A summary of a NIOSH fire fighter fatality investigation December, 2014

Fire Crew Supervisor Suffers Sudden Cardiac Death During 

Pack Test – Wyoming

Executive Summary

2014

13

Fire Fighter Fatality Investigation Death in the line of duty... and Prevention Program

On May 17, 2014, a 63-year-old male career 

wildland fire crew supervisor (“Supervisor”) 

performed the U.S. Forest Service arduous duty 

work capacity test (WCT) (commonly known as 

the pack test) to obtain his “red card,” certifying 

him to fight wildland fires on state property. The 

pack test requires an individual to complete a 

3-mile walk within 45 minutes while wearing a 

45-pound weighted vest. After four laps around 

the track (about 1 mile), the Supervisor grabbed 

his left leg and collapsed. Crew members found 

him unresponsive, not breathing, and with a weak 

pulse. A few seconds later his pulse stopped. 

Cardiopulmonary resuscitation (CPR) was begun, 

and an ambulance was requested. A weak pulse 

and breathing returned briefly as an automated 

external defibrillator (AED) was retrieved from the 

vehicle of a responding police officer. The AED was 

nonfunctional, so a second AED was brought to the 

scene by the local fire department approximately 

2 minutes later. One shock was delivered without 

any change in the Supervisor’s clinical status. The 

ambulance arrived at 0826 hours, and ambulance 

service paramedics provided advanced life support 

(ALS), which included defibrillation, intubation, and 

intraosseous line placement. Two additional shocks 

were administered during transport to the hospital’s 

emergency department (ED), again with no change 

in the Supervisor’s clinical status. CPR and ALS 

continued for an additional 11 minutes in the ED. 

Despite CPR and ALS performed on the scene, en 

route to the ED, and inside the ED, the Supervisor 

was pronounced dead. The death certificate, 

completed by the county medical examiner, listed 

“acute myocardial infarction” due to “hypertension, 

type II diabetes mellitus, and morbid obesity” as 

the cause of death. No autopsy was performed. 

Given the Supervisor’s underlying undiagnosed 

atherosclerotic coronary heart disease (CHD), 

the NIOSH investigators concluded the physical 

exertion associated with the pack test triggered a 

probable acute myocardial infarction (heart attack) 

and his sudden cardiac death.

NIOSH investigators offer the following 

recommendations to reduce the risk of heart attacks 

and sudden cardiac arrest among fire fighters at this 

and other wildland fire fighting agencies.

Require completion of a health screen questionnaire 

(HSQ) prior to participating in the WCT.

Require exercise stress tests for fire fighters at 

increased risk for CHD.

Restrict fire fighters with medical conditions that 

have an increased risk of sudden incapacitation 

(e.g., cardiac arrest) as detailed in NFPA 1582.

Check WCT participants’ vital signs before and 

after testing.

Phase in a mandatory comprehensive wellness and 

fitness program for fire fighters.

Perform a candidate and member physical ability 

evaluation.
A Summary of a NIOSH fire fighter fatality investigation Report #2014-13

Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

Test – Wyoming

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

federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress 

appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH “Fire Fighter Fatality Investigation and Prevention Program” 

which examines line-of-duty-deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar 

fire fighter deaths in the future. The agency does not enforce compliance with State or Federal occupational safety and health standards and does not 

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

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

the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The 

agency’s reports do not name the victim, the fire department or those interviewed. The NIOSH report’s summary of the conditions and circumstances 

surrounding the fatality is intended to provide context to the agency’s recommendations and is not intended to be definitive for purposes of determining 

any claim or benefit. For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
A Summary of a NIOSH fire fighter fatality investigation Report #2014-13

Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

Test – Wyoming

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Executive Summary (cont.)

Provide fire fighters with medical clearance to wear 

a self-contained breathing apparatus (SCBA) as part 

of the fire department’s medical evaluation program.

Conduct annual respirator fit testing.

Perform an autopsy on all on-duty fire fighter 

fatalities.

Introduction & Methods

On May 17, 2014, the Supervisor arrived 

at the local school track at 0750 hours to 

participate in the state agency-scheduled 

pack test. The pack test requires participants 

to wear a 45-pound weighted vest and walk, 

not run, around a track for 3 miles within 45 

minutes [Sharkey and Gaskill 2009]. This test 

is required to obtain a “red card,” which allows 

the card holder to fight wildland fires on 

state property. Two state forestry supervisors 

coordinated the test for three crew supervisors 

including the Supervisor and two members of 

the local volunteer fire department.

Participants were briefed, drank some water, 

donned their weighted vests, and stretched. 

After confirming that all participants were 

ready, the test began at approximately 0805 

hours. The Supervisor had nearly completed 

lap 4 (1 mile) without difficulty when he 

grabbed his left leg and stepped off the track. 

Participants thought he was having a leg 

cramp, but then he suddenly collapsed (about 

0815 hours). Crew members rushed over and 

removed his weighted vest and assessed him. 

He was unresponsive, but had a weak pulse. An 

ambulance was requested as CPR was begun 

(0817 hours). The Supervisor initially regained 

a pulse and respirations, but a few seconds 

later was not breathing and had no pulse. A 

police officer responded at about 0820 hours 

with an AED, but the AED did not function 

properly. The local fire department responded 

at about 0822 hours and applied their AED; 

one shock was delivered as the ambulance 

arrived (0826 hours).

The ambulance arrived on the scene to find CPR 

in progress. ALS was initiated, which included 

On May 17, 2014, a 63-year-old male fire crew supervisor (“Supervisor”) suffered a probable heart attack 

and sudden cardiac death during his pack test. Despite 

CPR and ALS performed by crew members, ambulance service personnel, and in the ED, the Supervisor 

died. The United States Fire Administration notified 

NIOSH of this fatality on May 19, 2014. NIOSH contacted the affected agency on May 19, 2014, to obtain 

further information and on July 3, 2014, to initiate the 

investigation. On July 14, 2014, a safety and occupational health specialist from the NIOSH Fire Fighter 

Fatality Investigation Program traveled to Wyoming 

to conduct an on-site investigation of the incident.

During the investigation NIOSH personnel interviewed the following people:

● State forestry conservation program manager

● Camp site manager

● The Supervisor’s crew members

● The Supervisor’s wife

During the site visit NIOSH personnel reviewed 

the following records:

● Primary care physician records

● Ambulance report

● Hospital’s ED report

● Death certificate

● U.S. Forest Service WCT requirements
A Summary of a NIOSH fire fighter fatality investigation Report #2014-13

Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

Test – Wyoming

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Investigative Results (cont.)

cardiac monitoring and two defibrillations, 

placing an intraosseous line with cardiac 

resuscitation medications administered, and 

intubation with tube placement verified by breath 

sounds and capnography [Neumar et al. 2010]. 

The ambulance departed the scene at 0841 hours 

en route to the ED, arriving at 0843 hours.

Inside the ED, ALS measures continued 

without a change in the Supervisor’s clinical 

status. Cardiac resuscitation efforts continued 

for 11 minutes, when the attending physician 

pronounced the Supervisor dead, and 

resuscitation efforts were discontinued (0854 

hours).

Medical Findings. The death certificate, 

completed by the county medical examiner, 

listed “acute myocardial infarction” due to 

“hypertension, type II diabetes mellitus, and 

morbid obesity” as the cause of death. No 

autopsy was performed.

The Supervisor had a number of chronic medical 

conditions. These included: 

● Hyperlipidemia diagnosed in 2010. His last 

laboratory blood tests revealed a normal level 

of total cholesterol level of 183 milligrams 

per deciliter (mg/dL) (normal is 100–199 

mg/dL); an elevated low density lipoprotein 

level of 117 mg/dL (normal is 0–99 mg/dL); 

a reduced high density lipoprotein level of 38 

mg/dL (normal is > 39 mg/dL); and a normal 

triglyceride level of 142 mg/dL (normal is 

0–149 mg/dL). He was being treated with diet 

and exercise.

● Diabetes mellitus type II diagnosed in 2011. 

His last laboratory blood test revealed an 

elevated glucose level of 111 mg/dL (normal is 

65–99) and an elevated hemoglobin A1C level 

of 6.1% (normal is 4.8%–5.6%). His diabetes 

was complicated by peripheral neuropathy 

and possibly nephropathy since 2011. He was 

being treated with diet.

● High blood pressure. His blood pressure was 

within normal limits when he took Losartan, 

an antihypertensive medication.

● Obesity since at least 2007.

● Nephropathy (presumably a complication 

of diabetes) diagnosed in 2011. His last 

laboratory blood test revealed an elevated 

creatinine level of 1.30 mg/dL (normal is 

0.76–1.27 mg/dL), a low glomerular filtration 

rate of 41 milliliters per minute per 1.73 meters 

squared (mL/min/1.73m2) (normal > 59 mL/

min/1.73m2), and no evidence of proteinuria.

● Metabolic syndrome.

In January 2014, the Supervisor weighed 303 

pounds (body mass index of 36.9 kilograms 

per square meter, which is considered obese 

[CDC 2014], had a blood pressure of 130/80 

millimeters of mercury (mmHg) (normal is 

120/80 mmHg), and a pulse rate of 72 beats 

per minute (normal 60–80). In April 2014, the 

Supervisor weighed 275 pounds, 28 pounds 

lower than 3 months earlier.

According to the Supervisor’s wife and agency 

personnel, the Supervisor exercised and had 

recently lost about 30 pounds. Additionally, 

he routinely performed physically demanding 

activities at his regular job as a crew boss. The 

Supervisor was asymptomatic while working and 

performing fire fighting duties.
A Summary of a NIOSH fire fighter fatality investigation Report #2014-13

Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

Test – Wyoming

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Description of the Agency

At the time of the NIOSH investigation, the state 

agency consisted of five districts, one helibase, and 

a forestry conservation program. All employees 

are state employees; prison inmates provide 

supplementary staff for the conservation program.

Membership and Training. The agency requires 

applicants to be 18 years of age, have a valid state 

driver’s license, pass a background check, and have 

a red card to fight wildland fires on state property.

The Supervisor was trained as a crew boss, felling 

boss, fire fighter I and II, firing boss, incident 

commander type 5, and helicopter crew member. 

He had 8 years of wildland fire fighting experience.

Screening Medical Questionnaire and Medical 

Evaluations. The state agency does not require 

candidates/members to complete an HSQ prior to 

any of the annual WCTs, which include the walk 

test, field test, or the pack test. Preplacement and 

annual medical evaluations also are not required. 

When members are injured on duty, a medical 

clearance for return to duty by the state workers’ 

compensation physician is required. If a member 

is ill and misses more than 3 days, a medical 

clearance is required by a primary care physician, 

who forwards an opinion for return to duty to the 

state agency.

Health and Wellness Programs. The state agency 

has a draft fitness policy that encourages employees 

to participate in the state wellness program and the 

National Interagency Fire Center fitness program 

called “FireFit” [NIFC 2010]. Although the 

Supervisor regularly participated in physical fitness 

activities, he did not participate in the state wellness 

program or FireFit. Annual pack tests are required 

for all employees who fight wildland fires. 

Discussion

Atherosclerotic Coronary Heart Disease and 

Sudden Cardiac Death. In the United States, 

atherosclerotic CHD is the most common risk 

factor for cardiac arrest and sudden cardiac death 

[Meyerburg and Castellanos 2008]. Risk factors 

for its development include age older than 45, 

male gender, family history of coronary artery 

disease, smoking, high blood pressure, high blood 

cholesterol, obesity/physical inactivity, and diabetes 

[NHLBI 2012; AHA 2014]. The Supervisor had 

three modifiable CHD risk factors (diabetes, high 

blood cholesterol, obesity) and had metabolic 

syndrome.

The narrowing of the coronary arteries by 

atherosclerotic plaques occurs over many years, 

typically decades [Libby 2013]. However, the 

growth of these plaques probably occurs in a 

nonlinear, often abrupt fashion. Heart attacks 

(myocardial infarctions) typically occur with 

the sudden development of complete blockage 

(occlusion) in one or more coronary arteries that 

have not developed a collateral blood supply. This 

sudden blockage is primarily due to blood clots 

(thrombosis) forming on top of atherosclerotic 

plaques [Libby 2013].

Establishing a recent (acute) heart attack 

requires any of the following: characteristic 

electrocardiogram (EKG) changes, elevated 

cardiac enzymes, or coronary artery thrombus. The 

Supervisor did not have a heart rhythm on which to 

acquire an EKG, cardiac enzymes were not tested, 

and no autopsy was performed. Therefore, although 

the death certificate listed an acute heart attack 

as the cause of death, this cannot be definitively 

diagnosed.
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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Discussion (cont.)

Primary Arrhythmia. Another possible etiology 

for the Supervisor’s sudden cardiac death is a 

primary cardiac arrhythmia (e.g., ventricular 

tachycardia/fibrillation). Risk factors for ventricular 

tachycardia/fibrillation include cardiac disease, 

heart attack, sleep apnea, dietary supplements, 

smoking, alcohol, drug abuse, medications, 

diabetes, and hyperthyroidism [AHA 2012; 

Mayo Clinic 2013]. Because an acute heart attack 

cannot be definitively diagnosed, it is possible the 

Supervisor had a primary cardiac arrhythmia.

In addition to medical conditions, sudden cardiac 

death has been linked to heavy physical exertion 

[Tofler et al. 1992; Mittleman et al. 1993; Willich 

et al. 1993; Albert et al. 2000]. Among fire fighters, 

sudden cardiac events have been associated with 

alarm response, fire suppression, and heavy exertion 

during training (including physical fitness training) 

[Kales et al. 2003; Kales et al. 2007; NIOSH 2007]. 

The Supervisor had completed one third of the pack 

test. This activity expended about 7–8 METs, which 

is considered moderate to heavy physical activity 

[Gledhill and Jamnik 1992; Ainsworth et al. 2011]. 

NIOSH investigators conclude the Supervisor’s 

sudden cardiac death was probably due to a “silent” 

(no angina) heart attack or, less likely, a primary 

arrhythmia triggered by the physical exertion 

associated with the pack test.

Occupational Medical Standards for Wildland 

Fire Fighters. National Fire Equipment System 

(NFES) Standard 1596, Fitness and Work 

Capacity, provides information on fitness, work 

capacity, nutrition, hydration, the environment, 

work hardening, and injury prevention. It requires 

medical clearance for return to work, but not for 

preplacement, periodic, or pre-WCT evaluation 

[Sharkey and Gaskill 2009]. NFES 1596 refers to 

the American College of Sports Medicine (ACSM) 

recommendation for a medical examination for 

persons who are over the age of 40, who have heart 

disease risk factors (smoking, high blood pressure, 

elevated cholesterol), or who have been sedentary and 

plan a major increase in activity. For many others, 

a simple health screening questionnaire ensures 

readiness to engage in training, work, or a job-related 

WCT [Sharkey and Gaskill 2009]. The Supervisor 

had at least one of these ACSM triggers for a medical 

evaluation, but an HSQ was not completed.

NFES 1109, Work Capacity Test Administrator’s 

Guide, addresses requirements and 

recommendations for performing the WCT pack 

test. It does not require a pre-WCT medical 

examination for all applicants [Whitlock and 

Sharkey 2003]. When a medical examination is 

required, neither blood testing for lipid and glucose 

levels nor exercise stress tests (EST) are required. 

NFPA 1051, Standard for Wildland Fire Fighter 

Professional Qualifications, sets forth the requirements 

to become a wildland fire fighter including physical 

fitness and medical considerations. For medical 

clearance, NFPA 1051 refers to NFPA 1582, Standard 

on Comprehensive Occupational Medical Program for 

Fire Departments [NFPA 2012; NFPA 2013a]. NFPA 

1582 was developed, in part, to reduce the risk of 

sudden cardiac arrest or other incapacitating medical 

conditions among fire fighters. This voluntary industry 

standard provides the components of a preplacement 

and annual medical evaluation and medical fitness for 

duty criteria. The Supervisor had a medical condition 

that, according to NFPA 1582, should have resulted in 

his restricted work activity (diabetes mellitus) and two 

conditions that should have triggered an exercise stress 

test (metabolic syndrome and coronary heart disease 

risk factors).
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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Discussion (cont.)

Diabetes Mellitus. NFPA 1582 provides guidance 

for fire department physicians to follow when 

treating diabetic fire fighters [NFPA 2013a]. The 

standard states that fire fighters with diabetes 

mellitus that is controlled by diet, exercise, or oral 

hypoglycemic agents should be restricted from 

duty unless the member meets all of the following 

criteria:

(1) If on oral hypoglycemic agents, has had no 

episodes of severe hypoglycemia (defined as 

requiring assistance of another in the preceding 

year)

(2) Has achieved a stable blood glucose as 

evidenced by HA1C level less than 8 during the 

prior 3-month period

(3) Has a dilated retinal exam by a qualified 

ophthalmologist or optometrist that shows 

no higher grade of diabetic retinopathy than 

microaneurysms

(4) Has normal renal function on the basis of a 

calculated creatinine clearance greater than 

60 milliliters per minute and absence of 

proteinuria

(5) Has no autonomic or peripheral neuropathy

(6) Has normal cardiac function without evidence 

of myocardial ischemia on cardiac stress testing 

(to at least 12 METs) by EKG and cardiac 

imaging [NFPA 2013a]

The Supervisor had diabetes mellitus complications 

of nephropathy and peripheral neuropathy and 

according to NFPA 1582, should have been 

restricted from full duty.

Exercise Stress Tests. On the basis of the 

Supervisor’s age and history of high blood pressure, 

cholesterol, and diabetes mellitus, the NFPA, the 

American College of Cardiology/American Heart 

Association (ACC/AHA), and the American 

College of Sports Medicine (ACSM) would have 

recommended a symptom limiting exercise stress 

test to screen for CHD. The following paragraphs 

summarize the positions of widely recognized 

organizations on this topic.

NFPA. NFPA 1582’s Appendix A recommends 

using submaximal (85% of predicted heart rate) 

EST as a screening tool to evaluate a fire fighter’s 

aerobic capacity. Maximal (i.e., symptom-limiting) 

EST with imaging should be used for fire fighters 

with the following conditions:

● abnormal screening submaximal tests

● cardiac symptoms

● known coronary artery disease (CAD)

● one or more risk factors for CAD (in men older 

than 45 and women older than 55) 

Risk factors are defined as hypercholesterolemia 

(total cholesterol greater than 240 milligrams per 

deciliter), hypertension (diastolic blood pressure 

greater than 90 mm of mercury), smoking, diabetes 

mellitus, or family history of premature CAD 

(heart attack or sudden cardiac death in a firstdegree relative less than 60 years old). Given the 

Supervisor’s age, hypercholesterolemia, diabetes, 

and metabolic syndrome, a symptom-limiting EST 

should have been performed.

ACC/AHA. The ACC/AHA has also published 

exercise testing guidelines [Gibbons et al. 2002]. 

The ACC/AHA guideline states that the evidence 

to conduct stress tests in asymptomatic individuals 

is “less well established” (Class IIa) for those with 

diabetes mellitus Type II who plan to start vigorous 

exercise and (Class IIb) for the following groups: 

● persons with multiple risk factors (defined similarly to those listed by the NFPA)
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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Discussions (cont.)

● asymptomatic men older than 45 years and 

women older than 55 years:

○ who are sedentary and plan to start vigorous exercise

○ who are involved in occupations in which 

impairment might jeopardize public safety 

(e.g., fire fighters)

○ who are at high risk for coronary artery disease due to other diseases (e.g., peripheral 

vascular disease and chronic renal failure)

ACSM. The ACSM considers individuals with 

diabetes mellitus to be at high risk for CHD and 

recommends a medical examination and exercise 

testing [ACSM 2006].

Like NFPA, the above ACC/AHA and ACSM 

criteria suggest an EST would have been 

appropriate for the Supervisor. Had an EST been 

performed, perhaps the Supervisor’s CHD could 

have been identified, leading to further evaluation 

and treatment.

The National Wildfire Coordinating Group 

developed and follows the NFES 1596 and NFES 

1109 guidelines. Neither guideline requires an 

EST for asymptomatic individuals, although 

given the Supervisor’s age, diabetes mellitus, 

and high cholesterol, an EST would have been 

recommended by NFPA, AHA/ACC, and ACSM. 

Additionally, a mandatory comprehensive 

wellness/fitness program, including weight 

reduction, dietary education, and exercise would 

have benefited the Supervisor.

Recommendations

NIOSH investigators offer the following 

recommendations to reduce the risk of heart 

attacks and sudden cardiac arrest among fire 

fighters at this and other wildland agencies.

Recommendation #1: Require completion of an 

HSQ before participating in the WCT.

The WCT Administrator’s Guide states that the 

candidate must complete an HSQ or medical 

history designated by the hiring agency before 

training for the WCT [Whitlock and Sharkey 

2003]. Depending on the results of the HSQ and 

the age of the candidate, the agency may require 

a medical examination. Once individuals have 

received medical clearance, they may begin 

training for the WCT. The test administrator 

reviews the forms and determines whether to 

allow participants to take the test. If the test 

administrator is concerned that an applicant is not 

capable of completing the test, the administrator 

may require a medical clearance from the 

applicant’s primary care physician. 

The HSQ, located in Appendix B of the WCT 

Administrator’s Guide [Whitlock and Sharkey 

2003], does not cover all CAD risk factors 

identified by the AHA/ACC (Appendix A). 

Specifically, the HSQ includes no question 

regarding smoking status. In addition, some 

questions are ambiguous (e.g., Are you more 

than 20 pounds overweight?) without giving 

the fire fighter any guidance regarding ideal 

body weight, such as body mass index. NIOSH 

investigators suggest replacing these yes/no 

questions with questions that require the fire 

fighter to enter specific information (Appendix 

B). The WCT Administrator would then make the 

decision whether the fire fighter was fit to perform 
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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Recommendations (cont.)

the WCT. Using these questions puts more 

responsibility on fire fighters to know the results 

of their medical tests. The state should modify the 

WCT Administrator’s Guide HSQ to ensure that 

adequate and appropriate information regarding 

the health status of the fire fighter is identified.

In this instance, the state did not require that WCT 

candidates complete an HSQ prior to the walk test, 

the more arduous field test, or the most arduous 

pack test [Sharkey and Gaskill 2009]. If the 

Supervisor had completed the HSQ and checked 

the boxes for diabetes and high cholesterol 

(Appendix A), the WCT Administrator may not 

have allowed the Supervisor to take the pack test.

Recommendation #2: Require exercise stress 

tests for fire fighters at increased risk for CHD.

NFPA 1582, the IAFF/IAFC Fire Service 

Joint Labor Management Wellness/Fitness 

Initiative, and the ACC/AHA recommend an 

exercise stress test for male fire fighters older 

than 45 with one or more CAD risk factors 

[IAFF, IAFC 2008; Gibbons et al. 2002; NFPA 

2013a]. The Supervisor was over the age of 

45 and had hypercholesterolemia and diabetes 

mellitus. The EST could be conducted by the 

fire fighter’s personal physician or the statecontracted physician. If the fire fighter’s personal 

physician conducts the test, the results must be 

communicated to the state-contracted physician, 

who should be responsible for decisions regarding 

medical clearance for fire fighting duties. The 

state should ensure ESTs are conducted on high 

risk individuals during the fire fighters’ physical 

evaluations. 

Recommendation #3: Restrict fire fighters with 

medical conditions that have an increased risk 

of sudden incapacitation (e.g., cardiac arrest) as 

detailed in NFPA 1582.

The Supervisor’s CHD was undiagnosed; 

however, according to NFPA 1582, the continuing 

presence of modifiable CHD risk factors (high 

cholesterol, diabetes mellitus, and hemoglobin 

A1c) should have restricted his participation 

in fire suppression tasks [NFPA 2013a]. This 

guidance from NFPA is similar to that of the 

American College of Cardiology/American 

Heart Association and the U.S. Department of 

Transportation for commercial truck drivers 

[Gibbons et al. 2002; Blumenthal et al. 2007; 

NFPA 2013a].

Recommendation #5: Check WCT participants’ 

vital signs before and after testing.

NFES 1109, Work Capacity Test Administrator’s 

Guide, requires that an emergency medical 

technician or someone with equivalent 

qualifications observe candidates during and after 

the test and be available to provide emergency 

medical assistance, if needed [Whitlock and 

Sharkey 2003]. The emergency medical technician 

should take participant vital signs (pulse, blood 

pressure, and respirations) before and after the 

WCT to ensure that the participant does not have 

a precluding condition before the test, and that the 

participant’s vital signs return to normal levels 

after the test.

Recommendation #6: Phase in a mandatory 

comprehensive wellness and fitness program for 

fire fighters.
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Recommendations (cont.) References

Guidance for fire department wellness/fitness 

programs to reduce risk factors for cardiovascular 

disease and improve cardiovascular capacity is 

found in NFPA 1583, Standard on Health-Related 

Fitness Programs for Fire Fighters, the IAFF/

IAFC Fire Service Joint Labor Management 

Wellness/Fitness Initiative, and in Firefighter 

Fitness: A Health and Wellness Guide [IAFF, 

IAFC 2008; NFPA 2008; Schneider 2010]. 

Worksite health promotion programs have 

been shown to be cost effective by increasing 

productivity, reducing absenteeism, and reducing 

the number of work-related injuries and lost 

work days [Pelletier 2009; Baicker et al. 2010]. 

Fire service health promotion programs have 

been shown to reduce CAD risk factors and 

improve fitness levels, with mandatory programs 

showing the most benefit [Dempsey et al. 2002; 

Womack et al. 2005; Blevins et al. 2006; Poston 

et al. 2013]. A study conducted by the Oregon 

Health and Science University reported a 

savings of more than $1 million for each of four 

large fire departments implementing the IAFF/

IAFC wellness/fitness program compared to 

four large fire departments not implementing a 

program. These savings were primarily due to a 

reduction of occupational injury/illness claims 

with additional savings expected from reduced 

future nonoccupational healthcare costs [Kuehl 

et al. 2013]. At the time of our investigation, the 

Agency had a draft wellness/fitness program, 

but exercise equipment was not available in 

the fire station. NIOSH recommends a formal, 

mandatory wellness/fitness program to ensure 

all members receive the benefits of a health 

promotion program.

ACSM (American College of Sports Medicine) 

[2006]. Preparticipation health screening and risk 

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RM, eds. ACSM’s guidelines for exercise testing and 

prescription. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins.

AHA [2012]. Understand your risk for arrhythmia. 

Dallas, TX: American Heart Association. [http://www.

heart.org/HEARTORG/Conditions/Arrhythmia/UnderstandYourRiskforArrhythmia/Understand-YourRisk-for-Arrhythmia_UCM_002024_Article.jsp]. 

Date accessed: September 2014.

AHA [2014]. Understand your risk of heart attack. 

Dallas, TX: American Heart Association. [http://www.

heart.org/HEARTORG/Conditions/HeartAttack/

UnderstandYourRiskofHeartAttack/Understand-YourRisk-of-Heart-Attack_UCM_002040_Article.jsp]. 

Date accessed: September 2014.

Ainsworth BE, Haskell WL, Herrmann SD, Meckes 

N, Bassett DR Jr, Tudor-Locke C, Greer JL, Vezina J, 

Whitt-Glover MC, Leon AS [2011]. Compendium of 

physical activities: a second update of codes and MET 

values. Med Sci Sports Exerc 43(8):1575–1581. 

Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE [2000]. Triggering of sudden 

death from cardiac causes by vigorous exertion. N 

Engl J Med 343(19):1355–1361.

Baicker K, Cutler D, Song Z [2010]. Workplace wellness programs can generate savings. Health Affairs 

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Blevins JS, Bounds R, Armstrong E, Coast JR [2006]. 

Health and fitness programming for fire fighters: does 

it produce results? Med Sci Sports Exerc 38(5):S454.
A Summary of a NIOSH fire fighter fatality investigation Report #2014-13

Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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References (cont.)

CDC (Centers for Disease Control and Prevention) [2014]. Assessing your weight. [http://www.

cdc.gov/healthyweight/assessing/index.html]. 

Date accessed: September 2014.

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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Page 13

This incident was investigated by the 

NIOSH Fire Fighter Fatality Investigation 

and Prevention Program, Cardiovascular 

Disease Component in Cincinnati, Ohio. Mr. 

Tommy Baldwin (MS) led the investigation 

and co-authored the report. Mr. Baldwin is a 

Safety and Occupational Health Specialist, 

a National Association of Fire Investigators 

(NAFI) Certified Fire and Explosion 

Investigator, an International Fire Service 

Accreditation Congress (IFSAC) Certified 

Fire Officer I, and a former Fire Chief and 

Emergency Medical Technician. Dr. Thomas 

Hales (MD, MPH) provided medical 

consultation and co-authored the report. Dr. 

Hales is a member of the NFPA Technical 

Committee on Occupational Safety and 

Heath, and Vice-Chair of the Public Safety 

Medicine Section of the American College 

of Occupational and Environmental 

Medicine (ACOEM).

Investigator Information
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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Appendix A

USDA Forest Service/Department of the Interior FS-5100-31 (v 03/2013) OMB 0596-0164 (Expires 03/2016) WCT Level

 Health Screening Questionnaire (HSQ) __ Arduous 

 Assess your health needs by marking all true statements __Moderate 

 __Light

The purpose is to identify individuals who may be at risk in taking the Work Capacity Test (WCT) and recommend an exercise program and/or medical examination 

prior to taking the WCT.

Employees are required to answer the following questions. The questions were designed, in consultation with occupational health physicians, to identify individuals 

who may be at risk when taking a WCT. The HSQ is not a medical examination. Any medical concerns you have that place you or your health at risk should be 

reviewed with your personal physician prior to participating in the WCT.

Check ‘Yes’ or ‘No’ in response to the following questions:

[ ] Y [ ] N 1) During the past 12 months have you at any time (during physical activity or while resting) 

 experienced pain, discomfort or pressure in your chest. 

[ ] Y [ ] N 2) During the past 12 months have you experienced difficulty breathing or shortness of breath, 

 dizziness, fainting, or blackout?

[ ] Y [ ] N 3) Do you have a blood pressure with systolic (top #) greater than 140 or diastolic (bottom #) greater 

 than 90?

[ ] Y [ ] N 4) Have you ever been diagnosed or treated for any heart disease, heart murmur, chest pain (angina), 

 palpitations (irregular beat), or heart attack?

[ ] Y [ ] N 5) Have you ever had heart surgery, angioplasty, or a pace maker, valve replacement, or heart 

 transplant?

[ ] Y [ ] N 6) Do you have a resting pulse greater than 100 beats per minute?

[ ] Y [ ] N 7) Do you have any arthritis, back trouble, hip /knee/joint /pain, or any other bone or joint condition 

 that could be aggravated or made worse by the Work Capacity Test?

[ ] Y [ ] N 8) Do you have personal experience or doctor’s advice of any other medical or physical reason that 

 would prohibit you from taking the Work Capacity Test?

[ ] Y [ ] N 9) Has your personal physician recommended against taking the Work Capacity Test because of 

 asthma, diabetes, epilepsy or elevated cholesterol or a hernia?

Regardless whether you are taking the Work Capacity test at the Arduous, Moderate or Light duty level, a “Yes” answer requires a determination from your personal 

physician stating that you are able to participate. 

I understand that if I need to be evaluated by a physician, it will be based on the fitness requirements of the position(s) for which I am qualified. 

Signature:______________________________________ Printed Name ______________________________________Date ______________ 

Unit: ________________________________________________ City ______________________State _________________

Privacy Statement

The information obtained in the completion of this form is used to help determine whether an individual being considered for wildland firefighting can carry out those 

duties in a manner that will not place the candidate unduly at risk due to inadequate physical fitness and health. Its collection and use are covered under Privacy Act 

System of Records OPM/Govt-10 and are consistent with the provisions of 5 USC 552a (Privacy Act of 1974).

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless 

it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0164. The time required to complete this information 

collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 

data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and 

activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, 

etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 

1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and 

employer.
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Fire Crew Supervisor Suffers Sudden Cardiac Death During Pack 

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Appendix B

NIOSH-recommended Questions

History:

● Male older than 45 years

● Female older than 55 years

● Father or brother has had a heart attack before age 55

● Mother or sister has had a heart attack before age 65

● Smoker

● Previously diagnosed with hypertension (high blood pressure)

○ Take prescription medication for high blood pressure

○ Most recent blood pressure measurement

○ Date of most recent blood pressure measurement

● Previously diagnosed with hypercholesterolemia/hyperlipidemia (high blood cholesterol) 

○ Take prescription medication for high blood cholesterol

○ Most recent cholesterol levels [e.g., low density lipoprotein (LDL), total cholesterol/high density lipoprotein (HDL) ratio]

○ Date of most recent cholesterol measurement

● Previously diagnosed with diabetes mellitus

○ Take prescription medication for diabetes

○ Most recent blood sugar measurement

○ Date of most recent blood sugar measurement

Current height:

Current weight:

Physically inactive (i.e., you get less than 30 minutes of exercise at least 3 days per week)