NIOSH Fire Fighter Fatality Investigation and Prevention Program

F2021-08

Career Probationary Firefighter Dies 

During SCBA Confidence Training 

at Fire Academy – New York
NIOSH Fire Fighter Fatality Investigation and Prevention Program 2

Summary

• On March 12, 2021, a 21-year-old career 

probationary firefighter (PF) died nine 

days after a medical event during a 

training exercise. 

• The PF was maneuvering through a selfcontained breathing apparatus (SCBA) 

course training prop when he 

experienced a medical emergency and 

lost consciousness. 

• On March 3, 2021, after two days of 

physically strenuous training, the PF 

spent the morning shift practicing 

individual obstacles to prepare for the 

maze. 

• Recruit interviews reveal varying reports 

of the PF appearing nervous, pale, 

sweaty and cramping at different times 

during the late morning and while at 

lunch.

Tunnel Prop

(Photo by NIOSH)
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Summary

• The afternoon training session 

continued with negotiation of the 

escape and confidence props practiced 

during the morning. 

• In addition to the props from the 

morning session, a 21-feet-long wooden 

entanglement and obstacle confined 

space tunnel prop (tunnel prop) was 

added (see photo). 

• While in the tunnel prop, the PF 

stopped moving. 

• The instructors provided coaching to 

encourage the PF to continue moving 

through the prop, and assistance with 

displacing equipment interfering with 

forward movement. Tunnel prop made from a ladder 

shipping box

(Photo by NIOSH)
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Summary

• When forward movement did not 

continue by the PF, the instructors 

pulled him partially from the tunnel 

prop to ensure no gear or equipment 

were obstacles, leaving his lower 

extremities within the prop, and 

continued to coach him through the 

tunnel prop. 

• When the PF continued to not move, 

the instructors pulled him completely 

from the prop, removed his facepiece, 

and provided a rapid assessment. 

• The PF was identified as not breathing 

and having no pulse. The instructors 

began cardiopulmonary resuscitation 

(CPR). 

• The PF was transported to Hospital A 

and spontaneous circulation was gained 

before transport to Hospital B

The third restricted opening in the 

tunnel prop

(Photo by NIOSH)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 5

SCBA Confidence Drills training layout in the gymnasium.
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Contributing Factors

• A patent airway was not maintained from the period of the PF’s initial 

collapse in the tunnel prop until a definitive airway was established via 

endotracheal intubation on arrival at Hospital A

• Ineffective rehabilitation and medical monitoring were conducted and 

not in accordance with written policy

• Lack of a designated safety officer placed safety responsibilities on the 

instructors at the respiratory protection training evolutions

• Lack of standard operating procedures (SOPs) and instructional 

objectives that specify actions to be taken by instructors and recruits 

when personal alert safety system (PASS) and End-of-Service-TimeIndicator (EOSTI) devices are engaged and alarming during training 

evolutions

• Lack of a written risk management plan to address administrative 

controls that includes manufacturer recommended training on 

limitations of structural gear and SCBA and heat-related illness/injury 

recognition and reporting
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Contributing Factors

• Lack of instructional objectives developed and communicated for each 

activity of the evolution based on the training facility’s written Job 

Performance Requirements (JPR)

• Lack of comprehensive SOPs for each training prop and associated drill.
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Recommendations

• Adhere to certification requirements for Basic Life Support (BLS) for 

Healthcare Providers, either through American Heart Association or 

American Red Cross, which require a clear and open airway and assisted 

ventilations with an oxygen source to prevent anoxic brain injury in a 

person in respiratory arrest

• Fire training facilities should ensure use of a comprehensive 

rehabilitation program complying with NFPA 1584, Standard on the 

Rehabilitation Process for Members During Training Exercises [NFPA 

2015]

• Fire training facilities should appoint a safety officer to review the 

planned training exercises and actively observe all training activities

• The PASS and EOSTI activations during training should be addressed in 

training SOPs, and the instructional objectives should be outlined in 

training SOPs and repeated during pre-training safety briefings
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Recommendations

• Fire training facilities should implement a systematic risk management 

process in all activities, and ensure that it includes training on structural 

gear and SCBA limitations and heat-related illness/injury recognition and 

reporting

• Fire training facilities should ensure instructional objectives are 

developed and communicated for training evolutions intended to satisfy 

a job performance requirement and ensure instructors follow 

compliance with instructional objectives and reasons associated with 

deviation from the objective(s)

• Fire training facilities should ensure that SOPs for each skill/drill are 

developed and implemented
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Recommendations

The following recommendations were not considered contributing factors in 

this incident but are being provided as accepted standard operating 

guidelines and best practices:

• During advanced SCBA skills and confidence building training 

programs, recruits should be cautioned against “filter breathing”

• Fire training facilities should ensure that training props and 

confined spaces used in SCBA confidence training have adequate 

safety features, such as, emergency egress panels, emergency 

lighting, ventilation, and a temperature monitoring system to 

measure the internal ambient temperature
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CONTACT US

Fire Fighter Fatality Investigation and Prevention Program

Surveillance and Field Investigations Branch

Division of Safety Research

NIOSH 1000 Frederick Lane, MS 1808

Morgantown, West Virginia 26505-2888

FFFIPP Webpage

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