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

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

Executive Summary

2014

12

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

On March 8, 2014, a 61-year-old male paid-call 

lieutenant (LT) performed the 

U. S. Forest Service arduous duty Work Capacity 

Test (WCT), also known as the “Pack Test.” 

The test is a required component of “red card 

certification” allowing wildland firefighters to 

work on federal property. The Pack Test requires 

a 3-mile walk within 45 minutes while wearing a 

45-pound weighted vest. After completing 6 laps 

around the track (1.5 miles), the LT stumbled, 

appeared dizzy, and then collapsed. Crewmembers 

assessed him and found him unresponsive, not 

breathing, and without a pulse; they initiated 

cardiopulmonary resuscitation (CPR) and 

advanced life support (ALS). Despite CPR and 

ALS on-scene and in the hospital’s emergency 

department (ED), the LT could not be revived. The 

death certificate and the autopsy, completed by the 

County Medical Examiner, listed “complications 

of acute myocardial infarct (heart attack)” due to 

“hypertensive and arteriosclerotic cardiovascular 

disease” as the cause of death. The LT had a 

left ventricular rupture and cardiac tamponade. 

Prior to this incident, the LT was not known 

to have coronary heart disease (CHD). The 

NIOSH investigators concluded that the physical 

stress of the Pack Test probably precipitated 

his left ventricle rupture in an area weakened 

by an asymptomatic heart attack occurring 

approximately 1 week earlier.

It is unclear if any of the following 

recommendations would have prevented the 

LT’s death. Nonetheless, NIOSH investigators 

offer the following recommendations to reduce 

the risk of heart attacks and sudden cardiac 

arrest among fire fighters at this and other FDs. 

Provide preplacement and annual medical 

evaluations to all fire fighters consistent with 

NFPA 1582, Standard on Comprehensive 

Occupational Medical Program for Fire 

Departments, to identify fire fighters at 

increased risk for CHD.

Perform exercise stress tests on fire fighters at 

increased risk for CHD.

Check Pack Test participants’ vital signs 

before testing.

Require the completion of a Health Screen 

Questionnaire (HSQ) prior to participating in 

the Pack Test.
A Summary of a NIOSH fire fighter fatality investigation Report #2014-12

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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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 #2014-12

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

Page 3

Introduction & Methods

On March 8, 2014, a 61-year-old male LT suffered 

sudden cardiac death during his Pack Test. Despite 

CPR and ALS performed by crewmembers, ambulance service personnel, and physicians in the 

hospital’s ED, the LT died. The United States Fire 

Administration notified NIOSH of this fatality on 

March 10, 2014. NIOSH contacted the affected 

FD on March 14, 2014, to obtain further information and on June 5, 2014, to initiate the investigation. On June 24, 2014, a Safety and Occupational 

Health Specialist from the NIOSH Fire Fighter 

Fatality Investigation Team traveled to Arizona to 

conduct an on-site investigation of the incident.

During the investigation NIOSH personnel met 

and/or interviewed the following people:

● Acting Fire Chief

● LT’s crewmembers

● Pack Test Administrator, who also was the FD 

Training Officer

● LT’s wife

During the site visit NIOSH personnel reviewed 

the following records:

● FD training records

● FD annual response report for 2013

● Primary care physician records

● Ambulance report

● Death certificate

● Autopsy report

Results of Investigation

On March 8, 2014, at 0730 hours, the LT arrived at 

his fire station to participate in the FD-scheduled 

U.S. Forest Service arduous duty WCT, also known 

as the “Pack Test.” Seven other fire fighters were 

scheduled to take the test. After arriving at the fire 

station and retrieving the equipment and water, the 

crew departed for the local high school track. The 

FD’s on-duty crew remained at the track to assist.

All attendees were briefed, drank water, donned 

the weighted vests, and stretched. The Training 

Officer began the test at approximately 0800 

hours. The LT completed 6 laps without difficulty 

(1.5 miles in 23 minutes) but as he began lap 7, 

he stumbled, appeared dizzy, and then collapsed. 

A crewmember caught the LT and assisted him 

to the ground; he was unresponsive with agonal 

breathing. Crewmembers initially thought he was 

suffering from heat exhaustion, possibly heat 

syncope. After removing his vest and elevating 

his feet, further assessment revealed the LT had 

no pulse. As medical equipment was retrieved, an 

ambulance and a neighboring city engine company 

were requested (0831 hours).

Crewmembers began CPR and ALS including 

cardiac monitoring which revealed pulseless 

electrical activity and asystole. An intravenous line 

was inserted, cardiac resuscitation medications 

were administered, and an oral airway for oxygen 

was placed. Engine paramedics arrived on-scene 

at 0835 hours. After a second round of cardiac 

medications was administered, the LT’s heart 

rhythm went into ventricular fibrillation and a 

shock was delivered; his heart rhythm reverted to 

pulseless electrical activity. CPR continued as the 

LT was intubated, with tube placement confirmed 

by breath sounds and capnography [Neumar et al. 
A Summary of a NIOSH fire fighter fatality investigation Report #2014-12

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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Results of Investigation (cont.)

2010]. The ambulance departed the scene at 0845 

hours en route to the ED, arriving at 0852 hours.

Inside the ED, ALS measures continued without 

a change in the LT’s clinical status. Cardiac 

resuscitation efforts continued until 0917 hours, 

when the attending physician pronounced the LT 

dead and resuscitation efforts were discontinued. 

Subsequent blood testing revealed a markedly 

elevated level of troponin I (5.57 nanograms per 

milliliter [ng/mL] [normal < 0.05]). Troponin I is 

a protein released into the blood when the heart 

muscle is damaged [NIH 2014]. Troponin I levels 

become elevated about 6 hours after a heart attack 

and these levels persist for 1 to 2 weeks [NIH 

2014].This finding suggests the LT suffered a heart 

attack days or weeks prior [Ellis 1991; Mair et al. 

1992; Antman et al. 1995]. The autopsy findings, 

described below, confirm this timing of events.

Medical Findings. The death certificate 

and the autopsy, completed by the County 

Medical Examiner, listed “complications 

of acute myocardial infarct” over days 

due to “hypertensive and arteriosclerotic 

cardiovascular disease” occurring over years as 

the cause of death. The complications included a 

transmural tear in an area of damaged (necrotic) 

tissue in the LT’s left ventricle. This tear 

resulted in acute bleeding into the pericardial 

sac (hemopericardium) and constricted the 

heart’s ability to function (cardiac tamponade). 

The necrotic tissue was due to a heart attack that 

occurred days to weeks earlier; evidence for the 

heart attack included the LT’s troponin I levels 

and an organizing blood clot (thrombus) in the 

LT’s left anterior descending coronary artery. 

See Appendix A for additional findings from the 

autopsy.

At his last medical evaluation (September 2013) 

by his primary care physician, the LT weighed 

183 pounds giving him a body mass index of 

24 kilograms per square meter (normal) [CDC 

2014]. The LT had a history of hyperlipidemia. 

His most recent tests (September 2013) showed a 

triglyceride level of 195 milligrams per deciliter 

(mg/dL) (normal), a cholesterol level of 217 mg/

dL (normal is 100-199 mg/dL), a high density 

lipoprotein level of 46 mg/dL (normal), and a low 

density lipoprotein level of 32 mg/dL (normal). He 

was not prescribed cholesterol-lowering medication 

or diet modification. He was not known to be 

hypertensive; he had normal annual blood pressure 

readings over 13 years except for one elevated 

diastolic reading of 92 millimeters of mercury 

(mmHg) in September 2013.

About 1 month prior to this incident, the LT 

complained of rib pain attributed to a pulled 

muscle when he was repairing an FD engine. 

After taking over-the-counter pain medication, 

the pain subsided. On March 2, 2014, the LT 

complained of “not feeling well.” No additional 

symptoms or complaints were mentioned. An 

informal electrocardiogram (EKG) performed 

by paramedics at his fire station revealed a slight 

ST-segment depression, which was considered 

insignificant; immediate evaluation by a physician 

was not considered necessary. The LT was advised 

to follow-up with a physician, and had scheduled 

an appointment with a cardiologist for March 10, 

2014 (2 days after this incident). The record of the 

informal EKG taken 6 days earlier was discarded 

and not available for review. It is unclear if the LT’s 

earlier heart attack occurred on the job and if it was 

triggered by work activities.
A Summary of a NIOSH fire fighter fatality investigation Report #2014-12

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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Description of the Fire Department

At the time of the NIOSH investigation, the FD 

consisted of three fire stations with 42 (11 fulltime and 31 volunteer) uniformed personnel. The 

FD served 4,600 residents in a geographic area of 

34 square miles. In 2013, the FD responded to 336 

fire/rescue calls.

Membership and Training. The FD requires fire 

fighter applicants to be 18 years of age, have a 

valid state driver’s license, perform three ridealongs, and pass the following before being offered membership/employment: officer evaluation, three-panel interview, background check, 

preplacement medical evaluation (discussed below), physical agility test (Appendix B), and Fire 

Chief’s interview. The new member is on probation for 1 year and has 2 years to complete Fire 

Fighter I and II and Emergency Medical Technician certifications. The LT was trained as a Fire 

Fighter I and II, Apparatus Operator, Emergency 

Medical Technician, Fire Officer, Wildland Fire 

Fighter, and in Hazardous Materials Awareness. 

He had 15 years of fire fighting experience.

Medical Evaluations. Preplacement medical 

evaluations are required by the FD. The medical 

evaluations are performed by an FD-contracted 

physician who makes a determination regarding 

medical clearance for fire fighting duties and forwards this decision to the FD. Components of this 

evaluation include the following:

● Complete medical history

● Physical examination (including vital signs 

– height, weight, blood pressure, pulse, and 

respirations)

● Vision test (acuity, color, peripheral fields, and 

depth perception)

● Audiogram

● Urinalysis

● Urine drug screen

● Self-contained breathing apparatus respirator 

clearance

Annual medical evaluations are not required. 

When members are injured on duty, a drug test 

and medical clearance for return to duty by the 

treating physician are required. If a member is ill 

and misses more than two shifts, a medical clearance is required by their primary care physician, 

who forwards a determination for return to duty to 

the FD. Annual facepiece fit testing is conducted 

as required by OSHA [OSHA 2011] under the approved plan for Arizona.

Health and Wellness Programs. The FD has a 

mandatory wellness/fitness program and exercise 

equipment is available in all fire stations. An annual 

job performance physical ability test is required for 

all members (Appendix B) as required by NFPA 

1500, Standard on Fire Department Occupational 

Safety and Health Program [NFPA 2013a]. The LT 

regularly participated in physical fitness activities.

Pre-placement/Pre-WCT Evaluations. Before 

training for the WCT or the duties of the job, the 

Administrator’s Guide states that the candidate must 

complete an HSQ (or medical history) designated 

by the hiring agency [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. In 

Arizona, the State did not require that WCT candidates be medically cleared, pass a medical examination, or complete an HSQ prior to the Walk Test, the 

more arduous Field Test, or the most arduous Pack 

Test [Sharkey and Gaskill 2009].
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Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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Discussion

Cardiac Tamponade. In cardiac tamponade, blood 

or fluid collects in the sac around the heart. This 

accumulation constricts the heart, which prevents 

it from filling properly, and causes a sharp drop in 

blood pressure. Unless treated immediately, fatal 

cardiac tamponade typically ensues [Braunwald 

2008; AHA 2013].

Left Ventricular Rupture. In patients with acute 

myocardial infarction, left ventricular free wall 

rupture is an infrequent complication (2-4%) 

but it is associated with a high mortality from 

pericardial tamponade [Figueras et al. 2000; Amir 

et al. 2005]. Risk factors, or triggering factors, 

for free wall rupture include age >55 years, the 

presence of persistent arterial hypertension (≥150 

mmHg) during the first 10-24 hours of the acute 

infarction, and significant physical effort [Figueras 

et al. 2000; Amir et al. 2005]. Late rupture (≥ 24 

hours between onset of symptoms and hospital 

admission) is associated with physical exercise 

probably due to rupture of the necrotic tissue 

caused by the heart attack [Figueras et al. 1998; 

Figueras et al. 2000; Raposo et al. 2006]. The LT 

probably suffered a heart attack approximately 

1 week prior to this incident as evidenced by 

an organizing thrombus in his left anterior 

descending coronary artery and focal area of 

necrotic tissue in the left ventricle. The physical 

exertion associated with the Pack Test probably 

triggered a rupture of the LT’s left ventricle.

Atherosclerotic Coronary Heart Disease 

and Heart Attacks. 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 (CAD), smoking, high blood pressure, 

high blood cholesterol, obesity/physical inactivity, 

and diabetes [NHLBI 2012; AHA 2014]. The 

LT had one known modifiable CHD risk factor 

(high blood cholesterol), although his autopsy 

showed signs of longstanding hypertension (left 

ventricular hypertrophy, borderline cardiomegaly, 

and nephrosclerosis).

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 

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 ruptured atherosclerotic plaques [Libby 2013]. 

Establishing a recent heart attack requires any of 

the following: elevated cardiac enzymes, coronary 

artery thrombus, or characteristic EKG changes. 

In this case, the LT had elevated cardiac enzymes 

(troponin I), an organizing thrombus revealed 

at autopsy, as well as a focal necrotic area of 

myocardium in the distribution of the left anterior 

descending coronary artery. The EKG taken 6 

days prior was reported to have abnormalities, 

but none of the characteristic changes of an acute 

heart attack. Finally, chest pain (angina) typically 

accompanies a heart attack. The LT reported rib 

pain 1 month prior to this incident and then “not 

feeling well” 6 days prior. It is unclear if these 

symptoms represented angina or whether the LT 

experienced a “silent” heart attack [Thaulow et al. 

1993; Libby 2008].
A Summary of a NIOSH fire fighter fatality investigation Report #2014-12

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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Discussion (cont.)

Occupational Medical Standards for Structural 

Fire Fighters. To reduce the risk of sudden 

cardiac arrest or other incapacitating medical 

conditions among fire fighters, the National Fire 

Protection Association (NFPA) developed NFPA 

1582, Standard on Comprehensive Occupational 

Medical Program for Fire Departments [NFPA 

2013b]. This voluntary industry standard 

provides the components of a preplacement 

and annual medical evaluation and medical 

fitness for duty criteria. The LT’s underlying 

CHD was not identified until after this incident. 

Recommendations on whether to screen 

asymptomatic individuals for CHD using EST are 

varied. The following paragraphs summarize the 

positions of widely recognized organizations on 

this topic.

NFPA 1582, a voluntary industry standard, 

recommends an EST performed “as clinically 

indicated by history or symptoms” and refers the 

reader to Appendix A [NFPA 2013b]. Items in 

Appendix A are not standard requirements, but 

are provided for “informational purposes only.” 

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 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 

first-degree relative less than 60 years old). Given 

the LT’s age with no defined risk factors, NFPA 

1582 would not have recommended a symptomlimiting EST.

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 IIb) for the following groups: 

● persons with multiple risk factors (defined 

similarly to those listed by the NFPA)

● 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)

Given the LT’s public safety position, the ACC/

AHA criteria suggest an EST may have been 

appropriate for the LT.

The U.S. Department of Transportation provides 

guidance for those seeking medical certification 

for a commercial driver’s license. An expert 

medical panel recommended exercise tolerance 

tests (stress tests) for asymptomatic “high risk” 

drivers [Blumenthal et al. 2007]. The panel 

defines high risk drivers as those with any of the 

following:
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Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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Discussion (cont.)

● diabetes mellitus

● peripheral vascular disease

● age 45 and above with multiple risk factors for 

CHD

● Framingham risk score predicting a 20% CHD 

event risk over the next 10 years 

Given the LT’s Framingham risk score of 11%, 

the U.S. Department of Transportation would 

not have recommended an EST for a commercial 

truck driver with a similar profile [NHLBI 2013].

The U.S. Preventive Services Task Force 

(USPSTF) does not recommend stress tests for 

asymptomatic individuals at low risk for CHD 

events. For individuals at increased risk for CHD 

events, the USPSTF found “insufficient evidence 

to recommend for or against routine screening 

with EKG, exercise tolerance test, or electron 

beam computerized tomography scanning....” 

Rather, they recommend the diagnosis and 

treatment of modifiable risk factors (hypertension, 

high cholesterol, smoking, and diabetes) [USPSTF 

2004]. The USPSTF does note that “For people 

in certain occupations, such as pilots, and 

heavy equipment operators (for whom sudden 

incapacitation or sudden death may endanger 

the safety of others), consideration other than 

the health benefit to the individual patient may 

influence the decision to screen for coronary heart 

disease.”

Had an EST been performed, perhaps the LT’s 

CHD could have been identified, leading to further 

evaluation and treatment.

It is unclear if any of the following 

recommendations would have prevented the 

LT’s death. Nonetheless, NIOSH investigators 

offer the following recommendations to reduce 

the risk of heart attacks and sudden cardiac 

arrest among fire fighters at this and other FDs. 

Recommendation #1: Provide preplacement 

and annual medical evaluations to all fire 

fighters in accordance with NFPA 1582, 

Standard on Comprehensive Occupational 

Medical Program for Fire Departments, to 

identify fire fighters at increased risk for CHD.

Guidance regarding the content and frequency 

of these medical evaluations can be found in 

NFPA 1582 and in the International Association 

of Fire Fighters (IAFF)/International 

Association of Fire Chiefs (IAFC) Fire Service 

Joint Labor Management Wellness/Fitness 

Initiative [IAFF, IAFC 2008; NFPA 2013b]. 

These evaluations are performed to determine 

fire fighters’ medical ability to perform duties 

without presenting a significant risk to the safety 

and health of themselves or others. Following 

this recommendation will require significant 

resources and may be particularly difficult for 

smaller fire departments to implement. The 

FD is not legally required to follow the NFPA 

standard or the IAFF/IAFC guideline.

To overcome the financial obstacle of medical 

evaluations, the FD could urge current members 

to get annual medical clearances from their 

private physicians. Another option is having 

the annual medical evaluations completed by 

paramedics and emergency medical technicians 

from the local ambulance service (vital signs, 

height, weight, visual acuity, and EKG). 

Recommendations
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Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

- Arizona

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Recommendations (cont.)

This information could then be provided to a 

community physician (perhaps volunteering 

his or her time), who could review the data 

and provide medical clearance (or further 

evaluation, if needed). The more extensive 

portions of the medical evaluations (e.g., EST) 

could be performed by a private physician at 

the fire fighter’s expense (personal or through 

insurance), provided by a physician volunteer, 

or paid for by the FD, city, or state. Sharing the 

financial responsibility for these evaluations 

between fire fighters, the FD, the city, the 

state, and physician volunteers may reduce 

the negative financial impact on recruiting and 

retaining needed fire fighters.

Recommendation #2: Perform exercise stress 

tests on 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 2013b]. The 

LT was over the age of 45 and had borderline 

high blood cholesterol. A symptom-limiting 

EST may have identified his underlying CHD, 

possibly leading to further evaluation and 

treatment.

Recommendation #3: Check Pack Test 

participants’ vital signs before 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 WCTs to ensure that the 

participant does not have a precluding condition 

prior to the test, and that the participant’s vital 

signs return to normal levels after the test. After 

this incident, the FD began requiring vital sign 

checks for all members performing strenuous 

physical exertion activities.

Recommendation #6: Require the completion of 

a HSQ prior to participating in the Pack Test.

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 or the 

duties of the job [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. In 

this instance, the State did not require that WCT 

candidates complete a HSQ prior to the Walk 

Test, the more arduous Field Test, or the most 

arduous Pack Test [Sharkey and Gaskill 2009]. 

Nonetheless, NIOSH investigators recommend 

the FD follow National Wildland Coordinating 

Group (NWCG) guidance.
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- Arizona

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NFPA [2013b]. Standard on comprehensive occupational medical program for fire departments. 

Quincy, MA: National Fire Protection Association. 

NFPA 1582.

NHLBI [2012]. Who is at risk for coronary artery 

disease? National Heart, Lung, and Blood Institute. 

[http://www.nhlbi.nih.gov/health/health-topics/topics/cad/atrisk.html]. Date accessed: July 2014.

NHLBI [2013]. Risk assessment tool for estimating your 10-year risk of having a heart attack. 

National Heart, Lung, and Blood Institute. [http://

cvdrisk.nhlbi.nih.gov/calculator.asp]. Date accessed: July 2014.

NIH (National Institutes of Health) [2014]. Troponin test. [http://www.nlm.nih.gov/medlineplus/

ency/article/007452.htm]. Date accessed: July 

2014.

Neumar RW, Otto CW, Link MS, Kronick SL, 

Shuster M, Callaway CW, Kudenchuk PJ, Ornato 

JP, McNally B, Silvers SM, Passman RS, White 

RD, Hess EP, Tang W, Davis D, Sinz E, Morrison 

LJ [2010]. Part 8: Adult advanced cardiovascular 

life support. 2010 American Heart Association 

Guidelines for cardiopulmonary resuscitation and 

emergency cardiovascular care. Dallas, TX: American Heart Association.

OSHA [2011]. Respiratory protection. Occupational Safety and Health Administration. [https://

www.osha.gov/pls/oshaweb/owadisp.show_

document?p_table=STANDARDS&p_id=12716]. 

Date accessed: July 2014.

Raposo L, Andrade JM, Ferreira J, Aguiar C, 

Couto R, Abecasis M, Canada M, Jalles-Tavares 

N, da Silva JA [2006]. Subacute left ventricle free 

wall rupture after acute myocardial infarction: 

awareness of the clinical signs and early use of 

echocardiography may be life-saving. Cardiovascular Ultrasound 4(1):46-54.

Sharkey BJ, Gaskill SE [2009]. Fitness and work 

capacity. NWCG. [http://www.nwcg.gov/pms/

pubs/pms304-2.pdf]. Date accessed July 2014.
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Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

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Page 12

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).

References (cont.) Investigator Information

Thaulow E, Erikssen J, Sandvik L, Erikssen G, Jorgensen L, Cohn PF [1993]. Initial clinical presentation of cardiac disease in asymptomatic men with 

silent myocardial ischemia and angiographically 

documented coronary artery disease (The Oslo 

Ischemia Study). Am J Cardiol 72(9):629–633.

USPSTF [2004]. U.S. Prevention Services Task 

Force. Screening for coronary heart disease: 

Recommendation Statement. Ann Intern Med 

140(7):569–572.

Whitlock C, Sharkey B [2003]. Work Capacity 

Test Administrator’s Guide. NWCG. [http://www.

nwcg.gov/pms/pubs/PMS307.pdf]. Date accessed 

July 2014.
A Summary of a NIOSH fire fighter fatality investigation Report #2014-12

Lieutenant Suffers Sudden Cardiac Death During the “Pack Test” 

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Appendix A

Autopsy Findings

● Transmural left ventricular tear in a focal area of necrotic tissue

● Cardiac tamponade due to hemopericardium (400cc of blood in pericardial sac)

● Coronary artery atherosclerosis

○ 90% narrowing of the left anterior descending coronary artery with small adherent thrombus 

(blood clot)

○ 60% focal narrowing of both the circumflex coronary artery and the right coronary artery

● Hypertensive heart disease

○ Mild left ventricular hypertrophy (1.9 centimeter [cm])

● Normal at autopsy is 0.76–0.88 cm [Colucci and Braunwald 1997] Borderline cardiomegaly (heart 

weighed 420 grams [g]; predicted normal weight is 349 g [ranges between 265 g and 461 g as a 

function of sex, age, and body weight]) [Silver and Silver 2001]

● Normal cardiac valves

● No evidence of a pulmonary embolus (blood clot in the lung arteries)

● Negative drug and alcohol tests 

References

Colucci WS, Braunwald E [1997]. Pathophysiology of heart failure. In: Braunwald, ed. Heart disease. 

5th ed. Philadelphia, PA: W.B. Saunders Company, p. 401.

Silver MM, Silver MD [2001]. Examination of the heart and of cardiovascular specimens in surgical 

pathology. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadelphia, 

PA: Churchill Livingstone, pp. 8–9.
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Appendix B

Physical Agility Test – Performed Annually

1. Hose Placement: The station is set up at the back of the engine that the candidate is stepping out 

of. If the rear tailboard is too narrow, utilize a folding table. The six 21⁄2-inch hose rolls will be placed 

6-feet from the table and stacked in 3 stacks of two each. The candidate picks up one roll at a time and 

places the roll onto the tailboard until 3 stacks of two are on the tailboard. Then, pausing by standing 

upright before resuming, the candidate replaces the hose to the original position.

2. High Rise Pack/Stair Climb: Carry the 100-feet, 13⁄4-inch high rise pack placed at the bottom of the 

stairs. The candidate places the pack on his/her shoulder and walks up the steps without skipping a step. 

Both feet are placed on the landing or ground prior to turning around. The candidate will hold onto the 

rail or wall with one hand for stability during this station. The candidate will go up twice and down 

once before placing the pack at the top of the stairs.

3. Hose Lift: One 21⁄2-inch taped hose roll is lying flat on the ground with a 50-foot rope attached and 

draped over the rail. The candidate will pull the hose up and over the rail, placing it on the landing.

4. Ladder Climb: The 24-foot ladder is placed between Bay 1 and Bay 2 and extended to be able to reach 

the ceiling by the “bell.” The candidate will climb the ladder one rung at a time and climb until he/she 

strikes the “bell” on the metal portion and then climbs down the ladder to the ground. The ladder will be 

tied off to the bay and roof to prevent slippage and spotters will be utilized on each side of the ladder.

5. Ventilation Exercise: The weighted sled will be placed at the first screw marks on the Kaiser sled and 

will be struck as many times as necessary to move the sled until one end passes the opposite edge of the 

sled. Prior to every 5th person attempting the station, the sled will be wiped down with a light coat of oil.

6. Ceiling Pull Exercise: The candidate, keeping one hand on the 8-foot pike pole at all times and never 

sliding or losing control of the pole, will hook the metal edge of the interior of the building and give a 

tug to set the pole. Unhooking and lowering the pole to the ground will constitute one repetition. A total 

of 15 repetitions is required.

7. Water Tender/Engine Connection: Placing the water tender 45-feet from the engine and at an angle 

to leave room for the candidate to walk between them, the candidate will pull a section of 21⁄2-inch hose 

from the center bed of the water tender and make the connection at the engine for incoming water on 

the captain’s side. The candidate will then make the connection at the water tender on the engineer side 

discharge. All connections will be hand tight.
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8. Hose Pull: The two 13⁄4-inch hoselines are connected and placed in an “S” pattern by the engine. The 

candidate will pick up the hose and extend it until just past the edge of the station building or until extended without jerking. The candidate can run/jog on this station.

9. Rescue Drag: The 140-pound mannequin will be placed with the head toward the bay lying flat on 

the ground. The candidate will pick up the mannequin in whatever manner they choose and drag or 

carry the object 45-feet around the barrel without using the barrel as a fulcrum and return to the station 

starting line. Time is complete when the mannequin’s feet cross the line.

The test is a timed test which must be completed within 5 minutes. The following rules apply:

1. No running at any time, except during the hose pull. (10 second penalty)

2. Face inward while stepping off the apparatus and utilize all safety devices, such as hand rails, steps, 

etc. (5 second penalty)

3. Do not drop any equipment on the ground including but not limited to nozzles, couplings, hose 

packs, pike pole, etc. (5 second penalty)

4. Sliding the pike pole through hands or not maintaining control of the pike pole. (5 second penalty)

5. Not hooking the pike pole over the rail or touching the ground. (No time penalty but repetition 

doesn’t count)

6. Not hand over hand on the hose raise. (5 second penalty)

7. Skipping steps on the stair climb. (5 second penalty)

8. Not “sinking your heels” on the ladder climb. (3 second penalty)

9. Coupling not hand tight on the water tender connection. (10 second penalty)

10. Failing to pause/stand tall after placing hoses on tailboard/table. (5 second penalty)

11. Lift with your legs, not your back. (No penalty, but enforced)

12. One hand on the hand rail or wall during the stair climb. (5 second penalty)

One warning may be given per infraction to remind the candidate about the rules.

Appendix B (cont.)