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2018

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June 30, 2022

Career Lieutenant Suffers a Sudden Cardiac Event During 

Fireground Survival Training and Dies 2 days Later-Pennsylvania

Executive Summary

On June 25, 2018, a 62-year-old career

Fire Lieutenant (LT) suffered a sudden 

cardiac event during a training evolution 

at the fire training center and died 2 days 

later at the local hospital. The LT was 

participating in a 3-day International 

Association of Fire Fighters (IAFF) 

Fireground Survival Program. He 

collapsed on the third and final day of 

training while maneuvering through the 

entanglement prop of the self-containedbreathing-apparatus (SCBA) maze

course. He was wearing full personal 

protective equipment (PPE) consisting of 

turnout gear and SCBA. He had 

exhausted his SCBA’s compressed air 

and was “filter breathing.” Filter 

breathing is a term some firefighters 

use when they disconnect their mask 

mounted regulator (MMR) and cover 

the opening with the lower portion of 

their PPE hood. 

The instructor observing the LT from outside of the entanglement box (see Cover Photo) noted he had 

stopped moving and was not responding to commands. The instructor opened the entanglement prop 

and removed the LT to the drill room floor for assessment. The LT was unresponsive, and CPR 

(cardiopulmonary resuscitation) was begun by fire instructors. On-scene fire department paramedics 

responded with advanced life support and transported the LT to the local hospital’s emergency 

department. In the emergency department, advance life support measures continued and, although the 

LT never regained consciousness, his cardiac status improved. He was admitted to the hospital’s 

intensive care unit where subsequent testing revealed anoxic (without oxygen) brain damage. He was 

removed from life support and pronounced deceased on June 27, 2018. NIOSH investigators 

concluded that the exertion associated with the training activity triggered a sudden cardiac event in an 

individual with underlying cardiovascular disease (CVD). The autopsy report listed the cause of death 

as “hypertensive cardiovascular disease.” 

The Lieutenant became unresponsive during the final 

SCBA entanglement prop on the 3-day survival class 

and died 2 days later at the hospital. 

(Cover Photo Courtesy Fire Department.)
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Contributing Factors

• Undiagnosed hypertensive CVD

• Infrequent exercise stress tests (ESTs) for firefighters at risk for CVD

• Lack of annual medical clearance for unrestricted firefighting duties which includes training 

involving heavy physical exertion

• Physically strenuous training.

Key Recommendations

• Fire departments should provide and require annual medical evaluations for all firefighters

• Fire department physicians should ensure symptom-limiting ESTs are provided to firefighters 

at increased risk of CVD

• Fire department physicians should use the information from the annual medical evaluation to 

make final medical recommendations regarding medical clearance for unrestricted firefighting 

duties and participation in physically strenuous training exercises

• Fire departments should complete annual physical performance evaluations

• Fire departments should phase in a mandatory comprehensive wellness-fitness program for all 

firefighters to reduce CVD risk factors and improve cardiovascular capacity.

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).

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 firefighter initiative that resulted in the 

NIOSH Firefighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of 

firefighters to assist fire departments, firefighters, the fire service, and others to prevent similar firefighter 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).
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2018

16

June 30, 2022

Career Lieutenant Suffers a Sudden Cardiac Event During 

Fireground Survival Training and Dies 2 days Later-Pennsylvania

Introduction

On June 25, 2018, a 62-year-old male LT suffered a sudden cardiac event during fireground survival 

training and was transported to the hospital where he died two days later. The U.S. Fire Administration 

notified NIOSH of this fatality on June 28, 2018. In November 2018, a physician and a safety and 

occupational health specialist from the NIOSH Fire Fighter Fatality Investigation and Prevention 

Program visited the incident site for an on-site review and investigation. 

During the investigation, NIOSH personnel interviewed the following individuals:

• Fire Commissioner

• Deputy Fire Commissioner

• Director, Fire Academy

• Deputy Fire Marshal

• Medical Director for the City

• Mother of the LT.

NIOSH personnel reviewed the following documents:

• Fire department standard operating guidelines

• Emergency medical services (ambulance) report

• Hospital ED records

• Autopsy report

• Fire department medical evaluation records

• Primary care physician records

• Fire department SCBA breathing air test records

• LT’s training records

• Witness statements.

Fire Department

The fire department involved in this incident has 63 fire stations. It provides emergency medical and 

fire suppression services to a population of approximately 1.6 million residents within an area of 

approximately 141 square miles. For fiscal year 2017, the department had a total of 2,573 budgeted 

positions, of which 2,447 were uniformed fire and emergency medical services (EMS) providers. In 

FY18, the positions grew to 2,806 with 2,681 being uniformed. For FY19 that number has further 

increased to 2,851 positions, with 2,707 uniformed. In FY 2017, the department responded to 314,725

incidents. Of these, 267,266 (85%) were EMS incidents and 47,456 (15%) were fire incidents and 203 

non-specific incidents. The department responded to 2,573 working structure fires.
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This fire department has a fire commissioner, who is appointed by the city’s mayor; a chief of staff; 

and deputy commissioners who manage the department. There is also a part-time medical director, a 

full-time communications director, and four assistant deputy commissioners. 

There are four major operating sections: Operations; Logistics; Planning/Risk Reduction; and 

Finance/Administration. The deputy commissioner for Operations commanded: Fire Suppression, 

EMS, Special Operations and the Aviation Operations Division. The deputy commissioner 

for Logistics commanded: Health and Safety, Fire Academy (training), Fire Communications Center, 

Technical Support Unit (apparatus, equipment, warehouse, water and facilities) and Information 

Technology. The deputy commissioner for Planning/Risk Reduction commanded: Fire Prevention, Fire 

Code, EMS Community Risk Reduction, Fire Marshal Units, Performance, Analytics and Management 

Information Systems. The deputy commissioner for Finance/Administration commanded: Fiscal, 

Human Resources, Recruitment, Employee Assistance, Employee Relations, and Special 

Investigations.

At the time of the incident, the city was divided into two divisions. Division 1, which consisted of 5 

battalions and 29 fire stations, and Division 2, which had 6 battalions and 34 fire stations. Since this 

incident, the department has added the following: a platoon-based assistant chief responsible for the 

entire city; a 3rd division each with their own deputy chief; and two more battalion chiefs, each with 

their own battalions (the new and existing battalions were re-assigned among the three divisions to 

limit the number of direct reports to each deputy chief). 

The department has 56 engine companies, 27 ladder companies, one heavy rescue company, two squad 

companies and two fire boats (plus one in reserve). The department operates specialty companies for 

technical rescue, hazardous materials incidents, and aircraft rescue & firefighting (ARFF). All nonspecialized engine companies carry 1,000 feet of 5-inch diameter hose. Two engine companies are 

designated as squirts, which have 54-foot articulating booms. Two are elevated water towers, which 

have 50-foot booms. Three engine companies are designated as foam and carry class B foam. Also, 

Foam Tender 1 operates with Foam 33. Two ladder companies are 85-foot snorkels and have an

articulating boom with a platform. Two ladder companies are ladder towers. The remainder of the 

ladder companies are tractor-drawn aerials. 

The staffing on an engine company is an officer and three firefighters. The staffing on a ladder 

company is an officer and four firefighters. Each squad is staffed with an officer and four firefighters. 

Rescue-1 is staffed with an officer and five firefighters. Each Division Chief and Battalion Chief is 

assigned a staff assistant or chief’s aide.

The fire department’s EMS division consists of 60 medic units, and supervisory staff including EMS 

field officers. Fifty of the medic units operate on a full-time basis, and ten operate on a part-time basis. 

The fire department operates an ARFF station at the international airport in the southern part of the 

city. 
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Department members assigned to the operations division work a daily 12/12 shift (0800–2000 and 

2000–0800) with four platoons or shifts (on average a 42-hour work week).

Medical and Fitness Requirements for Firefighter Candidates 

The fire department requires a pre-placement medical evaluation for all firefighter candidates. 

Components of the evaluation are as follows:

• Complete medical history

• Height, weight, and vital signs

• Physical examination

• Vision test

• Hearing test

• Blood tests: complete blood count, cholesterol and triglycerides, Sequential Multi-channel

Analysis (SMA) 12, cholinesterase level

• Urinalysis

• Urine drug test

• Spirometry 

• Resting electrocardiogram (EKG)

• Exercise stress test (EST) 

• Chest x-ray.

These evaluations are performed by the city’s medical director, who oversees the Medical Evaluation 

Unit and reports directly to the citywide Office of Human Resources. The city’s medical director

makes the decision regarding pre-hiring medical clearance for firefighting duties. New hires are 

required to complete a physical capacity test at the city’s fire academy. This is a non-timed 

performance evaluation of typical firefighting duties. The city’s medical director is also responsible for 

all return-to-duty and promotional medical evaluations ensuring fit for duty status for firefighting 

duties.

Wellness and Fitness Programs for Members In 2015, municipal administration and the local union 

negotiated a comprehensive fitness and wellness program for members. A key component of the 

wellness program included a mandatory biennial medical examination performed by a physician who 

is board certified in internal medicine, has a background in occupational medicine, is familiar with the 

requirements of the fire service, and with National Fire Protection Association (NFPA) 1582 and 1583. 

The required elements of the medical examination are consistent with the above pre-placement medical 

evaluation with three exceptions: 1) the EST is only for members over the age of 40 years, 2) the chest 

X-ray is taken every 5 years (or more frequently if indicated), and 3) no urine drug test. In addition to 

the required elements, there are 5 encouraged, but not required, elements:

1) maximal cardiopulmonary test with EKG, 

2) colonoscopy (baseline and follow-up), 
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3) annual digital rectal exam, 

4) for males, examination of the testes and penis,

5) for females, vaginal and pelvic exams, pap smears, breast exam, and mammogram.

Oversight for this program is done by a Labor/Management Fitness and Wellness Committee with 

representatives from the local union, the fire department, labor relations, and the city’s risk 

management division.

The other components of the wellness and fitness program are administered and funded by the local 

union’s health fund with oversight by the Labor/Management Fitness and Wellness Committee. The 

fitness program uses peer fitness trainers and fitness equipment at fire houses. Participation is 

voluntary. Members can exercise off duty, or on-duty with time provided by the fire department if it 

does not interfere with the firefighter’s work responsibilities. There is no annual physical ability testing 

of members.

Training and Experience

The Commonwealth of Pennsylvania does not have prerequisite training or education requirements for 

an individual to become a firefighter. The department participates with the Pennsylvania State Fire 

Academy in the Voluntary Participation and Certification Program, which was started in 2003 to 

provide national certification for department members through the National Board on Fire Service 

Professional Qualifications and the International Fire Service Accreditation Congress. 

To become a member of the fire department, an individual must apply and successfully complete a 

civil service examination for firefighters. Prospective candidates are selected from the established civil 

service list by highest test score. The process includes department interviews, a criminal investigation, 

and a background investigation. If selected for conditional appointment, a candidate must successfully 

pass a medical examination that complies with NFPA 1582, Standard on Comprehensive Occupational 

Medical Program for Fire Departments. Selected candidates are appointed as cadets or recruit 

firefighters in an extensive 36-week academic, practical, and physical training program at the 

department’s fire academy.

At the fire academy, recruit firefighters are trained in firefighting operations as well as emergency 

medical services, for which they must obtain state certification as an emergency medical technician. 

Upon the successful completion of training, recruit firefighters are assigned as probationary firefighters 

and receive national certification to NFPA 1001, Standard for Fire Fighter Professional 

Qualifications, Fire Fighter I and Fire Fighter II; Hazardous Material Awareness and Hazardous 

Materials Operations certification; and cadets complete the IAFF Fireground Survival Course and are 

state-certified as an emergency medical technician (EMT), [NFPA 2013b; NFPA 2015]. A 

probationary firefighter is assigned to the operations division on either an engine company or a ladder 

company. As an EMT, firefighters are also assigned as needed to work on basic life support (BLS) and 
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advance life support (ALS) medic units. During the probationary period, the probationary firefighter is 

tested by the fire academy staff at 12 months (written and practical examinations). Recertification for 

an EMT is every 3 years (24 continuing education hours) and paramedics is every 2 years (36 

continuing education hours).

Members assigned to the operations division are required to complete at least 1 hour of training per 

shift. 

Advanced Fireground Survival Course

There are a number of different SCBA training/confidence and/or skills classes being taught around the 

country with varying levels of difficulty, hazards, challenges, and expected outcomes. The program 

that the LT was participating in was a formal 3-day fireground survival program developed by the 

IAFF that combined classroom and practical skills challenges [IAFF 2022]. 

After a LODD incident in a structural fire in 2014, the NIOSH FFFIPP conducted an investigation and 

recommended that “Fire department’s should ensure that all fire fighters and officers are trained in 

Mayday techniques and communications” [NIOSH 2017]. The NIOSH report provided examples of 

programs designed to teach firefighters some of these techniques (e.g., Mayday techniques and 

communications). The National Fire Academy classes “Q133-Firefighter Safety, Calling the Mayday” 

and “H134-Calling the Mayday, Hands-on training” as well as the IAFF Fireground Survival program 

were identified as resources fire departments could consider. The department selected the IAFF 

Fireground Survival Training program which was fully implemented in January 2018. 

The training program being followed by the department was initially developed by the International 

Association of Fire Fighters (IAFF), Division of Occupational Health, Safety and Medicine in 

cooperation with the International Association of Fire Chiefs (IAFC).

Day 1 consisted of program orientation, classroom instruction and SCBA familiarization. The program 

orientation described size-up, fire behavior (based on National Institute for Standards and Technology 

(NIST) research, reading smoke, crew integrity (crew continuity), Mayday knowledge and preventing 

Maydays, SCBA air management, building construction and features, NFPA standards, NIOSH reports 

and self-survival skills. The program also covered the relationship between cardiovascular fitness, air 

management and fitness for survival. More SCBA hands-on training followed with emphasis on 

checking the SCBA and being able to don it in limited or restricted visibility. The students also had to 

locate a SCBA with a Personal Alert Safety System (PASS) activated and follow a hoseline through a 

maze set-up.

Day 2 focused on practical skills and built on the skills demonstrated and taught on day 1. This

included practical survival skills such as low window hang maneuvers, disentanglement escape using 

low profile crawling and ladder escape practical skills.
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Day 3 consisted of students using their bail-out gear and performing three jumps from the training

trailer. The last portion of day three is a skills practical drill that includes all of the practical evolutions 

that were taught in the first 2 days as part of a confidence maze. 

The last training simulation station (prop) in the confidence maze is the disentanglement prop. The 

disentanglement prop is a box that has a series of wires that simulates wires and entanglement hazards 

that can happen with a ceiling collapse. The overhead ductwork common in ceilings can entangle 

firefighters trying to escape. The disentanglement prop simulates this situation (see Photo 1).

As firefighters progress through the prop (with full PPE and SCBA with obscured face pieces), they 

need to contort their bodies and equipment to get through the hazard. There are wires hanging in the 

path of travel and the students need to use techniques taught in the class to move, remove, disentangle 

or get through and exit the box. There are emergency pull handles on the end of the box that will 

release all of the wires in case of emergency (see Photo 1).

During the practical skills evolutions, the program provided two instructors per skill station with the 

exception of the ladder escape skill station where there were five instructors. During the SCBA 

confidence maze course there was one instructor for every student on that skill course and there was an 

instructor closely monitoring the progress of the victim during his time in the skill course and in the 

disentanglement prop.

At the time of his medical event, the LT was participating in the day 3 final confidence maze (SCBA 

disentanglement prop) portion of the advanced fireground survival program (see Cover Photo and 

Photo 1). 
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Photo 1. Close up photo of the disentanglement prop. 

(Photo Courtesy of the Fire Department.)
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Equipment and Personnel

The minimum staffing in an engine company is an officer and three firefighters. The minimum staffing 

in a ladder company is an officer and four firefighters. Each squad is staffed with an officer and four 

firefighters. Rescue 1 is staffed with an officer and five firefighters. Each Division Chief and Battalion 

Chief are assigned a staff assistant or chief’s aide.

All members are assigned portable radios and the radio is electronically linked to the riding position. In 

the event of an emergency button activation, the fire communications center is able to identify the 

member by position and relay that information to the incident commander. 

At the time of the incident, the department had a Health and Safety Office comprised of the following:

1 Deputy Chief in charge of the Health and Safety Office

1 Captain

4 Lieutenants.

Additionally, the department has four field Deputy Chiefs that serve as operational Incident Safety 

Officers. They work shifts and respond to “All Hands” notifications or larger fires.

Personal Protective Equipment

The LT was wearing full personal PPE including NFPA compliant coat, bunker pants, helmet, gloves, 

boots and a 2013 Edition, 5500 psi, 1800-liter, SCBA with an integrated Personal Alert Safety System 

(PASS). There were no deficiencies found with the victim’s PPE or the SCBA’s pneumatic or 

electronic performance. At the training site, breathing air quality certificates were checked for the 

breathing air source. Breathing air quality was not considered a factor in this incident. 

Weather Conditions

At approximately 1454 hours on June 25, 2018, the weather in the immediate area was 81 degrees 

Fahrenheit and the relative humidity was 34%. The winds were out of the north at 15 mph [Weather 

Underground 2018].

Investigation 

The training that the LT was participating in was part of a 3-day class and focused on fireground

survival and respiratory protection training (SCBA training) with both classroom and practical skills 

learning as described in the Advanced Fireground Survival Course section.

On day three, the LT was in the last prop in the confidence mazed (disentangle prop), accompanied by 

an instructor. While crawling in the disentanglement prop and attempting to navigate through, the LT 

became unresponsive. The instructor who was with him noticed a change in the LT’s condition and 

called a code red. (All instructors had radios and the instructor group as well as the safety officer 
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monitored the portable radio.) This immediately stopped all training and summoned the additional 

instructor staff and the EMS unit to his location. 

The instructor released the emergency handle (that released the entanglement wires) and removed the 

LT to the drill room floor for assessment. The LT was unresponsive, and CPR was begun by fire 

instructors. The on-scene/stand-by fire department paramedics responded with advanced life support 

and transported the LT to the local hospital’s emergency department. In the emergency department, 

advance life support measures continued and, although the LT never regained consciousness, his 

cardiac status improved. He was admitted to the hospital’s intensive care unit where subsequent testing 

revealed irreversible brain damage due to lack of oxygen. Brain death examinations/tests (pain 

response, reflexes, apnea test, and cerebral blood flow) over two days were consistent with clinical 

brain death. On June 27, 2018, life support measures were withdrawn, and the LT was pronounced 

deceased at 1453 hours.

The training incident was documented by the department’s Fire Marshal’s Office (FMO) and 

investigated by the fire department’s Field Incident Safety Office. The departmental investigation 

noted that all safety protocols and procedures were followed. 

Both the department’s Fire Marshal’s Office and the department’s Health and Safety Office as well as 

the IAFF local assisted NIOSH with this investigation.

Medical Findings

According to the medical records available to NIOSH, the LT’s past medical history was notable for 

high blood pressure (hypertension), high blood lipids (hyperlipidemia), and obesity, all of which put 

the LT at increased risk for CVD.

Hypertension – The LT was diagnosed with hypertension in 1988 by his primary care provider and 

treated with diet and exercise. During the years 2006 to 2016, the LT had blood pressure measurements 

consistent with stage 1 hypertension [Chobanian et al. 2003]. 

Testing for complications of longstanding hypertension included periodic EKGs, EST, and an 

echocardiogram. His most recent EKG was conducted in 2016 and was reported to be normal with the 

exception of a single premature ventricular contraction (PVC). NIOSH reviewed another EKG dated 

October 6, 2016, performed by a contractor with the fire department’s medical evaluation program. 

This tracing showed no PVCs, but did have a right bundle branch block in the precordial leads. The LT 

had an EST conducted in 1999 and again in 2010. During his 1999 EST he exercised to 12.9 metabolic 

equivalents (METS) with no reported ischemic changes or arrhythmias. However, by 2010 he only was 

able to achieve 10.2 METS before needing to stop the test due to shortness of breath. His tracings 

showed no ischemic changes, however increasing ventricular ectopy during exercise and multiple 

PVCs during recovery were noted. Both these findings, ventricular ectopy during exercise and multiple 

PVCs during recovery, are risk factors for sudden CV events [Frolkis et al. 2003; Jouven et al. 2000]. 

Although an echocardiogram was performed and reported as normal in 2011, NIOSH investigators 
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could not find any further cardiac work-up, work restrictions, or periodic cardiac testing due to these 

findings.

Hyperlipidemia – The LT’s hyperlipidemia was diagnosed in the 1990s treated by diet and exercise. 

His most recent results, conducted by the fire department in 2015, showed persistence of his 

hyperlipidemia, and he was referred to his primary care physician for follow-up [NHLBI 2005].

Obesity – The LT’s had a recorded weight of 243 pounds on 10/6/2016. With a height of 5 feet 4 

inches, the LT had a body mass index of 40.4.

Cause of Death

The city’s Office of the Medical Examiner completed an autopsy which listed the cause of death as 

“Hypertensive Cardiovascular Disease” and “Morbid Obesity” (body mass index of 41.3) as another 

significant condition. The diagnosis of hypertensive cardiovascular disease was supported by the 

following findings: 

• Cardiomegaly, 580 grams (expected weight = 438 grams)

• Left ventricular hypertrophy, 20/20 millimeters

• Moderate concentric coronary artery vessel wall thickening

• Hypertensive kidneys, on gross examination.

Discussion

Sudden Cardiovascular (CV) Events

Sudden CV events (heart attacks, sudden cardiac death, and strokes) are the leading cause of on-thejob deaths among firefighters, constituting approximately 40%–45% of all duty-related fatalities [Fahy 

et al. 2020]. Coronary heart disease (CHD) and cardiomyopathies are the most common underlying 

medical conditions for sudden CV events in the general population and in firefighters [Farioli et al. 

2015; Myerburg and Junttila 2012]. Many individuals are unaware of these underlying medical 

conditions and the sudden CV event is frequently the first sign of their underlying disease [Myerburg 

and Junttila 2012]. The LT was aware of his hypertension and hyperlipidemia but was unaware of his 

underlying hypertensive CV disease which includes his moderate CHD.

Single markers or tests are not able to identify people at risk for a sudden CV event. However, the 

well-established risk factors for CHD can also identify individuals at risk for future sudden CV events. 

Non-modifiable risk factors include male gender, older age (males >45, females >55), and family 

history of premature heart disease or sudden cardiac death [AHA 2016]. The LT had two of these risk 

factors (age and male gender). Modifiable risk factors include hypertension, hyperlipidemia, smoking, 

diabetes, overweight/obesity, and physical inactivity [AHA 2016]. The LT had three of these risk 

factors (hypertension, hyperlipidemia, and obesity). 

The American Heart Association / American College of Cardiology (AHA/ACC) and the Framingham 

Heart Study have developed on-line calculators to estimate the risk of future CV events [AHA/ACC 
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2020; D’Agostino 2000]. Using the following 12 risk factors (age, gender, race, total cholesterol, LDL

cholesterol, HDL cholesterol, use of statins to control cholesterol, systolic blood pressure, blood 

pressure lowering medication use, diabetes mellitus status, smoking status, and aspirin therapy), the 

AHA/ACC’s CV risk calculator estimates an individual’s 10-year risk of developing atherosclerotic 

CVD [AHA/ACC 2020]. Using the LT’s medical information from 2015, he had a 10-year risk of 

15.8%. The Framingham Heart Study uses the following 8 risk factors (age, gender, systolic blood 

pressure, use of antihypertensive medication, current smoking status, fasting total cholesterol, fasting 

HDL cholesterol, and physician diagnosis of diabetes), to estimate an individual’s 2-year risk of 

developing a CHD first event [D’Agostino et al. 2000]. Using the LT’s medical information from 

2015, his 2-year risk of developing a first CHD event was 2%. 

Physical Activity and Sudden Cardiovascular (CV) Events

Strenuous physical activity has been shown to “trigger” heart attacks and sudden death in susceptible 

individuals (e.g., those with underlying CV disease or CHD) [Thompson et al 2007; Mittleman and 

Mostofsky 2011]. Since firefighting tasks require heavy physical exertion, this association is also 

found in firefighters [Hales et al. 2006; Hales 2016; Haller and Smith 2019; Kales et al. 2007; Smith et 

al. 2016]. The tasks in the fireground survival training are estimated to be approximately 9 METS,

which is considered a heavy level of exertion [Ainsworth et al. 2011]. 

Heat Stress and Heat-Related Illness

The fireground survival training occurred during the summer with a heat index of 80 degrees 

Fahrenheit. NIOSH investigators were unable to find a patient temperature taken by on-scene first 

responders, in the ambulance, or in the emergency department, therefore it is unclear if the LT was 

hyperthermic. It is likely that the heavy physical exertion in turnout gear would have caused some heat 

stress and which perhaps had some physiologic effects on the cardiovascular system [Wilkinson et al. 

2020]. However, given that the training occurred indoors, and the LT reported no symptoms consistent 

with heat-related illness, NIOSH investigators felt it was unlikely that heat stress/hyperthermia was a 

significant contributing factor to his sudden cardiac event.

Occupational Medical Standards for Structural Firefighters

To reduce the risk of sudden CV events or other incapacitating conditions among firefighters, NFPA 

developed 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments

[NFPA 2013, 2018, 2022]. This voluntary consensus-based standard outlines the specific medical 

evaluation (physical exam, medical history, ancillary tests) recommended to assess a firefighter’s 

medical ability to perform their duties safely and effectively. The standard also provides specific 

medical criteria used to determine fitness-for-duty for certain diseases or conditions. While the 2022

edition of NFPA 1582 is now available, the 2013 edition was in effect at the time of this investigation. 

The LT had four known health issues addressed in NFPA 1582: hypertension, elevated risk of a sudden 

CV event, ventricular ectopy (PVCs/non-sustained ventricular tachycardia), and metabolic syndrome.

Hypertension - The 2013 edition of NFPA 1582 recommended referral of firefighters with Stage 1 

hypertension (systolic BP 140–159 or diastolic 90–99) to their primary care physician for blood 
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pressure control and to “consider” screening for end-organ damage (cardiac findings, nephropathy, 

retinopathy, etc.). Given the LT’s 30-year history of hypertension, screening for these complications 

was indicated. While his screening echocardiogram in 2011 was reported as normal, his EST in 2010 

was concerning. On the EST in 2010, the LT was unable to achieve the required 12 METs, and his 

tracing showed ventricular ectopy (non-sustained ventricular tachycardia and numerous PVCs during 

recovery). According to NFPA 1582, duty restrictions should have been considered despite a normal 

echocardiogram in 2011, and further cardiac evaluation on a periodic basis should have occurred 

[NFPA 2013, 2018, 2022]. In addition, the LT’s EKG in 2016 showed a right bundle branch block 

which, according to NFPA 1582, might compromise the member's ability to safely perform essential 

job task(s). Finally, it is unclear if the LT had a dilated eye examination to screen for retinopathy.

Elevated Risk of Sudden CV Events - As mentioned earlier, the LT had a 10-year CV risk of 15.8% 

and a 2-year risk of developing a first CHD event of 2%. According to NFPA1582, either one of these 

findings should have required a symptom-limiting EST to at least 12 METS. If the FF is unable to 

achieve 12 METS (as the LT could not do in 2010), NFPA 1582 recommends counseling and a 

prescribed aerobic exercise program to improve fitness [NFPA 2013, 2018, 2022]. 

Ventricular Arrhythmias and Ectopy – NFPA 1582 states that, “on the basis of increased risk of a 

sudden cardiac event, ventricular ectopy might compromise a firefighter’s ability to function as an 

integral member of a team during emergency response” [NFPA 2013, 2018, 2022]. The LT had two 

types of ventricular ectopy of concern: non-sustained ventricular tachycardia during exercise and PVCs 

that increased during recovery. NFPA 1582 requires both findings to be followed up with an imaging 

EST to 12 METS. The LT’s last EST in 2010 did not include an imaging component and the LT did 

not reach 12 METS.

Metabolic Syndrome - According to the results from the LT’s fire department medical in 2015, he met 

the criteria for metabolic syndrome (waist circumference > 40 inches, triglycerides > 150 mg/dL, blood 

pressure > 130/85) [NPFA 2013]. Metabolic syndrome increases the risk for cardiovascular ischemic 

disease, diabetes, and accelerated hypertension. According to NFPA 1582, members with metabolic 

syndrome should receive an imaging symptom-limiting EST to 12 METS, be counseled as to lifestyle 

adjustments, receive an exercise prescription, and be referred to their personal physician for treatment 

[NFPA 2013]. If the member is unable to achieve an aerobic capacity of 12 METs, the member’s 

ability to safely perform essential job tasks will be compromised [NFPA 2013].

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 fatality. 

• Undiagnosed hypertensive CVD

• Infrequent symptom-limiting exercise stress tests (ESTs) for firefighters at risk for CVD
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• Lack of annual medical clearance for unrestricted firefighting duties which includes training 

involving heavy physical exertion 

• Physically strenuous training. 

Recommendations

Recommendation #1: Fire departments should provide and require annual medical evaluations to 

all firefighters. 

Discussion: NIOSH applauds the fire department and the local union for implementing a biennial 

medical examination in 2015. However, NFPA 1582, recommends medical examinations occur on an 

annual basis [NFPA 2013, 2018, 2022]. Annual medical evaluations help determine a firefighter’s 

medical ability to perform duties without undue risk to the safety and health of self or others.

According to the medical records provided to NIOSH, the LT’s last fire department medical evaluation 

was in 2015 with an EKG tracing from 2016.

Recommendation #2: Fire department physicians should ensure symptom-limiting exercise stress 

tests (ESTs) are provided to firefighters at increased risk of CVD.

Discussion: NFPA 1582 requires all firefighters 40 years and older be assessed for asymptomatic 

atherosclerotic CVD [NFPA 2013, 2018, 2022]. This assessment includes a 10-year cardiac risk 

estimate from the American College of Cardiology /American Heart Association, and/or a 2-year 

cardiac risk estimate from the Framingham Heart Study [AHA/ACC 2018; D’Agostino 2000]. 

According to NFPA 1582, firefighters with a 10-year risk between 10%–19.9%, or a 2-year risk 

between 2 to 4% shall be further evaluated with a symptom limiting EST to at least 12 METS with 

negative tests repeated every 2 to 5 years or when clinically indicated [NFPA 2013, 2018, 2022].

Using the LT’s medical information from 2015, he had a 10-year risk of 15.8% and a 2-year risk of 

2%. Thus, the LT should have undergone a symptom limiting EST to at least 12 METS and the EST 

should have been repeated every 2 to 5 years.

It is important to point out that NFPA 1582 and the AHA/ACC, due to validity issues, do not 

recommend ESTs for young adults (<40 years old) or individuals with low CVD risk. Finally, some 

fire departments use the EST to assess a firefighter’s aerobic capacity rather than as a screening test for 

CVD. This represents an unnecessary expense for the department because one’s aerobic capacity can 

be easily determined in a non-medical setting (e.g., the Cooper test) [Cooper KH 1968; TREK 2021].

Recommendation #3: Fire departments physicians should use the information from the annual 

medical evaluation to make final medical recommendations regarding medical clearance for 

unrestricted firefighting duties and participation in physically strenuous training exercises. 

Discussion: In addition to outlining the components of a medical evaluation, NFPA 1582 also provides 

guidance on when certain medical conditions might require restrictions from full duty [NFPA 2013, 
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2018, 2022]. As mentioned in this report’s discussion section, the LT had a number of medical 

conditions that should have required medical restrictions until further testing was performed or 

treatment given.

NFPA 1582 defines a fire department physician as “a licensed doctor of medicine or osteopathy who 

has been designated by the fire department to provide professional expertise in the areas of

occupational safety and health as they relate to emergency services.” In this department, the fire 

department physician was the city medical director in the Medical Evaluation Unit (MEU). Using 

contractors to conduct medical evaluations, the city medical director reviews not only all the firefighter 

medical evaluations to make critical medical clearance and return-to-work decisions, but does this for 

ALL city employees. In addition to these medical clearance responsibilities, the fire department 

physician is also responsible for 9 other job duties (see section 4.2.1 of the following editions of NFPA 

1582) [NFPA 2013, 2018, 2022]. Given the unique job demands of the firefighters, the need to be very 

familiar with NFPA 1582, and the extensive responsibilities of the fire department physician, the city 

may want to consider appointing a physician dedicated to the fire department.

Recommendation #4: Fire departments should perform annual physical performance evaluations.

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

Wellness Program, states that “members who engage in emergency operations shall be annually 

qualified as meeting the physical performance requirements established by the fire department” [NFPA 

2021]. The standard goes on to state that members not meeting this requirement cannot engage in 

emergency operations [or training involving heavy physical exertion] and shall be required to enter a 

physical performance rehabilitation program [NFPA 2021].

The essential job tasks of firefighting require an aerobic capacity of at least 12 METS [Gledhill and 

Jamnik 1992]. In 2010 the LT was capable of only 10.8 METS and his EST showed had findings 

suggestive of underlying CVD. At that time, the LT should have been put on restricted duty until 

further medical testing and evaluations were performed, and he should have entered into aerobic 

fitness/rehabilitation program [NFPA 2013, 2018, 2022].

Recommendation #5: Fire departments should consider phasing in a mandatory comprehensive 

wellness-fitness program for all firefighters to reduce CVD risk factors and improve cardiovascular 

capacity. 

Discussion: NFPA 1583, Standard on Health-Related Fitness Programs for Fire Department 

Members, allows firefighters to build and maintain a level of health and fitness which reduce their risk 

of illness, injury, and premature death [NFPA 2015a]. Fire service health promotion programs have 

been shown to improve fitness, reduce CHD risk factors, reduce absenteeism, reduce work-related 

injuries, reduce lost workdays, reduce workers’ compensation claims, reduce medical costs, and have a 

favorable return on investment with mandatory programs showing the most benefit [Blevins et al. 
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2006; Dempsey et al. 2002; Griffin et al. 2016; Kuehl et al. 2013; Poston et al. 2013; Sokolowski et al. 

2020].

Currently, the fire department offers a voluntary wellness and fitness program. Again, we applaud the 

fire department and the local union for their commitment to protecting and maintaining their member’s 

health. However, modifying this program to be a mandatory non-punitive program would benefit all 

members, particularly members at risk for CVD who choose not to participate. Guidance on 

comprehensive wellness and fitness programs for firefighters is provided in NFPA 1583 (Standard on 

Health-Related Fitness Programs for Fire Department Members) [NFPA 2015a], the Fire Service 

Joint Labor Management Wellness/Fitness Initiative [IAFF/IAFC 2018], and the Emergency Services 

Road Map to Health and Wellness [IAFC 2017].

While not consider contributing factors in this incident, the following recommendations are 

provided as examples of good safety and health practices for fire departments.

Recommendation #6: Fire Departments and Authorities Having Jurisdiction (AHJs) should ensure 

training maze props and/or trailers used in advanced SCBA confidence training have adequate 

safety features such as emergency egress panels, emergency lighting, ventilation and temperature 

monitoring to measure the ambient temperature inside the maze or prop.

Discussion: Some SCBA maze trailers, buildings or SCBA training props have confined spaces that 

are used for skills and confidence building of the student, while using full PPE and their SCBA. By 

design, they may restrict or complicate movement and work area of the student. This is very often 

combined with restricted vision of the student to simulate a fireground condition that can occur. 

These SCBA maze trailers, buildings, and props challenge the firefighters and improve their skills with 

disentanglement and escaping from a collapse scenario and other challenges firefighters may face 

while performing their jobs. There is also a key element of skill building by having the firefighter 

increase their manipulative skills with their particular SCBA and building muscle memory through 

repetitive skill performance.

Some SCBA maze trailers, buildings or props may be designed and constructed by individual fire 

departments and may not possess the necessary safety features to provide emergency access for a 

student in any portion of the maze. Instructors should have complete access to the students in order to 

remove a student who suffers an emergency medical condition or panics. Although no smoke or IDLH 

conditions are introduced into these training props, firefighters have experienced serious medical 

issues while inside the props and had to be extricated before treatment could be rendered (see the 

additional information section in this report that details a number of NIOSH LODD investigations in 

SCBA training).

Removing a student or a firefighter who has suffered a debilitating medical condition from inside a 

severely restricted space is difficult and can be time consuming and labor intensive and may delay 
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medical treatment until access can be achieved. Emergency egress panels should be considered as part 

of the design and construction so instructors and/or medical teams can access, remove and/or treat 

students. Emergency lighting should also be provided throughout the training maze. In some instances, 

darkness may be used as the limiting vision factor in place of a blacked out SCBA face piece. In these 

situations, the instructor should have access to thermal imaging cameras and emergency lighting to 

monitor and react to any student emergency. Emergency lighting is essential to rapid removal from 

entanglement hazards and medical evaluation of the student in an emergency.

The students will likely be in full PPE and SCBA and the risk of heat-related illness can be high. 

Temperature monitoring and ventilation of SCBA training maze trailers, buildings or props is an 

important safety feature for the students and instructors. A temperature monitoring system should be in 

place to measure the ambient temperatures and be monitored and kept within the safety guidelines 

established for the event. Ventilation of the building and/or prop should be considered to control the 

temperature. 

Instructors and safety officers should keep in mind that the students are in full PPE (where the 

instructors may not be) and the addition of full PPE with SCBA can increase the student’s internal 

temperature and risk of heat-related illness. Periodic wellness/status checks should also be performed 

on the students. Checkpoints could be SCBA milestone activation, such as End-Of-Service-TimeIndicator (EOSTI), and considerations for stop points when a student isn’t clear in their responses 

during check points, or when they have exhausted all of their air supply.

In this incident, the SCBA training maze (props) were constructed inside of the department’s Class A 

burn building. The props were built to the program guidelines and had all of the appropriate safety 

releases. The burn building that housed part of the course and props was reported to be designed in the 

1970’s and constructed in the 1980’s. There were no emergency lighting, ventilation nor temperature 

controls in that building or props. Fire departments should re-evaluate whether routine training should 

be performed in buildings used for live burns due to potential exposure to lingering carcinogens from 

combustion by-products. 

Additional information on fire service training props can be found in NFPA 1402, Standard on 

facilities for fire training and associated props [NFPA 2019].

Recommendation #7: As a part of a respiratory protection program, FDs and Authorities Having 

Jurisdiction (AHJs) should consider which levels of SCBA skills training are essential (awareness 

level) and which levels are advanced (operations level) and may be optional for members. 

Discussion: NFPA 1404 provides guidance on the three levels of respiratory protection. As a part of a 

fire departments respiratory protection plan, the department should consider minimum levels of 

respiratory protection for all of its members and also identify advanced levels of SCBA training for 

specialty companies and other members. SCUBA (Self-Contained Underwater Breathing Apparatus)

teams, heavy rescue teams, SCT (structural collapse teams), tunnel rescue teams and others identified 
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by the department should have advanced training that is commensurate with their responsibilities and 

experience. These training disciplines are offered in graduated levels of difficulty and skill levels 

beginning with awareness as a pre-requisite to operations and then to technician level. The mental and 

emotional pressure placed on firefighters to complete physically demanding advanced training 

evolutions (tasks that are beyond essential job task levels as defined by the organization) should be 

considered, however all of the members should have physical and medical clearance prior to the 

training.

The pressure to complete physically demanding advanced training evolutions can occur from within 

the firefighter himself or herself (e.g., “those who may no longer be as physically fit could also feel a 

similar pressure to push their body beyond its limitations”) or it can come from well-intended members 

wanting to help the firefighter. The IAFF Fireground Survival training is now offered in awareness and 

operations levels as well as train the trainer courses. The awareness class is a pre-requisite to the 

operations level. 

If a department or an AHJ decides that advanced (or operations level) survival training involving 

SCBA maze trailers and confidence building courses are essential respiratory training knowledge, 

skills, and abilities (KSAs), then the department should have a plan for members who cannot attain the 

medical clearance for the training. If the respiratory protection program identifies the advanced 

respiratory training as essential, then they should have a program in place to allow for waivers and/or 

referrals to a health and wellness program that ensures they are fit for duty and can continue their 

essential job functions. For advanced respiratory training involving SCBA maze trailers, the FD or 

AHJ should consider opt-out waivers where a member could remain at a level suitable for all ranks and 

experience levels (e.g., awareness) similar to high angle, trench and confined space, and hazmat 

disciplines.

Finally, the fire department and/or AHJ should identify a level of fitness for duty for all firefighters to 

participate in all levels of respiratory protection training. This involves the commitment to the physical 

and medical components of NFPA 1500 and NFPA 1582 and 1583. 

1. Physical clearance (PAT)

2. Medical clearance (medical evaluation)

NFPA 1500 states firefighters must have an annual Physical Ability Test (PAT). The standard does not 

identify a specific physical ability test; however, the content should be consistent with the firefighter’s

essential job tasks (EJT). Prior to enrollment in a strenuous training program (such as advanced SCBA 

maze training), the firefighter’s medical clearance must be up to date. 

NFPA 1582 requires an annual medical evaluation and like the physical ability test, a list of the 

firefighter’s essential job functions should be provided by the fire department to the doctor. After the 

evaluation, the physician makes a recommendation to the fire department about whether the firefighter 

is medically able to complete those essential job functions without putting the firefighter, their peers, 
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or the public at risk. If not, the physician should provide a list of restrictions and the department should 

determine whether they can accommodate those restrictions (e.g., move to a non-suppression role).

Recommendation #8: Fire departments and training organizations should ensure that established 

SCBA training protocols are followed for each level of SCBA skills taught, and that students are 

physically capable and medically cleared to participate. 

Discussion: As part of a fire department’s Respiratory Protection Program, SCBA training is required 

and is accomplished through a layered skill level of instruction (NFPA 1404, NFPA 1001). These skill 

levels range from basic SCBA and introductory level training to advanced level SCBA training. 

Accordingly, these levels of SCBA training have significantly different levels of physical and mental 

capability requirements. NFPA 1404 (NFPA 1404 Standard for Fire Service Respiratory Protection 

Training 2018, Edition) provides guidance to FDs and AHJ’s to address three levels of SCBA 

instruction. The first level of instruction takes place in a classroom with both didactic and hands-on 

training. SCBA skills are best learned and then practiced to establish “cockpit time” with that student’s 

particular brand and model SCBA. Repetitive skills training to build muscle memory is a key aspect of 

all levels of SCBA skills training and there is no substitute for continued hands-on training (NIOSH 

2010-13KS, 2014-15TX, 2011-18NC, 2016-07NC). Note: the term “cockpit time” is a phrase that is 

used in the military and airline training programs that refer to familiarity and ease of use with that 

student’s particular aircraft and or resource.

The second level of respiratory protection instruction uses the skills taught in the first level through 

performance of various emergency response tasks and builds confidence and familiarity with the 

SCBA and equipment. NFPA 1404 states “This training should take place in a setting that can be 

safely controlled by the instructor and should be pertinent to the tasks. The use of a training maze is 

one alternative application for this level of training and builds confidence in the student.”

The third level of respiratory protection instruction described in NFPA 1404 describes the 

advancement to allowing the student to operate using an SCBA under simulated emergency conditions. 

These escalating series of respiratory training allow the students to demonstrate their ability to identify, 

operate and use their SCBA while performing various manipulative skills during emergency scene 

tasks and helps to build the necessary muscle-memory through repetitive skills necessary to operate an

SCBA and react to potential out of air emergencies.

Fire service respiratory training can certainly be a strenuous activity and advanced respiratory training 

sometimes described as SCBA maze trailer and confidence building KSA’s can certainly be classified 

as strenuous. Fire departments and AHJs who provide this training should ensure that their candidates 

are physically capable and medically cleared to participate in the training [NFPA 2013, 2015a]. 
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A number of fire departments across the country have SCBA training props and maze facilities. 

Physiological strain from exertion or heat stress has been involved in medical LODDs that have 

occurred in SCBA training and maze trailers. In the section “Additional Information” in this report, we 

list NIOSH LODD reports that involved SCBA training/maze and/or confidence training. Instructors 

and safety officers should keep in mind that the students are in full PPE (where the instructors may not 

be) and the addition of full PPE with SCBA can increase the student’s internal temperature and risk of 

heat related illness. Periodic wellness/status checks should be performed on the students. These 

wellness/status checks could be referred to as check points. Check points could be SCBA milestone 

activation such as EOSTI and considerations for stop points when a student isn’t clear in their 

responses during check points, or they have exhausted all of their air supply.

Recommendation #9: Fire departments should ensure a comprehensive rehabilitation program and 

process is in place during training exercises that pose a potential safety and health risk to 

firefighters. 

Discussion: Rehabilitation considerations should be provided during practical training events when the 

training and safety plan identify a need. NFPA 1500 [NFPA 2022] provides guidance on rehabilitation 

operations and NFPA 1584, Standard on the Rehabilitation Process for Members During Emergency 

Operations and Training Exercise provides the components of a comprehensive rehab program [NFPA 

2015b, NIOSH 2016]. 

Rehabilitation efforts should include the following:

1. Medical monitoring

2. Relief from climatic conditions

3. Rest and recovery

4. Rehydration (electrolyte and calorie replacement)

5. Active and/or passive cooling or warming as needed

6. Accountability

7. Release from rehab back to duty status [NFPA 2015b, NIOSH 2016].

Recommendation #10: During advanced SCBA skills and confidence building training programs, 

students should be cautioned against “filter breathing.” 

Discussion: During advanced SCBA skills training class, there may be occasions when (due to the 

complexity and length of the skills and confidence class) the students run out of SCBA cylinder air in 

non-IDLH (immediately dangerous to life and health) training scenarios. Some programs instruct 

students, as a last resort, to disconnect their mask mounted regulator (MMR) and cover the opening 

with the lower portion of their PPE hood; a maneuver sometimes called “filter breathing.” NIOSH has 

cautioned against using this method in training and during actual fire suppression for the following 

reasons.
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First, fire smoke is composed of toxic gases, vapors, and particulates [Fabian et al., 2010]. Like other 

filter facepiece respirators, using a hood as a filtering material might provide protection against larger 

particles. However, they will not protect against chemicals, gases, or vapors [NIOSH 2020]. Fire 

smoke contains dangerous levels of several gases that can cause asphyxiation, for example carbon 

monoxide and hydrogen cyanide [Fabian et al., 2010]. Teaching students filter breathing during 

training may increase the risk of filter breathing during an actual fire which puts the firefighter at risk 

of asphyxiation. 

Second, some modern hoods may have vapor and/or moisture barriers to prevent skin burns. Like 

surgical masks and N-95 respirators, using the hood material as a respiratory filter may increase the 

amount of carbon dioxide on the inside of the mask or nose cup [Sinkule et al., 2013]. The clinical 

significance of this amount of carbon dioxide is unclear [Rhee et al., 2021], but theoretically it could 

increase the firefighters respiratory rate leading to the potential for increased inhalation of carbon 

dioxide.

Finally, filter breathing has not been shown, or even tested, in laboratory studies to reduce the 

inhalation of fire smoke particulates. Despite the lack of testing, based on respirator science, it will 

NOT reduce the inhalation of carbon monoxide gases due to the small molecular size of carbon 

monoxide relative to the filtering material. During SCBA training, departments should consider a 

running out of air event, a stopping point of the exercise and not encourage filter breathing in a training 

exercise.

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Investigator Information

This incident was jointly investigated by the NIOSH Firefighter Fatality Investigation and Prevention 

Program, Cardiac and Medical Line of Duty Death Investigations Team in Cincinnati, Ohio, and the 

Trauma Line of Duty Death Investigation Team in Morgantown, WV. 

Stephen T. Miles, Investigator/Safety and Occupational Health Specialist, Dr. Tom Hales, Medical 

Officer with the Firefighter Fatality Investigation and Prevention Program, Surveillance and Field 

Investigations Branch, Division of Safety Research, NIOSH located in Morgantown, West Virginia, 

investigated and co-authored the report, with significant assistance from Dr. Wendi Dick, Medical 

Officer/Team Lead for the Medical FFFIPP investigations. 

Additionally, the NIOSH investigators recognize the collaborative effort and input from the many 

public safety partners that included the Fire Department’s Executive Team, the Health and Safety 

Division, Fire Training Division, Field Operations and Local 22 of the International Association of 

Fire Fighters.

Additional Information

A number of fire departments across the country have SCBA training props and maze facilities. 

Physiological strain from exertion or heat stress has been involved in medical LODDs that have 

occurred in SCBA training and/or maze trailers or confidence training. Following are NIOSH reports 

that involved SCBA training/maze and/or confidence training. 

• Fire Fighter Trainee Suffers Sudden Cardiac Death During Maze Training – Virginia (2008), 

https://www.cdc.gov/niosh/fire/pdfs/face200902.pdf.

• Captain Dies from Hyperthermia and Exertional Heat Stroke While Performing Advanced 

Survival Training – Texas (2012), https://www.cdc.gov/niosh/fire/pdfs/face201227.pdf.

• Cadet Dies from Hypothermia and Exertional Heat Stroke During Indoor SCBA Maze Training 

- Texas (2018), https://www.cdc.gov/niosh/fire/pdfs/face201605.pdf.

• Fire Fighter Trainee Suffers Sudden Cardiac Death During Strenuous Training Drill – Georgia 

(2008), https://www.cdc.gov/niosh/fire/pdfs/face200804.pdf

• Fire Suppression Technician Involved in Maze Training Incident – Texas (1999), 

https://www.cdc.gov/niosh/fire/pdfs/face9908.pdf

• Lieutenant Suffers Sudden Cardiac Death After SCBA Training – Florida (2006), 

https://www.cdc.gov/niosh/fire/pdfs/face200602.pdf

• Fire Fighter Dies During Search and Rescue Training -Ohio, (2000), 

https://www.cdc.gov/niosh/fire/pdfs/face200024.pdf
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• Lieutenant Suffers a Stroke Following Training and Dies – New York, (2012), 

https://www.cdc.gov/niosh/fire/pdfs/face201126.pdf

• Captain Suffers Cardia Death While Attending Training Drills – New York, (2010), 

https://www.cdc.gov/niosh/fire/pdfs/face201022.pdf

• Probationary Fire Fighter Suffers Sudden Cardiac Death During Maze Drill – Connecticut, 

(2005), https://www.cdc.gov/niosh/fire/pdfs/face200438.pdf

• Fire Fighter Trainee Suffers Sudden Cardiac Death During Maze Training – Arkansas, (2011), 

https://www.cdc.gov/niosh/fire/pdfs/face201108.pdf

• Fire Fighter Suffers Heart Attack During Training and Later Dies – Kansas, (2015), 

https://www.cdc.gov/niosh/fire/pdfs/face201502.pdf

• Senior Captain Suffers Sudden Cardiac Death During Training – Alaska, (2014), 

https://www.cdc.gov/niosh/fire/pdfs/face201410.pdf

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). 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.