain and Seriously Injuring Three Other Firefighters – Illinois

Executive Summary 

On March 5, 2019, a brick gable 

end (rafter) collapsed during a 

residential structure fire, killing a 

37-year-old career fire captain. 

Three other firefighters were 

seriously injured during the 

collapse. At 1615 hours, the 

county 9-1-1 received a telephone 

call from the homeowner stating 

their home was on fire. Engine 

2311 (E2311) and Engine 2312 

(E2312) were dispatched from 

county fire protection district 

(FPD) 23. The fire chief from the 

volunteer FPD 23 drove E2311 

to the incident. While enroute 

the fire chief requested

automatic aid from two

independently operated county 

fire departments: county FPD 16 (volunteer) and fire department (FD) 22 (career). 

Firefighters flowing water through a window on Side Alpha. 

The roof had partially collapsed, but no collapse zone had 

been established. (Photo courtesy of the fire department.)

At 1627 hours, E2311 arrived on scene. Flames and smoke were venting through the roof on Side 

Bravo, with a partial roof collapse. Both the occupants were out of the house upon arrival of the fire 

department, but multiple caged animals remained in the Side Alpha/Bravo corner of the home. The fire 

chief assumed Command as the incident commander (IC) and declared a defensive strategy, although 

this was not heard or received by dispatch or responding firefighters. Firefighters from FPD 23 pulled 

and began flowing water from a 13⁄4-inch handline from E2311 to the Alpha/Bravo corner (Photo 

above). E2312 laid a 5-inch supply line from the nearest hydrant to E2311. The captain from E2312 

conducted an incomplete (2700) size-up in a counterclockwise direction (Side Alpha, Side Delta Side 

Charlie), but findings from this incomplete walk-around were not reported to the IC. 

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Report # F2019-03 

Brick Gable End Collapses at Residential Structure Fire Killing a Fire 

Captain and Injuring Three Fire Fighters – Illinois

At 1632 hours, the IC requested dispatch to send county FPD 14 to the scene. At 1633 hours, 

firefighters from E2311 initiated an interior attack through the front door on Side Alpha, but excessive 

storage in the foyer limited advancement to only 5 to10 feet. They directed water into the Side Bravo 

first floor and Side Charlie ceiling and attic space. 

County FPD 22 (E2211, fire chief via POV) arrived on-scene and were assigned to the Sides Bravo 

and Charlie with the fire chief from FPD 22 assigned as the Side Bravo/Charlie sector chief. After 

pulling a 21⁄2-inch hoseline and a 13⁄4-inch handline from E2311 and flowing water, E2211 radioed 

E2311 they had no water pressure. The IC, and the lieutenant operating E2311, began to investigate the 

cause of the low water pressure. 

At 1647 hours Engine 1412 (E1412) from county FPD 14 arrived on-scene and initially staged on Side 

Alpha. After a partial walk-around, the captain of E1412 discussed the possibility of a below grade 

Side Bravo walk out basement fire with the IC and the Side Bravo/Charlie sector chief. They discussed 

accessing the basement by cutting open the lower-level garage door with a K-12 saw (a saw fire 

departments frequently use to cut openings into a variety of materials). At 1656 hours, E1412 was at

the lower-level garage doors with a K-12 saw. 

At about 1655 hours, the assistant chief from FPD 16 became concerned that the entire roof could 

collapse. He told FD 22’s assistant chief to “watch those guys’ working on Side Bravo. The assistant 

chief from FD 22 then became concerned about the stability of the Side Bravo bricked gable rafter 

which extended to the roof ridge. The roof supporting the gable had burned away. These concerns were 

voiced to the Side Bravo/Charlie sector chief who felt the brick wall supporting the gable looked stable 

with no bulging, bowing, cracking, or spooling. Therefore, no collapse zone was established. NIOSH 

received conflicting information about whether these collapse concerns were voiced to the IC.

At 1656 hours, the IC radioed that the basement was about to be opened. It took a few minutes for the 

five firefighters operating and assisting with the K-12 saw to open the lower-level garage door. At 

1703 hours, the roof’s triangular brick gable rafter suddenly “tipped over” falling as a single sheet onto 

the driveway; a perimeter collapse. The gable fell approximately 21 feet before striking four 

firefighters from E1412 and E2212 working to open the garage door on Side Bravo. The fifth 

firefighter working on Side Bravo was not hit or injured. 

A Mayday was called. On-scene firefighters rushed to assist as the IC radioed county 9-1-1 to send 

more ambulances to the scene. The captain from E1412 was unconscious and not breathing. He was 

brought out of the collapse zone where cardiopulmonary resuscitation (CPR) was initiated. At 1718 

hours, the captain was transported to a local hospital with a police escort. At 1750 hours, the captain 

was pronounced deceased in the emergency department (ED) by the attending physician due to 

thoracic and cervicospinal trauma. On-scene paramedics stabilized the three remaining seriously 

injured firefighters who were subsequently transported to the ED. One was hospitalized, two were 

treated and released; these three firefighters survived. 
Report # F2019-03 

Brick Gable End Collapses at Residential Structure Fire Killing a Fire 

Captain and Injuring Three Fire Fighters – Illinois

Contributing Factors 

• Lack of a collapse zone

• Lack of situational awareness 

• Incomplete scene size-up 

• Incomplete risk assessment and incident action plan

• Incomplete duties of command safety

• Task saturation of the IC

• Lack of an IC aide 

• Lack of an incident safety officer

• Inadequate water supply

• Inconsistent live fire training among volunteer firefighters 

• Lack of a personnel accountability system

Key Recommendations 

• Fire departments should ensure the IC establish collapse zones including exclusion zones or 

no-entry zones at defensive fires as needed due to dangerous or hazardous conditions

• Fire departments should ensure firefighters are trained in situational awareness, personal 

safety, and accountability

• Fire departments should ensure the first arriving officer conducts a detailed scene size-up 

• During initial fire ground operations, fire departments should ensure the IC conducts a risk 

assessment, develops a risk management plan, and incorporates these into an incident action 

plan (IAP). The IAP needs to be clearly communicated to responding personnel and, for more 

extensive incidents, a tactical worksheet may be required

• Fire departments should ensure their IC incorporates the principles of command safety into the 

incident management system

• Fire departments should develop a process to prevent task saturation of ICs during complex or 

multi-alarm incidents

• Fire departments should make available an IC aide during working structure fires

• Fire departments should ensure that an incident safety officer, independent of the IC, is 

appointed at working structure fires

• Fire departments should ensure that an adequate sustainable water supply is established and 

maintained. Firefighters should have periodic training on hydrant operations

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Report # F2019-03 

Brick Gable End Collapses at Residential Structure Fire Killing a Fire 

Captain and Injuring Three Fire Fighters – Illinois

• Fire departments should ensure that all members engaged in emergency operations receive

annual training and evaluation on fireground operations including live fire training to improve

proficiency during fireground operations

• Fire departments should utilize a functional personnel accountability system, requiring a

check-in and check-out procedure with the designated accountability officer or IC.

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.

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

Page iv 
REPORT 2019-03 • November 1, 2023

Introduction 

On March 5, 2019, the perimeter collapse of a bricked gable rafter during a residential structure fire

killed a 37-year-old career fire captain. The collapse also seriously injured three other firefighters. On 

March 6, 2019, the United States Fire Administration notified the National Institute for Occupational 

Safety and Health (NIOSH) of this incident. NIOSH investigators with the Fire Fighter Fatality 

Investigation and Prevention Program (FFFIPP) contacted the fire department involved in this incident 

to arrange an investigation. On May 15, 2019, two investigators from the NIOSH FFFIPP and one 

investigator from the NIOSH Fatality Assessment and Control Evaluation program traveled to Illinois 

to initiate the investigation. During this investigation, the NIOSH representatives met with the fire 

chief of the affected FPD and fire chiefs and responding firefighters from the mutual aid departments. 

The NIOSH investigators also met with representatives of the International Association of Fire 

Fighters (IAFF) local, an investigator from the Illinois Office of the State Fire Marshal (OSFM), and 

members of the private ambulance company. The NIOSH investigators visited County 9-1-1 dispatch 

and the incident site. The NIOSH investigators conducted interviews with the officers and firefighters 

who responded to the fire scene from various FD and FPD. The NIOSH investigators inspected and 

photographed the victim’s personal protective clothing and self-contained breathing apparatus. The 

NIOSH investigators reviewed training records and standard operating procedures from the deceased 

firefighter’s department. NIOSH contacted the county medical examiner’s office to obtain an official 

cause of death. NIOSH also reviewed the Illinois Department Labor (OSHA) report. 

Fire Department

The county operates 55 different FD and/or FPD. One of these districts is county FPD 14 which 

operates 2 fire stations with 31 firefighters (18 career and 13 paid on-call) serving a city of 18,000 

citizens covering 36 square miles. The 18 career personnel are comprised of the fire chief, three 

assistant chiefs, three captains, three lieutenants, and eight firefighters. The fire chief reports to the 

elected board of trustees and the appointed fire commission board. The FPD operates three 24-hour 

shifts (0700 hours to 0700 hour). Firefighters work a 24-hour shift followed by 48-hours off. Minimum 

staffing is 2 firefighters per station per shift. Paid on-call firefighters supplement as needed. 

In 2018, the department responded to 1,973 emergency incidents. Approximately 85% of the incidents 

were emergency medical service calls. In addition, the district conducts over 300 fire inspections 

annually. All 18 career firefighters are certified by the Illinois Department of Public Health at the level 

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Report # F2019-03

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of emergency medical technician (EMT)-Basic and three members are advanced life support (ALS) 

providers (paramedics). Transport capabilities are provided by two ambulance providers, one private, 

and one hospital based. 

The FPD operates the following apparatus:

• Station 1

Command Vehicle (2009 Ford Explorer)

Rescue Engine (2009 Spartan/Toyne)

Tender (2005 Freightliner/Midwest Fire)

EMS Unit (2009 Ford F-150) 

Brush Unit (2011 Dodge 4500)

• Station 2

Reserve Engine (1998 KME)

Rescue Engine (1998 KME)

EMS Unit (1996 Ford F-350) 

Brush Unit (2012 Dodge 4500)

Air and Technical Rescue Trailer

There is no specific truck staffing, rather station personnel respond with appropriate apparatus based 

on dispatch information, staffing, and standard operating procedures. Table 1 lists the apparatus 

assignment for initial alarms.

Table 1: Apparatus Assignment for Initial Alarms

Structure Fire – no hydrants 2 pumpers, 1 tender

Structure Fire – hydrants 2 pumpers

Brush Fire 1st due brush*

Cardiac Arrest 1st due rescue, 2nd due apparatus

Medical 1st due rescue

Lift Assist 1st due rescue

Vehicle Accident - with injuries 2 pumpers

Vehicle Accident – no injuries 1st due pumper*

Technical Rescue 1st due pumper*

Lines Down 1st due pumper*

Alarm Sounding 1st due pumper*

Investigation 1st due pumper*

Smell of Smoke in Building 1st due pumper*

Smell of Gas 1st due pumper*

Carbon Monoxide 1st due rescue

*Shift commander or the initial IC has the discretion to

modify assignments as necessary.

Career Firefighter Hiring Process 
Report # F2019-03

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Report # F2019-03 

Interested candidates must be at least 21 years of age, have a high school diploma or general education 

diploma (GED), a valid Illinois driver’s license, pass a written test, and pass the oral interview 

conducted by the fire commissioners and the fire chief. A candidate must then pass the candidate 

physical ability test. In addition, the Illinois OSFM requires a 35-foot ladder climb. A preliminary 

candidate list is developed giving candidates the opportunity to claim preference points [e.g., veteran 

status, EMT-paramedic]. The district’s board of fire commissioners finalizes the eligibility list which 

remains in effect for two years. 

When a position(s) becomes available, the fire chief offers eligible candidates a condition of 

employment contingent on the candidate passing a criminal background check, passing a complete 

medical evaluation, and producing a valid Illinois EMT-Basic license. 

A recruit must then successfully complete the 7-week “Basic Firefighter Academy” training at the state 

fire academy. Upon completion of this training, recruits are assigned to a company for the remainder of 

their 12-month probationary period. Probationary firefighters are required to establish primary 

residency in the district within 12 months. During the probationary period, the recruit must participate 

in weekly in-house training. In-house examinations, both written and practical with minimum passing 

scores of 75-80% are administered at months 3, 4, 8, and 11 to ensure the probationary firefighter 

grasps and understands the presented material. At the end of the 12-month probationary period, the 

firefighter must become certified in Hazardous Materials Operations, Basic Operations Firefighter, and 

state licensed EMT-Basic, EMT-Paramedic, or pre-hospital registered nurse. 

Paid On-Call Firefighter Hiring Process

Paid on-call applicants must be at least 19 years of age, have a high school diploma or GED, a valid 

Illinois driver’s license, pass a background check, and be in excellent physical condition. Paid on-call 

firefighter applications are accepted year-round and applicants are encouraged to attend an orientation 

session to learn more about the position. Once hired as a probationary member, over 20 probationary 

training sessions/classes are required, each session/class lasting from three to eight hours. Upon 

completion of an initial series of training sessions, the probationary paid on-call firefighter can respond 

with career members. The probationary position requires a minimum of 30 training hours per month, 

or 90 hours per quarter. After completing the probationary period, training continues for the paid-on 

call firefighter. 

Mutual Aid Box Alarm System (MABAS) 

County FPD 14 is a member of an organization known as MABAS. MABAS is a mutual aid system 

designated to assist with mutual aid response of fire, emergency medical services (EMS), specialized 

response teams, and station coverage during a state declared disaster or when an incident overwhelms 

the available resources of a participating community. This allows a fire chief and an IC to focus on the 

operational needs during a significant incident. The IC knows that a predetermined set of resources is 

responding upon issuance of a single order by command. 

Established in the1960s and expanded in 2001, MABAS is a partnership with the Illinois Emergency 

Management Agency, the Cook County Department of Homeland Security and Emergency 
Report # F2019-03

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Report # F2019-03 

Management, the Illinois OSFM, the Illinois Department of Public Health – EMS Division, and the 

Illinois Fire Chiefs Association. Members must sign a contract to ensure uniform standards of 

operation, incident management procedures, minimal staffing requirements, fireground safety, and onscene operations. As of 2019, MABAS is present in all 102 Illinois counties and includes 

approximately 1,175 of Illinois’s 1,246 (94%) fire departments organized within 69 divisions. 

County FPD 14 belongs to MABAS Division 35. In addition to MABAS, FPD 14 has a written 

mutual-aid agreement with all FD and FPD in the county, and two other FPD in another county. The 

district also has an agreement with county FD 12 for structure fires and incidents involving other highrisk occupancies (e.g., schools, churches, hospitals). 

Training and Experience 

The Illinois OSFM does not mandate minimum training requirements for firefighters. However, the 

Office does maintain and oversee a Division of Personnel Standards and Education (DPSE) which 

promotes, encourages, and assists local governments to improve the levels of education and training 

standards for local firefighters. While this program is strictly voluntary, the OSFM and the DPSE

highly encourage local governments to adopt and complete firefighter certification programs. This 

encouragement includes a reimbursement program for firefighter training costs. Additional information 

about the DPSE’s programs can be found at the Division’s website, and the General Assembly's 

Illinois Administrative Code which includes training facilities, examinations and certifications, and a 

current list of certifications. 

Maintaining Training Records 

The student is responsible for maintaining their training log and documenting any training they attend. 

It is the responsibility of the authority having jurisdiction to validate the training and maintain all 

training records.

Illinois Department of Labor, Division of Occupational Safety and Health (IL-OSHA) 

Being a State Plan State, Illinois fire departments must comply with various occupational safety and 

health standards such as 1910.120 Hazardous Waste Operations and Emergency Response, 1910.132 

Personal Protective Equipment Standard, 1910.134 Respiratory Protection, 1910.156 Fire Brigades, 

1910.157 Portable Extinguishers, and the 1910.1030 Bloodborne Pathogens. 

County FPD 14 

NIOSH obtained the training records from the five members who responded to the fireground from the 

department suffering the fatality (FPD 14). All five completed annual burn (live fire) tower training in 

May 2018. From 1/1/2000 to 3/5/2019 these five members completed: 

Captain: 2,959 hours of training

Lieutenant: 2,813 hours of training

 Firefighter 1: 2,750 hours of training 

 Firefighter 2: 2,426 hours of training

 Firefighter 3: 600 hours of training (employed by FPD 14 since 2017). 
Report # F2019-03

Report # F2019-03 

Equipment and Personnel

The county dispatch center (county 9-1-1) is located at the county sheriff’s office. County 9-1-1 

dispatches for fire and law enforcement. Fire is dispatched on VHF frequencies. There are 14 public 

safety answering points (PSAP) throughout the county that answer 9-1-1 calls. The telecommunicators 

are civilian employees of the sheriff’s office. Telecommunicators work an 8-hour shift with a 

minimum staffing of two dispatchers. In 2018, the sheriff’s office answered 26,500 9-1-1 calls out of 

the 120,000 9-1-1 calls received in the county. Each PSAP can assign MABAS Red, White, and Blue 

tactical channels, all of which are non-repeater channels (operate on line-of-sight). 

 

The initial response to the structure fire on March 5 was: 

•

County FPD 23 

Engine 2311: 2 members (1 fire chief and 1 firefighter) 

• Engine 2312: 1 member: (1 captain) 

• Privately Owned Vehicles (POVs): 9 members (1 lieutenant, 3 engineers, 5 firefighters) 

County FPD 16 

• Engine 1610: 2 members (1 assistant chief and 1 captain) 

• POVs: 6 personnel (1 fire chief, 1 assistant chief, 2 captains, and 2 firefighters) 

County FD 22 

• Engine 2211: 2 members (1 captain and 1 firefighter) 

• POVs: 2 members (1 fire chief and 1 assistant chief) 

Medic 74: 2 members (1 EMT-paramedic, 1 EMT-Basic) 

Three additional fire departments were requested and dispatched to the scene:

County FPD 14 

• Engine 1412: 3 member (1 captain, 2 firefighters) 

• Tender 1460: 2 members (1 lieutenant, 1 firefighter) 

County FPD 48 

• Tender 4861: 2 members (1 captain and 1 firefighter) 

• Tender 4862: 2 members (1 deputy chief and 1 captain) 

• Chief’s car: 1 member (1 chief) 

• POVs: 1 member (1 lieutenant) 

County FD 37 

• Tender 1535: 2 members (2 firefighters) 

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Report # F2019-03

Report # F2019-03 

Structure

The residential structure was single-story ranch-style brick home of approximately 1,536 square feet 

located on 11.2 acres. The structure was built in 1970. The structure consisted of a first floor with a 

kitchen, family room, two bedrooms, one and a half baths, closets, and a large work/living area (See 

Diagram 1). The Side Alpha/Bravo corner contained an area with animal crates and cages.

The structure was wood construction with brick veneer. The roof consisted of wood truss covered with 

plywood with asphalt shingles. The gable roof ran east-to-west with the brick running up to the ridge 

on gabled end rafters on both Sides Bravo (east) and Delta (west). 

On Side Bravo (east) there was a below grade unfinished partial basement utilized as a two-car garage. 

The walkout basement/garage did not run the length of the house. An exterior set of steps led from 

Side Charlie down to the entrance of the basement/garage on the Side Charlie/Bravo corner. The 

entrance to the garage consisted of a man door and two single garage doors. The entrance was flanged 

by two retaining walls each being approximately 6 feet in height and about 15 feet long on the Side 

Charlie/Bravo corner and the Side Bravo/Alpha corner. Sitting in the driveway, just outside the garage 

doors, were a parked car, a large acetylene tank, a large air conditioner, equipment for repairing heat 

pumps, and many other items, both large and small, cluttering the area.

Side Alpha (north) consisted of a large front yard that ran about 180 feet from a frontage (feeder) road 

to the front door. A covered porch sheltered the front door and the middle two-thirds of the home. Side 

Charlie (south) included a back door with a few small steps leading down to the backyard where a 

horse trailer was parked. The brick siding and gable on Side Delta (east) did not have any doors or 

windows. The Side Delta yard contained a large chicken coop (Diagram 1). The nearest fire hydrant 

was located approximately 250 feet to the north-east.

 

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Report # F2019-03

Report # F2019-03 

Diagram 1. A diagram of the fire building’s first floor and its position on the property. 

Dimensions are approximate. The home’s square footage was 1,526 feet. 
Report # F2019-03

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Report # F2019-03 

Timeline

The following timeline is a summary of events that occurred as the incident evolved. Not all incident 

events are included in this timeline. The times are approximate and obtained by reviewing the dispatch 

records, audio recordings, witness statements, and other available information. All times are 

approximate and rounded to the closest minute. The timeline is not intended, nor should it be used, as a 

formal record of events.

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Tuesday, March 5, 2019

Homeowner returns home and finds fire

in the kitchen area and calls 9-1-1. 

1615 

Hours 

County FPD 23 dispatched to a report 

of a structure fire. 

1616 

Hours

County 9-1-1 dispatched a deputy 

sheriff to ensure the homeowners 

remained outside.

1618 

Hours

E2311 (PAR 2) enroute. 

E2312 (PAR 1) enroute.

E2311 requested county FPD 16, and 

county FD 22 be dispatched. 

1619 

Hours

County FPD 16 dispatched. 

Medic 74 self-dispatched to structure 

fire.

1620 

Hours

The county 9-1-1 notified county FD 

22’s public safety answering point 

(PSAP) to dispatch county FD 22 to the 

structure fire.

1621 

Hours 

Dispatch requested an ambulance to the 

address.

1622 

Hours

Medic 74 arrived on-scene and 

reported heavy smoke and fire

showing from the structure. 
Report # F2019-03

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Report # F2019-03 

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

1600 (PAR 1–fire chief) enroute via 

privately owned vehicle (POV). 

E2211 (PAR 2) enroute. 

FD 22’s fire chief and assistant chief 

enroute by POV.

1623 

Hours

A county deputy sheriff on scene 

advised the county 9-1-1 that both 

homeowners were out of the house.

1624 

Hours

Medic 74 advised county 9-1-1 that 

fire was coming out of the east side of 

the house (Side Bravo).

E2311 arrived on-scene. E2311 advised 

county 9-1-1 they had a “single-story

wood frame structure with heavy fire 

involvement.” 

1627 

Hours

The fire chief from FPD 23 assumed 

role as the Incident Commander (IC) 

and called for an initial defensive 

strategy. 

No one reported hearing the IC state 

he had assumed Command or a 

defensive strategy on the radio. 

IC was also performing engineer 

duties on E2311. 

E1610 (PAR 2) enroute. 

1603 (PAR 1) responded via POV.

1628 

Hours 

E2311’s probationary firefighter 

stretched 13⁄4-inch hoseline from 

E2311 to Side Alpha.

Flames and smoke were emitting 

from Side Bravo roof with partial roof 

collapse.

E2312 arrived on-scene as well as 2 

firefighters from FPD 23 in their POVs.

1600 (chief) arrived by POV.

1629 

Hours

Two firefighters from FPD 23 flowed

water from the 13⁄4-inch hoseline from

E2311 into the Side Alpha picture 

window. 

1600 (chief) assigned to Side Alpha. 

As FPD 23 firefighters arrived in their 

POVs. They were told report to Side 

Alpha. 
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Report # F2019-03 

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

1629-

1631 

Hours

E2312 laid a 5-inch supply to E2311. 

The hose lay was approximately 250 

feet.

A firefighter/EMT from Medic 74 

made the hydrant connection and 

charged the hydrant. 

Medic 74 was unaware that the 

hydrant was NOT completely open.

IC requested that county FPD 14 

respond. 

County 9-1-1 dispatched county FPD 

14 to the structure fire.

1632 

Hours

On Side Alpha, firefighters from FPD 

23 moved from the picture window to 

the front door with the 13⁄4-inch 

hoseline. 

The captain from E2312 conducted a 

2700 incomplete walk-around of Sides 

Alpha, Delta, and Charlie.

The IC was not informed about the 

finding of this walk-around size-up. 

FD 22’s fire chief arrives and was

assigned Side Bravo/Charlie sector 

chief.

E1610 (PAR 2) arrived. 

E2211 (PAR 2) arrived. 

1633 

Hours

Firefighters from FPD 23 initiated an 

interior attack through the front door 

but could only advance 5-10 feet due 

to excessive storage in the foyer. A 

water stream was directed to Side 

Bravo and the Side Alpha/Bravo 

corner.
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

E1412 (PAR 3) enroute.

1634 

Hours

1600 (chief) advised IC that there was 

ammunition stored in the foyer area of 

the home.

1600 (chief) conducted a 2700 

incomplete walk- around size-up. 

Findings from the walk-around were 

not reported to the IC. 

E2211 was told to report to their chief 

who was the Side Bravo/Charlie 

sector chief. E2212 positioned a 21⁄2-

inch hoseline from E2311 to the Side 

Bravo/Charlie corner and began to 

flow water. 

E1610 could not find the IC for an 

assignment. FPD 23’s captain 

assigned E1610 to Side Alpha to 

assist FPD 23’s crew.

Lieutenant from FPD 23 arrived by 

POV and took over E2311 pump 

operations. 

1635 

Hours

FPD 23 lieutenant noted weak 

pressure on the intake gage and 

questioned whether the hydrant was 

completely open. The lieutenant 

asked an engineer to check the 

hydrant. 

1604 (PAR 1) enroute. 1636 

Hours

E2211 notified IC regarding low 

water pressure in the 21⁄2-inch line. 

E2211 shut down the 21⁄2-inch line 

and pulled a 13⁄4-inch from E2311. 

Water pressure fell again.
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

The IC moved fireground 

communications to MABAS Red 

tactical channel. 

The MABAS Red channel is a nonrepeater channel, that transmits and 

receives only within a limited area.

1637 

Hours

Front door attack team (FPD 23) 

advised IC regarding low water 

pressure in their 13⁄4-inch line. IC 

became involved in addressing the 

water supply issue on E2311. 

The County 911 advised all members 

operating at the structure fire to switch 

to MABAS Red tactical channel.

1638 

Hours

The lieutenant on E2311 ran an 

additional 3-inch water line from 

E2312 to 2311.

E1412 switched to MABAS Red 

channel

1640 

Hours

Someone transmitted on the main 

dispatch channel that the occupancy 

was a hoarder house. 

FPD 16 firefighters arrived in their 

POVs and were told to report to their 

chief on Side Alpha.

FDP 16’s chief assigned district 16’s

assistant chief and captain to help FD 

22 on Side Bravo/Charlie. 

The IC requested a tender response due 

to water supply issues. 

County 911 had difficulty with this 

request due to MABAS Box Alarm 

assignment being incomplete.

1643 

Hours

Front door attack team (FPD 23) 

become low on air. They left the

structure and stage at E2311. They 

were replaced by FPD 16’s

firefighters. 

Engine 1412 arrived. 1647 

Hours

E1412 captain checked in with IC. 

E1412 was given an initial 

assignment on Side Alpha.

E1412 captain conducted brief sizeup. 
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Report # F2019-03 

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

IC directed 2 1⁄2-hoseline from Side 

Bravo/Charlie corner to basement door.

1650 

to 

1654 

Hours

E1412 captain, Side Bravo/Charlie 

sector chief, and IC discussed

possibility of this being a basement 

fire on Side Bravo.

Decision was made to open basement 

garage door with a K-12 saw to 

potentially put water on seat of the 

fire. 

K-saw retrieved from E1412.

911 advised IC that they were 35 

minutes into the incident and requested 

a status. The IC advised that they were 

still containing the fire.

1655 

Hours

Firefighters kicked open Side Bravo 

lower-level man door. Some lazy grey 

smoke escaped with minimal heat. A 

thermal imaging camera (TIC) 

showed a slight increase in 

temperature. 

Firefighters did not enter. They 

flowed water through the man door, 

but large amounts of clutter blocked

water streams.
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

The IC advised the first-floor attack 

teams that the basement was about to 

be opened.

1656 

Hours

FPD 16’s assistant chief was concerned 

that the entire roof could collapse. He 

told FD 22’s assistant chief to “watch 

those guys’ working on Side Bravo. 

FD 22’s assistant chief was concerned 

about the stability of the Side Bravo 

bricked gable rafter and notified his chief 

who is the Side Bravo/Charlie sector 

chief.

The Side Bravo/Charlie sector chief felt 

the brick wall supporting the gable 

looked stable with no bulging, bowing, 

cracking, or spooling. Therefore, no 

collapse zone was established. 

NIOSH received conflicting information

about whether the collapse concerns

were voiced to the IC.

1658 

Hours

Firefighters from FPD 14 and FD 22 

were positioned with hoses in front of 

the garage door. The E1412 captain 

utilized a TIC to direct water streams. 

E1412 opened the garage door with 

K-12 saw.

IC requested the power company 

respond to the scene to shutoff gas and 

disconnect electricity. 

1659 

Hours

Power line entering the home on the 

Side Alpha/Bravo corner, fell across 

the driveway. 

IC assigned firefighters from FPD 23 

to safeguard the area.

IC to County 9-1-1, “We’ll need more 

ambulances at the scene, building 

collapse.” 

1703 

Hours

Approximate time of Side Bravo 

brick gable end collapse. 
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

County 9-1-1 dispatched four 

ambulances to the structure fire.

1704 

Hours

Rescue efforts initiated. Four 

firefighters were pulled out of the 

collapse zone (E1412’s captain and 

firefighter, E2211’s captain and 

firefighter). 

County 9-1-1 advised all county fire 

departments that the dispatch channel 

was “emergency traffic only.” 

1705 

Hours

CPR started on E1412’s captain. 

Two air ambulances dispatched to the 

structure fire. 

1708 

Hours

1709 

Hours

IC informed on-scene firefighters 

about downed electrical line and to 

use caution.

County 9-1-1 requested a one-hour 

incident status.

IC: “We have building collapse with 

multiple injured firefighters.” 

County 9-1-1 acknowledged and requested

a personnel accountability report. 

IC stated all firefighters accounted for at 

this time.

1714 

Hours

Medic 74 was enroute to the hospital 

with the captain of E1412. CPR was in 

progress. 

1718 

Hours

County FPD 48 assumed IC duties. 

Power company on-scene. 1724 

Hours

Medic 74 arrived at the hospital. 1728 

Hours
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

1732 

Hours

Power company cut power to house. 

The IC requested County 9-1-1 to 

contact the OSFM.

1738 

Hours

Air ambulance departed the scene 

enroute to a trauma center with a 

firefighter from E1412. 

 1745 

Hours

The attending physician at the hospital 

emergency room pronounced the 

captain of E1412 deceased.

1750 

Hours 

Two firefighters from E2212 

transported to the hospital. 

The IC (fire chief from FPD 23) 

transported for chest pains.

1758 

Hours

The deputy chief from FPD 48 

assumed Command as the IC.

A fire marshal from the IL OSFM 

arrived on-scene.

1853 

Hours

Defensive fireground operations were

re-started. Cellar nozzles used to 

control and knockdown the fire.

2028 

Hours

Approximate time the fire was 

declared under control. 

IC advised County 9-1-1 that the fire 

was out. 

2300 

Hours
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Personal Protective Equipment 

At the time of the collapse, all firefighters were wearing full turnout gear and self-contained breathing 

apparatus (SCBA). NIOSH investigators inspected the SCBA worn by the captain and the injured 

firefighter from E1412. The turnout gear was not inspected. NIOSH investigators determined the 

turnout gear and SCBA were not a contributing factor in the fatality and injuries at this incident. 

Weather Conditions 

On March 5, 2019, at 1533 hours, the temperature was 21 degrees Fahrenheit (0F), the relative 

humidity was 55%, and the wind was from the west/north-west at 12 miles per hour. There were 

scattered clouds with 10 miles of visibility and no precipitation [Weather Underground, 2019]. 

Investigation

At approximately 1445 hours on March 5, 2019, the homeowners left their home to run some errands. 

They returned approximately an hour and a half later, finding a significant portion of their home on 

fire. Using a cellphone, they immediately called 9-1-1 (1615 hours), but the county telecommunicator 

couldn’t understand the caller’s panicked speech and directed a county deputy sheriff to a nearby 

address. Less than a minute later, the homeowners called 9-1-1 again, and relayed that smoke and fire 

was coming from their home and gave their address. The caller confirmed that the residents were out 

of the house. The dispatch mapping system could not locate the exact location of the address, and the 

street was the dividing line between two separate FPDs. The telecommunicator dispatched county FPD 

23 as first due, rather than the actual first due of county FPD 16. 
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Photo 1. Firefighters from county 

FPD 23 operating a hoseline into the 

picture window near Side Alpha and 

near the Side Alpha/Bravo corner. 

Time is approximately 1630 hours. 

(Photo courtesy of the fire department.) 

Two engines from district 23 responded at 1619 hours: 

E2311 (PAR 2 – chief and probationary firefighter) and 

E2312 (PAR 1 - captain). While E2311 was enroute, the 

fire chief requested county FPD 16 (volunteer), and FD 

22 (career) respond to the structure fire. In addition to 

sending these units, an ambulance was dispatched to the 

address. Medic 74, who happened to be in the area, selfdispatched. Arriving at 1622 hours, Medic 74 reported 

heavy smoke and fire. The county deputy sheriff arrived 

at the same time and reported the homeowners were out 

of the home at 1624 hours. 

At 1627 hours, E2311 arrived on-scene and parked in the 

driveway close to the Slide Alpha/Bravo corner. The fire 

chief reported a “single story, wood frame structure with 

heavy fire involvement.” The fire chief assumed 

Command as the IC and declared a defensive strategy. 

Neither dispatch nor the responding firefighters received 

this message over the radio. E2311’s probationary 

firefighter pulled a 13⁄4-inch hoseline from E2311 to Side 

Alpha of the structure. Two firefighters from county 

FPD 23 arrived in their personally owned vehicles 

(POV). Both firefighters put on their turnout gear and 

went to E2311 to don their SCBA. They proceeded to 

Side Alpha and operated the 13⁄4” hoseline flowing water 

into the Side Alpha picture window (Photo 1). The fire 

had caused a partial collapse of the roof over the kitchen 

(Side Bravo) and the fire was spreading toward Side 

Charlie and Delta. The homeowners were very 

concerned about eight caged and crated dogs inside the 

Side Alpha/Side Bravo corner. 

At approximately 1629 hours, the captain driving E2312 arrived on-scene followed by the chief from 

county FPD 16 arriving by POV. The captain laid a 5-inch supply line from the nearest hydrant to 

E2311, which was approximately a 250-foot lay. The firefighter/EMT from Medic 74 made the 

hydrant connection and charged the hydrant. During the NIOSH interviews, the firefighter/EMT from 

Medic 74 stated ice might have been in the barrel. The firefighter/EMT from Medic 74 was unaware 
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Report # F2019-03 

that the hydrant was NOT completely open. The time 

was approximately 1630 hours (Photo 2). The fire 

chief from district 23 was serving two functions: the 

IC and the engineer operating E2311. 

At approximately 1632 hours, after laying the supply 

line, the captain from E2312 conducted an 

incomplete (270°) walk-around of Sides Alpha, 

Delta, and Charlie. Findings from the walk-around 

size-up were not communicated to the IC. 

On Side Alpha, the two firefighters from district 23 

relocated the 13⁄4-inch line from the picture window 

to the front door. At 1633 hours, firefighters from 

district 23, on air from their SCBAs, entered the front 

door into the foyer where they directed water to Side 

Bravo and the Alpha/Bravo corner. They could only 

advance 5-10 feet due to excessive storage in the 

foyer. 

Photo 2 the hydrant to E2311. E2311. The 

5-inch hoseline connecting was parked in 

the resident’s driveway on Side Bravo. 

At 1629 hours (Photo courtesy of the fire department.) the fire chief from FPD 16 was 

assigned chief of the Side Alpha sector. After 

speaking with the homeowners, the chief announced on the radio that a large amount of ammunition 

was stored to the right of the front door on Side Alpha. Since fire had not spread to the foyer area, 

attack crews continued to flow water in the foyer area and to Side Bravo. 

At 1632 hours, the chief from FPD 16 conducted an incomplete (270°) walk-around of Sides Alpha, 

Bravo, and Charlie. Again, findings from this incomplete walk-around (2700) size-up were not 

communicated to the IC.

At 1633 hours, E2211 (PAR2) from county FD 22 and E1610 (PAR 2) from county FPD 16 arrived 

on-scene. E1610 was assigned to Side Alpha, while E2211 was assigned to the Bravo/Charlie sector

where their chief was the sector chief. E2211 positioned a 21⁄2-inch hoseline supplied by E2311 to Side 

Bravo/Charlie and began to flow water into the home (Diagram 2). Within a minute or two, the water 

pressure in the hoseline fell. E2211 notified the IC of the low water pressure situation. Firefighters 

operating on the Side Bravo/Charlie corner shut down the 21⁄2-inch line and pulled a 13⁄4-inch line from 

2311. The 13⁄4-inch line also had problems maintaining water pressure. The Side Bravo/Charlie sector

crews would close the hose’s nozzle, allowing the hose to recharge, then continued to flow water until 

the pressure dropped again. This cycle repeated several times. 
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Diagram 2. Sketch of the fire suppression equipment and personnel on the nozzles of the 

hoselines.
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At 1635 hours a lieutenant from FPD 23 arrived in his POV and was assigned pump operations of 

E2311 (replacing the IC). The lieutenant noted weak pressure on the intake gage and questioned

whether the hydrant was completely open. He asked an engineer from district 23 to check the hydrant. 

At 1637 hours, firefighters from FPD 23 conducting interior fire suppression from the foyer

experienced low water pressure in the 13⁄4-inch line and notified the IC. Though the fire was somewhat 

knocked down, flames were still showing from Sides Bravo and Charlie and the roof collapse was 

continuing to expand. At approximately 1643 hours, their end-of-service-time indicators started to 

sound from their SCBAs. They exited the front door and staged at E2311 after being replaced by 

county FPD 16 firefighters arriving in their POVs. At approximately 1642 hours, district 16 firefighters 

resumed the interior attack on Side Alpha via the front door. 

Photo 3. Firefighters conducting interior operations thru the front door even though

approximately 45 to 50% of the roof had collapsed into the 1st floor. Red arrow indicates the 

end of the bricked gable rafter that eventually collapsed onto the driveway on Side Bravo. 

(Photo courtesy of the fire department.)

At 1637 hours, the IC contacted County 9-1-1 and requested a tactical channel. County 9-1-1 radioed 

all on-scene firefighters to switch to MABAS Red. This incident was assigned MABAS frequency 
Report # F2019-03

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Report # F2019-03 

Red. This is a non-repeater channel that operates line of sight. Once this change was made, the IC had 

to switch back to the dispatch channel to communicate with county 9-1-1. The IC was monitoring both 

radio channels and trying to help the lieutenant solve the water supply problem. 

The roof on Sides Bravo and Side Bravo/Charlie corner roof continued to collapse onto the 1st floor

(See Photo 3). Firefighters on the Side Bravo/Charlie corner could see the 1st floor starting to burn and 

collapsing into the lower-level garage/basement. This information was not reported to the IC. 

Photo 4. Crews are operating interior and using an attic ladder to gain access to the attic. Crews are 

attempting to stop the fire from spreading to Side Delta via the attic.

(Photo courtesy of the fire department.)

On Side Alpha, firefighters placed a ladder in the foyer and used pike poles to pull down the ceilings

with the goal of preventing fire spread to Side Delta via the attic (Photo 4). Side Alpha interior crews

could see that the fire had burned through the 1st floor at the Side Alpha/Bravo corner. 

When the lieutenant from FPD 23 arrived by POV, he was assigned to take over E2311 pump 

operations from the IC. E2311 was supplying water via 13⁄4-inch lines to the attack crew on Side 

Alpha and the crew operating on the Sides Bravo and Charlie. Both crews experienced inadequate 
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Report # F2019-03 

water flow and pressure. The lieutenant operating E2311 sent an engineer to check the hydrant. At 

the hydrant, the engineer met Medic 74 FF/EMT, who originally opened the hydrant. The Medic 74 

FF/EMT reported that the hydrant was completely open. Without rechecking the hydrant, the 

engineer reported to the lieutenant that the hydrant was completely open. The lieutenant then ran an 

additional 3-inch water line from E2312 to E2311 with no change in the water pressure. 

At 1643 hours, the IC contacted county 9-1-1 and advised they were having problems accessing 

enough water from the fire hydrant. The IC requested dispatch to contact/request neighboring FD and 

FPD to send tenders. At 1651 hours, a tender from county FD 37 (PAR 2) departed their station

enroute to the fire scene. 

At approximately 1645 hours, 18 minutes after arrival, the IC conducted the first complete (3600) 

walk-around of the structure. Firefighters from districts 16 and 23 were operating on Side Alpha, 

firefighters from department 22 were operating on Side Bravo and Charlie. Additional firefighters from 

district 16 were operating on Side Alpha, while officers from district 16 were operating on Side 

Bravo/Charlie corner. The IC was preoccupied with running E2311 and investigating the water supply 

issue without formulating a strategy, an incident action plan, or an accountability tracking process.

County FPD E1412 (PAR 3) arrived on scene at 1647 hours. The captain of E1412 checked-in with the 

IC. E1412 was initially assigned to Side Alpha and, when needed, to relieve the district 16 crew 

operating inside the structure on the 1st floor. Since district 16’s crew had just relieved FPD 23’s crew

(1643 hours), the captain of E1412 was able to conduct a brief size-up evaluation. Shortly thereafter, 

during a face-to-face discussion with the IC and the Side Bravo/Charlie sector chief, the captain raised 

the issue of a possible basement fire. To flow water to the potential seat of the fire, the captain offered 

the use of their K-12 to cut an opening in the below grade garage doors (Diagram 2). 

At 1652 hours, the IC ordered the 21⁄2-inch hoseline moved from Side Charlie to Side Bravo near the 

below-grade garage door. While FD 22’s crew move the 21⁄2-inch hoseline, E1412’s engineer retrieved 

the K-12 from E1412. Firefighters from FPD 14 and FD 22 operating on the Side Bravo corner opened 

the lower-level man door (Diagram 2 and Photo 5). When crews opened the door, some lazy grey 

smoke escaped with minimal heat. A thermal imaging camera (TIC) showed a slight increase in 

temperature. Crews flowed water from the door into the garage using a 13⁄4-inch line, but many 

belongings obstructed the flow to other areas of the basement/garage. 

At approximately 1655 hours, FPD 16’s assistant chief became concerned that the entire roof could 

collapse. He told FD 22’s assistant chief to “watch those guys” working on Side Bravo. FD 22’s 

assistant chief was also concerned about the Side Bravo bricked gable rafter. The assistant chief 

notified his chief who was the Side Bravo/Charlie sector chief. The Side Bravo/Charlie sector chief 

thought the brick wall supporting the gable looked stable with no bulging, bowing, cracking, or 

spooling. Therefore, no collapse zone was established. NIOSH received conflicting information 

whether these collapse concerns were reported to the IC.

At 1655 hours, county 9-1-1 requested a status update for being 35 minutes into the response. The IC 

responded that they were still containing the fire. At 1656 hours, the IC radioed that the basement was
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about to be opened. Upon opening the garage door, firefighters flowed water from the driveway into 

the garage; no one entered the garage. The captain from 1412 was standing in front of the left garage 

door next to the air conditioner (Photo 5). He was using a TIC to direct water flow into the hot spots of 

the garage as firefighters used pike poles to pull debris out of the garage onto the driveway. 

At approximately 1703 hours, the triangular brick gable rafter tipped outward as one piece fell outward 

onto the driveway on Side Bravo. It fell approximately 21 feet striking four firefighters (a captain and 

one firefighter from 1412; a captain and one firefighter from E2211). The fifth firefighter from E1412

was not injured.

Photo 5. Side Bravo showing below grade man door on the Side Bravo/Charlie corner, as well 

as the left and right garage doors. The photo was taken after the brick gable had collapsed.

The right side of the garage door has been cut open. 

(Photo courtesy of the Office of the State Fire Marshal.)

At 1703 hours a Mayday is called. The IC radioed county 9-1-1 to send more ambulances to the scene. 

Firefighters from E1610 brought a 13⁄4-inch handline from Side Alpha to the Side Alpha/Bravo corner 

to extinguish the burning roof debris on the driveway. One firefighter from E2211 was conscious and 
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able to self-extricate. The captain from E2211 was unconscious for about 60 seconds and then selfextricated. The firefighter from E1412 was knocked unconscious but regained consciousness when 

pulled out of the collapse zone by rescuing firefighters. The captain from E1412 was unconscious and 

not breathing. He was brought out of the collapse zone and cardiopulmonary resuscitation (CPR) was 

started. At 1707 hours, the IC requested county 9-1-1 for an air ambulance. At 1718 hours, the captain 

from E1412 was onboard Medic 74 and enroute to a local hospital with a police escort. CPR was in 

progress. Medic 74 arrived at the hospital’s emergency department at 1728 hours. On-scene 

paramedics stabilized the three other injured firefighters.

At 1745 hours, the air ambulance departed the scene with the firefighter from E1412. This firefighter 

was admitted to the hospital and subsequently survived. The other two injured firefighters from FD 22 

were transported by ambulance to a local hospital’s emergency department where they were treated 

and released. At 1750 hours the captain from E1412 was pronounced deceased at local hospital. 

At approximately 1659 hours, the electrical service line that entered the house on the Side Alpha/Bravo 

corner, fell across the driveway (Photo 6). The IC requested dispatch to send the power company to 

the scene. Pending arrival of the power company at 1724 hours, the IC radioed on-scene firefighters 

about the downed line and assigned two firefighters from FPD 23 to safeguard the area. Power to the 

house was disconnected at 1732 hours.
Page 26 

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Report # F2019-03 

 

Photo 6: Downed power line entering the home at the Side Alpha/Bravo corner. 

(Photo courtesy of the Office of the State Fire Marshal.) 

At 1710 hours, county FPD 48 arrived on-scene with two tenders: T4861 and T4862. At 1714 hours, a 

personnel accountability report (PAR) ensued. Each sector/department conducted their own PAR and 

reported to the IC that all personnel were accounted for. At 1714 hours, IC informed county 9-1-1 that 

a building collapse has occurred with multiple injured firefighters. 

After the gable collapse fire suppression operations essentially stopped allowing firefighters to assist 

with the rescue and recovery effort. At 1718 hours, the engineer of E2311 asked a firefighter from 

E2311 to recheck the hydrant. The firefighter was able to make five additional turns that completely 

opened the hydrant. Water was no longer an issue at this incident. 

At 1758 hours the IC and an assistant fire chief from FPD 23 met with a deputy chief from county FPD

48. The district 48’s deputy chief assumed Command as the IC. The fire chief from FPD 23 was 

experiencing chest pains and was transported to a local hospital for evaluation and treatment. Whatever 

fireground operations still occurring were stopped. A complete personnel accountability report was 

conducted by each fire department on-scene. This information was recorded and provided to the new 
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IC. The IC met with all on-scene firefighters and ordered a defensive fire operation. A collapse zone 

was established on all sides of the structure. 

At approximately 1845 hours, fire suppression operations were re-started using cellar nozzles. At 2000 

hours, the IC advised county 9-1-1 that the fire was under control. The fire was declared out at 

approximately 2300 hours. 

Cause of Death

The forensic pathologist with the Office of the County Coroner listed thoracic blunt trauma and 

cervicospinal trauma as the cause of death of the captain from E1412.

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:

• Lack of a collapse zone

• Lack of situation awareness

• Incomplete scene size-up 

• Incomplete risk assessment and incident action plan

• Incomplete duties of command safety

• Task saturation of the IC

• Lack of an IC aide 

• Lack of an incident safety officer

• Inadequate water supply

• Inconsistent live fire training among the volunteer firefighters

• Lack of a personnel accountability system. 

Recommendations

Recommendation #1: Fire departments should ensure the IC establish collapse zones including 

exclusion zones or no-entry zones at defensive fires as needed due to dangerous or hazardous 

conditions. 

Discussion: While the number of firefighters killed due to a fire-related structural collapse has dropped 

over the past 20 years, structural collapse remains a significant cause of injury and death to firefighters. 
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In 2021, NFPA reported four structural collapse fatalities: two from a roof collapse, and two from floor 

collapses [Fahy and Petrillo 2022]. 

Four types of building collapse have been identified: roof, floor, perimeter wall, and building feature 

[Naum 2015]. Structural collapse or compromise can occur internally or externally to a building, with 

the external commonly occurring around its perimeter. The fireground perimeter has a high degree of 

risk due to factors such as building access and egress points, proximity of tactical operations, apparatus 

position, and staging of personnel. 

The potential for fire-related collapse in single-family dwellings is related to two distinct factors: 1) the 

presence or absence of lightweight construction materials and 2) whether the fire is attacking the 

structural components. Accordingly, firefighters should be trained and understand building design, 

construction, and conditions. In addition, firefighters should be trained on how to identify, assess, and 

predict a structure’s performance under fire conditions [Loflin et al. 2014; Naum 2015]. 

In many structure fires, the probability and anticipation of structural collapse or compromise are 

minimized, overlooked, or disregarded. This occurs until catastrophic conditions present themselves 

with little, or no, time to react. This loss of situational awareness can occur due to knowledge gaps in 

building and construction systems or to distracted attention to pre-collapse building indicators [Naum 

2015]. 

Because fire-related structural collapse can be difficult to predict, the following factors can help 

identify and assess the risk: 

• Construction type

• External load

• Age and condition of the building

• Pre-existing structural damage/deterioration

• Structural weakness caused by explosion or impact

• Presence of free-standing parapets

• Presence of wall anchor plates or stars

• Engineered load systems/lightweight construction

• Types of doors and windows

• Roof design and covering including HVAC units on fast food occupancy roofs

• Renovation/modifications to the structure

• Height of the building

• Fire duration, size, and location

• Fuel loads

• Fire behavior

• Fire protection features such as sprinkler systems and fire walls

• Weight of firefighters and water used for extinguishment [Loflin et al. 2014].
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A collapse zone should be established whenever the risk of structural collapse is identified. A collapse 

zone is defined as the area around the perimeter of a structure that could contain debris if the building 

collapsed. This area is often defined by establishing a perimeter at a distance from the building that is 

equal to 11⁄2 times the height of the structure [Loflin et al., 2014; Naum 2015; NFPA 1500, 2021]. 

When conditions warrant, a collapse zone can be expanded to an exclusion zone or no-entry zone. An 

exclusion zone is defined as a zone established by the IC to prohibit specific activities in a specific 

geographic area. If the fire is not contained and an exterior (defensive) attack becomes necessary, the 

exclusion zone is moved far enough away from the structure to place the firefighters outside of the 

collapse zone [Loflin et al. 2014]. 

When established, a collapse zone should be identified by a fireground transmission, colored tape, 

signage cones, flashing beacons, fences, or other appropriate means. A “No Entry” policy should be 

enforced by the IC, Safety Officer, Division/Group Supervisors, and company officers. When it is not 

possible or practical to visually mark a collapse zone, the IC should verbally identify the collapse zone 

area to all fireground personnel via radio or other communication methods. During structure fires, the 

IC should initially evaluate and continually reevaluate risk factors, including the potential for structural 

collapse based on direct observations; reports from company officers, division/group supervisors, 

and/or the safety officer [Loflin et al. 2014]. 

At this incident the partial roof collapse on Side Bravo was clearly visible to all arriving units as they 

approached the home from Side Alpha. The loss of the roof support should have alerted approaching 

officers and firefighters of the potential for an interior, or perimeter, collapse. Furthermore, the risk of 

the brick gable rafter collapse from the progressive loss of roof support should have been identified 

during scene size-up or during fire suppression activities on Side Bravo or the Bravo/Charlie corner. 

These eminently dangerous conditions were recognized by two assistant chiefs from FPD 16 and FD 

22 and voiced to the Side Bravo sector chief. NIOSH received differing accounts whether this 

information was also given to the IC during a face-to-face meeting. 

Recommendation #2: Fire departments should ensure firefighters are trained in situational 

awareness, personal safety, and accountability. 

Discussion: Situational awareness is defined as “...your ability to perceive and understand what is 

happening in the environment (in the context of how time is passing), and then, in turn, to accurately 

predict future events in time to avoid bad outcomes” [Gassaway 2017]. 

Situational awareness is a component of fireground safety and all firefighters operating at an incident 

should maintain situational awareness. Because fireground dangers and hazards are constantly 

evolving, situational awareness should be maintained by all firefighters throughout an incident. Any 

unsafe or changing conditions should be reported to the IC and other members in their environment. 

Situational awareness is a 3-level process: 

• Level 1 - Perception

• Level 2 - Comprehension 
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• Level 3 - Prediction [Gassaway 2022]. 

Level 1 - Perception

In the fire service, perception, also referred to as sensing or observing, is often associated with size-up. 

While size-up typically focuses on visual observations, effective perception should involve all 5 senses 

(hearing, taste, touch, sight, and smell). This first level in the situational awareness process must be 

deliberate, accurate, and ongoing. 

Level 2 - Comprehension 

Properly interpreting one’s perception on the fireground is the second level of situation awareness. 

Proper interpretation comes from education, knowledge, training, and experience. If firefighters have 

any doubts about what they are comprehending, they should re-evaluate, and when possible, seek the 

input of others. Different understandings of what is occurring on the fireground can arise due to 

misinterpretation, different frames of reference, or different perspectives. Thus, firefighters and 

officers with different grasps of the situation should not be simply dismissed. A shared understanding 

on the fireground at the task, tactical, and strategic level is critical for success. 

Level 3 – Prediction

Projecting, forecasting, or visioning is the third and final level of situational awareness know as 

prediction [Gassaway 2022]. Since the fireground is constantly changing and evolving, plans must not 

be based solely on what is currently happening. Like comprehension, a firefighter and officer’s ability 

to forecast fire progression relies on their education, knowledge, training, and experience. When 

firefighters are insufficient in this ability, they should seek input from others with the necessary skills 

for the situation. 

Firefighters must be aware of and avoid the various obstacles to situational awareness such as:

• task fixation or tunnel vision

• distraction

• task saturation

• mind drift

• short term memory overload [Gassaway 2019].

Effectively utilizing these 3 levels of situational awareness increases the chances of a safe and 

successful operation [Gassaway 2017, 2019, 2022]. Even though a safety officer may be assigned 

during an incident, all personnel must maintain their situational awareness. 

During this incident, various obstacles obscured the firefighters’ and the IC’s situational awareness. 

For the IC this included distraction due to managing the water supply issue, and task saturation due to 

the lack of a safety officer and the lack of an aide. It is unclear why seeing flames coming through a 

partial roof collapse did not trigger a concern about the stability of the roof, the brick gable, and the 

entire structure among other firefighters on scene. 
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Recommendation #3: Fire departments should ensure the first arriving officer conducts a detailed 

scene size-up. 

Discussion: The first two objectives of fireground operations in the International Association of Fire 

Chiefs’ (IAFC) Rules of Engagement for Structural Firefighting recommends rapidly conducting, or 

obtaining, a scene 3600 size-up and occupant survival profile [IAFC 2012]. The Rules of Engagement 

integrate several nationally recognized safety-related programs and principles. If physical barriers 

make the 360-degree size-up impractical for the 1st arriving officer, the size-up of Side Bravo, Side 

Charlie, and Side Delta may be delegated to another engine company or another resource on the 1st

Alarm. Subsequent scene size-up is an ongoing task that should be assigned to the safety officer. In 

addition to the 3600 size-up, resources should be assigned to Side Charlie, preferably an engine 

company with a hoseline. [Fire and Rescue Departments of Northern Virginia 2013].

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

• Emphasis on identifying the seat of the fire 

• Signal for a working fire, number of stories, type of occupancy, and location of fire 

• Unusual building features such as a grade difference between Sides Alpha and Charlie.

• Presence of a basement and basement access

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

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

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

channel. Command should then re-broadcast and receive acknowledgement from all operating 

companies.

In this incident, the ambulance and county deputy sheriff were the first arriving units. They reported 

heavy smoke and flames with all human occupants out of the house. The IC was the first arriving 

officer followed by an officer driving E2312. The IC radioed dispatch that they had a single-story 

wood frame with heavy fire involvement. The IC confirmed that the occupants were out of the house 

and called for a defensive strategy. This defensive strategy was not communicated to dispatch or 

during face-to-face meetings for assignments and was not heard by other firefighters arriving on-scene.

Two separate initial 2700 (not 3600) scene size-up walkarounds were conducted by two officers, but 

neither reported their findings to the IC or to dispatch. A complete scene size up should have been 

reported to the IC or, as the first arriving officer, the IC should have conducted the initial scene size up.

In addition, the IC was preoccupied with running the engine and working on the water supply problem 

(discussed in subsequent recommendations in this report). At about 1645 hours, 18 minutes after the 

E2311 arrived on-scene, the IC conducted his own scene size-up of all Sides (Alpha, Bravo, Charlie, 

Delta). 
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Finally, as mentioned in recommendation #1, the partial roof collapse on Side Bravo was clearly 

visible to arriving crews as they approached the home from Side Alpha. Given the loss of the roof 

support, this should have alerted approaching officers and firefighters of the potential for an interior or 

perimeter collapse. This finding should have been communicated to the IC as part of initial scene sizeup. 

 

Recommendation #4: During initial fire ground operations, fire departments should ensure the IC 

conducts a risk assessment, develops a risk management plan, and incorporates these into an 

incident action plan (IAP). The IAP needs to be clearly communicated to responding personnel and, 

for more extensive incidents, a tactical worksheet may be required.

Discussion: The third objective of the initial fireground operations involves conducting a risk 

assessment and developing an IAP [IAFC 2012]. NFPA has developed the following principles of risk 

assessment and risk management: 

(1) Activities that present a significant risk to the safety of members shall be limited to situations 

where there is a potential to save endangered lives

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

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

(3) No risk to the safety of members shall be acceptable when there is no possibility to save lives 

or property

(4) In situations where the risk to fire department members is excessive, activities shall be limited 

to defensive operations [NFPA 1500, 2021]. 

The IC must follow the decision-making model that includes identifying incident critical factors 

(through a situational evaluation or “size-up”), consider the standard risk management plan, declare the 

strategy (offensive or defensive), and then set 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. Upon assigning 

resources to a location assignment, the IC should assign the objectives and tasks with that location 

such as search and rescue, fire attack, ventilation, utility control, and exposure protection. The IAP can 

be as simple as a verbal transmission to all units assigned to an incident. More extensive incidents may 

require the IAP to include a tactical worksheet, written plan, or combinations thereof [NFPA 1561, 

2020].

Once the chief officer arrives on-scene, an update from the initial IC 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 subsequent ICs will be in a stronger position to manage an incident should an 

emergency event occur [NFPA 1561, 2020].

The following are guidelines for developing an IAP for defensive operations.

Defensive Incident Action Planning 
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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 defensive strategy is based 

on protecting firefighters. Defensive strategy tactical priorities include: 

• defining the hazard zone

• keeping firefighters out of the potential collapse zone(s)

• searching exposures 

• protecting exposures 

• establishing cut-offs where forward progress is halted.

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 water streams.

One of the most critical components of an IAP is anticipating a building’s performance and risk of 

structural collapse, compromise, or failure. The fire service must recognize that when any of the 

structural components start to fail or collapse due to fire involvement, this changes the IAP and 

strategy. An effective risk management plan could mean that defensive operations may be the only safe 

option at a structure fire because of the risk of collapse [Loflin et al. 2014]. 

Communicating the IAP to all assigned and staged members at an incident is an important 

responsibility of the IC [NFPA 1561, 2020]. Due to the constantly changing risks on the fireground, 

the risk assessment must be a continuous process. As the risks change, and benchmark are met (or not 

met), the IAP will need to be continually reviewed and updated as necessary [NFPA 1561, 2020]. 

At this incident, the fire chief driving E2311 (the IC for this incident) was the first fire officer to arrive 

on scene and reported a “single story wood frame [with] heavy fire involvement.” When he arrived on 

scene, the chief thought he had transmitted to dispatch that he assumed Command and declared a 

defensive strategy. The defensive strategy announcement was not heard or acknowledged by dispatch, 

and firefighters at, or enroute to, the fireground. 

Two officers independently conducted 2700 walk arounds as the initial size-up. The IC was not briefed 

on the findings of the size-ups, thus had very limited information to make a risk assessment or develop 

an IAP. As a result, when dispatched crews arrived on scene, the IC assigned them to various locations 

around the structure but did not assign any tactical or task objectives to their location. In addition, the 

IC experienced task saturation due to a water supply problem. 
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Recommendation #5: Fire departments should ensure their IC incorporates the principles of 

command safety into the incident management system. 

Discussion: Chapter 8 of NFPA 1561, Standard on Emergency Services Incident Management System 

and Command Safety, addresses the responsibilities of the command safety in the context of the 

incident management system. The IC has responsibility for the following: 

• initial and ongoing situational assessment of the incident 

• establishing an effective communications plan

• developing incident objectives from the situational assessment and form an applicable strategy 

and tactics 

• deploy and request additional resources based upon the needs of the incident

• develop an incident organization for the management of the incident

• reviewing, evaluating, and revising the strategy and tactics based upon the needs of the 

incident 

• provide for the continuity, transfer, or termination of command [NFPA 1561, 2020]. 

Additional components of command safety include: 

• establishing a stationary command post 

• establishing an accountability system

• assigning an additional person (staff aide) to facilitate the tracking and accountability of the 

assigned companies or crews when the IC supervisory responsibility involves three or more 

companies or crews

• move to defensive operations when the risk to emergency service responders is excessive

• appoint a safety officer at all application emergency incidents [NFPA 1561, 2020]. 

At this incident, the command post was initially operated from E2311 while the IC ran the pumper and 

worked on establishing a water supply. While E2311 was “stationary,” it was noisy and full of 

distractions, which are conditions not conducive to effective command. NFPA suggests utilizing the 

rear of a sport utility or van-style vehicle as an alternative [NFPA 1561, 2020]. 

Recommendation #6: Fire departments should develop a process to prevent task saturation of ICs

during complex or multi-alarm incidents.

Discussion: Since the inception of the IC, the duties and responsibilities of ICs have significantly 

increased. As an incident escalates, it is difficult for one individual to effectively manage a complex 

emergency operation. The IC needs to address issues dealing with situation evaluation, deployment 

management, strategy, the IAP, communications, personnel accountability, firefighter and responder 

safety, the tactical worksheet, RIC, and other essential job tasks. Asking one person to command and 

control a large and complex incident is unfair to this individual, their firefighters, and the citizens they 

have sworn to protect. Front loading the incident with support for the IC is essential, because the first 

hour of the incident is when most firefighters are seriously injured or killed [Brunacini and Brunacini 

2004]. 
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Fire departments should have a process to support the IC during large, complex, or multi-alarm 

incidents. This is especially important when the command officer does not have an aide (e.g., staff 

aide, incident command technician, or chief’s aide). The support process could include dispatching an 

additional battalion chief on the working alarm assignment. If this battalion chief is going to be 

assigned to supervise a division or group, then another battalion chief should be dispatched and 

function as the planning section chief. This will allow the IC to focus on operational issues.

In this incident, the IC did not have an aide or an incident safety officer. Because of the lack of an aide 

or safety officer, the IC had a tremendous number of tasks to attend to.

Recommendation #7: Fire departments should make an IC aide available during working structure 

fires. 

Discussion: The staff aide (e.g., chief’s aide, emergency incident technician, incident command 

technician, field incident technician, or staff assistant) is an essential component of the incident 

management system [Brunacini 2002]. Chapter 8 of NFPA 1561, Standard on Emergency Services 

Incident Management System and Command Safety, states that “an IC supervising three or more 

companies or crews under their command shall have an additional person (staff aide) assigned to 

facilitate the tracking and accountability of the assigned companies or crews” [NFPA 1561, 2020]. 

Some fire departments use firefighters as staff aides, other fire departments use fire officers. 

Regardless of the rank of the staff aide, the assigned personnel should be trained in the duties and 

responsibilities of an IC aide. 

The IC aide has three primary responsibilities: 

• resource and accountability status (discussed further in recommendation 12 of this report) 

• situation status 

• command post communications [Fire and Rescue Departments of Northern Virginia 2013]. 

Upon arrival at the fire scene, the staff aide should report to command. After conferring with the IC, 

the staff aide should set up the command post, allowing the IC to focus on the command and control of 

the incident. The IC will determine whether to operate from the front of the vehicle or to move to the 

rear. Once the command post is set up and ready to support communications and resource and situation 

tracking, both the IC and the staff aide may operate from the rear of the vehicle using the command 

board(s) and radio headsets for incident management.

Tasks required of the IC aide include: 

• Determine and track status of resources 

• Track units and members 

• Anticipate the need for additional resources based upon assignments being made 

• Manage command channel communications 

• Provide progress reports 

• Monitor secondary tactical channels if utilized in the operation 
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• Anticipate and recommend logistical needs to support the operation

• Brief incoming chief officers as necessary [Fire and Rescue Departments of Northern Virginia 

2013]. 

Depending on the scale and complexity of the incident, a single staff aide may not be able to manage 

all three of the primary responsibilities. IC needs to ensure these three responsibilities are being 

completed. If not, an additional aide, or aides, should be assigned. 

In this incident, no staff aide was available or assigned. As a result, the responsibility of resource 

accountability was not performed until after the Mayday occurred. 

Recommendation #8: Fire departments should ensure that an incident safety officer, independent of

the IC, is appointed at working structure fires. 

Discussion: The incident commander relies upon firefighters to report on fireground conditions which, 

in turn, allows the IC to make informed decisions regarding risk-versus-gain and offensive-versusdefensive operations. As incidents escalate in size and complexity, on scene firefighter health and 

safety are best preserved by delegating the function of safety and health oversight to an incident safety 

officer [NFPA 1500, 2022]. 

Fire departments should develop response procedures to ensure a pre-designated incident safety 

officer, independent of the incident commander, responds automatically to pre-designated incidents. 

The role and duties of a safety officer include: 

• recon of the fireground and reporting pertinent information back to the incident command

• ensure the department's accountability system is in place

• monitor radio transmissions

• identify barriers to effective communications

• ensure established safety zones, collapse zones, hot zones, and other designated hazard areas 

are communicated and respected by all members on scene [NFPA 1521, 2020; NFPA 1561, 

2020; NFPA 1026, 2024]. 

The requisite skills include: 

• critical identification, analysis, and judgment abilities

• applying AHJ building fire preplan systems at actual incidents

• interpreting collapse hazards

• communicating hazard information to personnel via the incident safety plan, IAP, face-to-face, 

radio, and safety briefings

• determining boundaries and markings for control zones

• formulating recommendations for incident command action

• exercising authority to suspend imminent danger operations

• anticipating evolving site conditions that require IAP changes [NFPA 1521, 2020]. 
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Upon arrival at the incident, the designated safety officer should meet with the IC to confirm the safety 

officer assignment and become integrated into the personnel accountability system. The safety officer 

should obtain the following information: 

• overall situation status and resource status 

• the IAP

• the presence of known hazards 

• concerns about the establishment of control zones 

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

channel)

• status of rapid intervention crews

• establishment of the rehabilitation [NFPA 1561, 2020]. 

Once the information is obtained, the safety officer should don the necessary personal protective 

equipment and wear a vest or helmet identifying themselves as the safety officer.

Larger fire departments may assign one or more full-time staff officers as safety officers who respond 

to working fires. In smaller departments, every officer should be prepared to function as the safety 

officer when assigned by the IC. The presence of a safety officer does not diminish the responsibility 

of individual firefighters and fire officers for their own safety and the safety of others. [NFPA 1561, 

2021]. 

At this incident, an incident safety officer was not assigned. 

Recommendation #9: Fire departments should ensure that an adequate sustainable water supply is 

established and maintained. Firefighters should have periodic training on hydrant operations.

Discussion: Establishing adequate water supply on the fireground is one of the most critical elements 

of firefighting. Many fire departments require, per standard operating procedure (SOP), that the 2nd 

due engine company and 4th due engine company should secure a water supply for the 1st due engine 

company and 3rd due engine company [Fire and Rescue Departments of Northern Virginia 2013]. 

Before committing resources in the hazard zone, the IC must ensure a sustainable water supply is 

available. Thus, during size-up and risk assessment, the IC should consider the following information: 

• fire load

• fire flows requirements for the incident 

• key tactical areas needing water 

• units needing a continuous water supply 

• number of handlines a pumper(s) can charge and pump

• number of large diameter openings the pumper(s) charge and pump 

• water sources

• staffing [NFPA 1142, 2022; Wieder 2019]. 

At this incident, the IC was also operating E2311. E2312 laid a 5-inch supply line from the hydrant to 

E2311, which was about 250-foot lay. A firefighter/EMT from Medic 74 made the hose connection to 
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the hydrant and charged the supply line. The firefighter/EMT from Medic 74 did not realize the 

hydrant was not completely open, which caused the inadequate water supply. The intake pressure 

dropped to zero and the pump started to cavitate when all three lines (the 21⁄2-inch hoseline and the two 

13⁄4 -inch hoselines) were flowing. 

One of the first issues when dealing with a loss of water is to ensure that the fire hydrant is completely 

open. The lieutenant who took over pump operations on E2311, asked an engineer from FPD 23 to 

check the hydrant. Instead of checking the hydrant himself, the firefighter asked the firefighter/EMT 

from Medic 74 who originally opened the hydrant if it was completely open. The firefighter/EMT from 

Medic 74 responded that the hydrant was completely open. Given that inaccurate information, the 

lieutenant and the IC began making other arrangements for water, contacting dispatch to send tenders 

from other fire departments. At 1718 hours, about 15 minutes after the gable collapse, the lieutenant 

operating E2311, asked another engineer to check the fire hydrant again. The firefighter went to the 

hydrant and opened it using 5 additional turns, which provided an adequate water supply for this 

incident. 

Recommendation #10: Fire departments should ensure that all members engaged in emergency 

operations receive annual training and evaluation on fireground operations including live fire 

training to improve proficiency during fireground operations. 

Discussion: NFPA 1500, Standard for a Fire Department Occupational Safety, Health, and Welfare 

Program, requires a fire department to establish and maintain a training, education, and professional 

development program commensurate with the duties and functions that they are expected to perform

[NFPA 1500, 2021]. Members who engage in structural firefighting should meet the qualification 

requirements of NFPA 1001, Standard for Fire Fighter Professional Qualifications [NFPA 1001, 

2019]. NFPA 1410, Standard on Training for Initial Emergency Scene Operations, defines basic 

evolutions that can be adapted to local conditions and serves as a method for the evaluation of 

minimum acceptable performance during initial fireground operations [NFPA 1410, 2020]. Proficiency 

training for fireground operations and emergency incidents should be conducted annually. This 

training should include, but not be limited to, scene size-up, situational awareness, use of the incident

management system, personnel accountability system, strategy and tactics, search and rescue, hoseline 

operations, ladder operations, ventilation, thermal imaging cameras, fireground communications, use 

of rapid intervention teams, and Mayday operations. Finally, live-fire training should be conducted in 

compliance with NFPA 1403, Standard on Live Fire Training Evolutions [NFPA 1403, 2018]. 

At this incident, NIOSH confirmed live fire training within the past year for all five members who 

responded to the fireground from county FPD 14. However, several of the responding fire departments 

did not require annual live fire training. NIOSH did not request live fire training completion dates for 

all the responding firefighters.
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Recommendation #11: Fire departments should utilize a functional personnel accountability system, 

requiring a check-in and check-out procedure with the designated accountability officer or IC. 

Discussion: The NIOSH FFFIPP has identified the lack of accountabRepor ility tot # F be2 a019 n imp -03 ortant 

contributing factor in many line of duty deaths [NFPA 1561, 2020]. A personnel accountability system 

is an important function of command safety. This system identifies the functional and geographical 

assignments from the beginning to the end of operations. Documenting the situation and resource 

status can occur on the tactical worksheet or other methods such as:

• accountability tags or keys (e.g., PASSPORT system)

• command boards

• apparatus riding lists

• company personnel boards

• electronic bar-coding systems [NFPA 1561, 2020]. 

Accountability should be separate from the role of the incident commander when 3 or more companies

or crews are operating. In addition, fire departments should develop an accountability SOP, train 

members on its use, and enforce its use during emergency incidents [NFPA 1500, 2021]. In addition, 

an important aspect of a personnel accountability system is the personnel accountability report (PAR). 

A PAR is an organized on-scene roll call in which each supervisor reports the status of their crew when 

requested by the IC [NFPA 1561, 2000]. In their SOP, fire departments should establish their own 

PAR frequency. Some departments conduct PARs every 15–20 minutes or when benchmarks are met. 

At this incident, all dispatched fire departments carried accountability tags. However, as crews 

approached the IC, with no aide to assist, no effort was made to track their functional and geographical 

assignments. The first PAR was conducted after the Mayday, approximately 30 minutes after units 

arrived on scene.

The following recommendations are provided as a reminder of a good safety practices. There is 

unlikely any of these recommendations would have prevented this fatality.

Recommendation #12: County communication centers (dispatch) should consider announcing an 

incident clock at 10-, or 15-miunte intervals to the IC.

Discussion: Chapter 8 of NFPA 1500, Standard for a Fire Department Occupational Safety, Health, 

and Welfare Program, has a section on communications during emergency operations. The standard 

recommends communication centers start an incident clock when the first arriving unit is on-scene of a 

working structure fire or hazardous materials incident. Then, at 10-minute increments, dispatch notifies 

the IC with an announcement such as, “incident clock is 10 minutes,” “incident clock is 20 minutes,” 

“incident clock is 30 minutes,” and so forth [NFPA 1500, 2021]. NFPA 1561 suggests the transmission 

be in 15-minute intervals [NFPA 1561, 2020]. For incidents with long travel times, some fire 

departments want elapsed time-from-dispatch announcements. This method can be more appropriate 

where significant incident progress could have occurred prior to the first unit arrival. Fireground 
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Report # F2019-03 

conditions allow the IC to cancel or change the intervals of the incident clock notifications [NFPA 

1500, 2021].

At this incident, the communication center’s first incident clock notification was at 1655 hours, 44 

minutes from time-from-dispatch and 27 minutes from time-from-arrival. Subsequent incident clock 

announcements were appropriately cancelled due to the Mayday.

Recommendation #13: Fire departments should ensure that all firefighters and fire officers are 

trained in managing a Mayday. 

Discussion: Chapter 8 of NFPA 1500, Standard on Fire Department Occupational Safety, Health, and 

Wellness Program and chapter 6 of NFPA 1561, Standard on Emergency Services Incident 

Management System and Command Safety addresses the use of the term Mayday [NFPA 1561, 2020]. 

Mayday is an internationally known radio distress signal used by firefighters who are in, or about to 

become in, a life-threatening situation. Any member in a potentially life-threatening situation can issue 

a “Mayday, Mayday, Mayday” on their portable radio. The communications center should clear all 

radio traffic to give priority to emergency messages. 

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. The two 

most important rescue tasks are protecting the downed firefighter from fire and getting air to the 

downed firefighter. The IC is responsible for ensuring these two tasks are completed and must revise 

the incident’s strategy, tactics, and tasks accordingly. In addition, as part of its Fire Ground Survival 

manual, the IAFF has developed a Mayday checklist [IAFF 2023]. 

The fire service has developed several Mayday training courses that are available at conferences or as 

standalone training programs. NIOSH recommends fire departments take advantage of these trainings 

to ensure their members are familiar with what to do if, or when, a Mayday strikes.

Recommendation #14: Fire departments should develop and implement a standard operating 

procedure/guideline on the deployment and use of rapid intervention crew(s) [RIC]. 

Discussion: In 1988 the Occupational Safety and Health Administration’s (OSHA) issued the 

respiratory protection standard. Since Illinois operates as an OSHA-approved State Plan covering state 

and local government workers, fire departments operating in Illinois must comply with 29 CFR 

1910.134 [OSHA 2023]. Relevant to the fire service, 29 CFR 1910.134(g)(4) outlines the rescue 

requirements for interior structural firefighting operations [OSHA 1988]. Commonly referred to as “2 

in 2-out,” the standard requires: 

• at least two employees enter the immediately dangerous to life and health (IDLH) atmosphere 

together [note: interior structure fires have an IDLH atmosphere] 

• at least two employees are located outside the IDLH atmosphere to provide rescue activities

• the two employees entering the hazard zone must always remain in visual or voice contact with 

one another and with the rescue employees outside the IDLH atmosphere
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• the employees located outside the IDLH atmosphere are trained and equipped to provide 

effective emergency rescue

• all employees engaged in interior structural firefighting use SCBA

• all employees located outside the IDLH atmosphere are equipped with SCBA

• the employer or designee is notified before an emergency rescue operation is initiated

• firefighters can perform emergency rescue activities before an entire team has assembled

• one of the two individuals located outside the IDLH atmosphere may be assigned to an 

additional role, such as IC in charge of the emergency or safety officer, so long as this 

individual is able to perform assistance or rescue activities without jeopardizing the safety or 

health of any firefighter working at the incident. 

The fire service calls these rescue teams either rapid intervention crews (RIC), rapid intervention teams 

(RIT), or firefighter assist and search teams (FAST). Several NFPA standards have expanded on the 

policies and procedures of OSHA’s 2-in 2-out regulation [NFPA 1407, 2020; NFPA 1500, 2021; 

NFPA 1521, 2020; NFPA 1710, 2020; NFPA 1720, 2020]. 

In this incident a RIC team was not in place prior to a first-floor attack crew entering the structure. 

This did not result or contribute in any way to the tragic death of the firefighter during this response, 

nor did it delay any of the heroic efforts to extract, resuscitate or transport the injured firefighters. 

Nonetheless, NIOSH recommends fire departments follow the relevant section of the above NFPA 

standards for RIC teams.

Recommendation #15: During significant structure fires, fire departments should ensure that power 

is disconnected to the structure early in the incident to reduce the risk of electrocution. 

Discussion: Firefighters are at risk of electrocution when working around downed power lines [NIOSH 

2006]. In 2021, one firefighter died due to electrocution [Fahy and Petrillo 2022]. Chapter 8.6 of 

NFPA 1500 addresses the procedures when firefighters are operating near hazardous energy sources 

including downed power lines [NFPA 1500, 2021]. During a structure fire locating and shutting off the 

electric service is typically tasked very early during the response to reduce the risk of firefighters being 

electrocuted [Bush 2022].

In this incident, a crew was not tasked with locating and shutting off the power. When a live power 

line fell across the driveway, the power company was notified, and a firefighter was posted to warn 

and keep firefighters away from the downed line. The power company cut power to the line 

approximately 30 minutes later (1724 hours).

Recommendation #16: Fire departments should document when hydrants in their jurisdiction are 

tested and flushed.

Chapter 4 of NFPA 291, Recommended Practice for Water Flow Testing and Marking of Hydrants, 

provides flow testing requirements for hydrants [NFPA 291, 2022]. For public hydrants, this NFPA 

standard recommends:
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• flow testing at least every 5 years to verify capacity and marking of the hydrant

• flushing at least annually to verify operation, address repairs, and verify reliability. 

At this incident, the agency having jurisdiction was not able to provide NIOSH investigators with the 

most recent flow testing or flushing of the hydrant used at this incident. 

Recommendation #17: Fire departments should ensure adequate incident scene rehabilitation is 

established in accordance with NFPA 1584, Standard on the Rehabilitation Process for Members 

during Emergency Operations and Training Exercises.

Discussion: NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency 

Operations and Training Exercises establishes the minimum criteria for developing and implementing 

a rehabilitation process for fire department members at incident scene operations and training exercises

[NFPA 1584, 2022]. The physical and mental condition of personnel should be monitored to ensure a 

fire fighter’s health and judgement is not negatively impacted which could affect the safety and 

integrity of the entire operation. The circumstances of each incident should determine the need for the 

following: 

• medical evaluation and treatment

• food and fluid replenishment

• rest and relief from extreme climatic conditions.

Despite essentially being a defensive strategy, the long duration of the incident (approximately eight 

hours) suggests a role for establishing rehab. 

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2020 ed. Quincy, MA: National Fire Protection Association.

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Command Safety, 2014 ed. Quincy, MA: National Fire Protection Association.
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Investigator Information

This incident was investigated by Thomas Hales, Medical Officer, and Murrey Loflin, Investigator, 

with the Firefighter Fatality Investigation and Prevention Program, and Jennifer Lincoln, Investigator, 

with the Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH. An expert 

technical review was provided by Michael Barakey. A technical review was also provided by the 

National Fire Protection Association, Public Fire Protection Division. 

Additional Information

IAFC Rules of Engagement for Firefighter Survival

The International Association of Fire Chiefs (IAFC) is committed to reducing firefighter fatalities and 

injuries. As part of that effort, the nearly 1,000 member IAFC Safety, Health and Survival Section has 

developed the DRAFT “Rules of Engagement for Structural Firefighting” to provide guidance to 

individual fire fighters and ICs, regarding risk and safety issues when operating on the fireground. The 

guidance provides a set of “modern procedures” for structural firefighting made available by the IAFC 

to fire departments as a guide for their own standard operating procedure development process. 

IAFF Fire Ground Survival Program

The International Association of Fire Fighters (IAFF) Fire Ground Survival Program provides training 

for Mayday prevention and Mayday operations for fire fighters, company officers, and chief officers. 

Fire fighters must be trained 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 the National Institute for Occupational Safety and Health (NIOSH) 

and has been developed by a committee of subject matter experts from the IAFF, the International 

Association of Fire Chiefs, and NIOSH. 

Underwriters Laboratories (UL) Firefighter Safety Research Institute

UL’s Fire Safety Research Institute (FSRI) advances fire safety knowledge to address the world’s 

unresolved fire safety risks and emerging dangers. Through advanced fire science, rigorous research, 

extensive outreach, and education in collaboration with our international network of partners, we 

impart stakeholders with the information, tools and resources that enable them to make better, more 

fire-safe decisions that ultimately save lives and property.
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Disclaimer

The information in this report is based upon dispatch records, audio recordings, witness statements, 

and other information that was made available to the National Institute for Occupational Safety and 

Health (NIOSH). Information gathered from witnesses may be affected by recall bias. The facts, 

contributing factors, and recommendations contained in this report are based on the totality of the 

information gathered during the investigation process. This report was prepared after the event 

occurred, includes information from appropriate fire service subject matter experts, and is not intended 

to place blame on those involved in the incident. Mention of any company or product does not 

constitute endorsement by NIOSH, Centers for Disease Control and Prevention (CDC). 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.