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2018

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Career Lieutenant Killed in Building Collapse While Fighting Row 

House Fire—Pennsylvania 

Executive Summary

On January 6, 2018, a 42-year-old career

Lieutenant (Engine-45 officer) was killed in 

a structural collapse while fighting a fire in 

an 1800’s era row house. Firefighters arrived 

to find a two-story row house heavily 

involved in fire. Fire crews faced limited 

street access to the fire dwelling (snow 

covered narrow road and civilian parking), 

excessive clutter in the building, extreme

cold, multiple inoperable fire hydrants and a 

frozen handline (nozzle). The first arriving 

crews operating only off tank water were 

able to locate and remove a civilian victim 

from the first floor and initially knock down 

the fire on the first floor. Interruptions in 

water supply hampered fire-fighting efforts 

and forced a change in strategy until a 

reliable supply was established.

Once the water supply was re-established, 

crews re-entered the structure to continue to 

extinguish the fire. Fire crews reported 

excessive debris scattered throughout the interior. Engine-45’s officer and his tip man re-entered the 

structure after changing out their SCBA cylinders and joined several other members on the first floor 

including, Rescue-1’s Search Firefighter, Squad-72’s officer and Engine-50’s Pak. There was a total of 

5 firefighters on the first floor with 2 additional firefighters (Squad-72 Tip and Squad-72 Pak) in the 

vestibule area at the front door. Another crew of 3 firefighters from different companies stretched a 

line in and up the interior stairs on the Bravo wall to the second floor. One firefighter from this crew 

advanced onto the second floor, while the two other members remained on the stairs to advance 

hoseline. The firefighter on the second floor experienced a shift in the floor and without time to react, 

the second floor collapsed into the first floor. Squad-72’s officer reported hearing a loud crack and 

went to the front door (side Alpha) and told Command to get everyone out. 

Some members operating on the first floor were pushed forward (towards side Alpha interior) during 

the collapse except for the Engine-45 officer. Members of the crew on the second floor either rode the 

floor down and escaped out of side Charlie or escaped out of the side Alpha entry door. The victim was 

The Lieutenant was killed in a V-shape collapse 

while fighting a row house fire. Arrow points to 

victim’s SCBA and the approximate area where 

the victim was trapped. 

 (Cover Photo Courtesy Fire Department) 
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pinned down by the second-floor joists and was unable to escape. Rescue crews worked continuously 

for approximately 60 minutes in extremely dangerous conditions to extricate the lieutenant. He died of 

positional asphyxia with superheated gas and smoke inhalation (see cover Photo). 

Contributing Factors

• Extreme cold weather, water supply (6 inoperable hydrants). 

• Inherent building characteristics and unique row house variation. 

• Structural overloading, excessive clutter and deteriorated building conditions. 

• Risk assessment that included a structural condition evaluation after strategy change (fire 

severity on primary building materials and extension within ceiling spaces). 

Key Recommendations 

• Fire Departments should consider increasing response capabilities during extreme weather. 

• Fire Departments should consider defensive operations when a dependable, continuous water 

supply is lost or not available and the building’s primary building materials may have been 

subject to severe fire conditions.

• Fire Departments should ensure that firefighters are trained to understand the influence of 

building age, use, design, modifications and construction on structural collapse, and consider 

defensive operations when hoarding/dilapidated conditions are evident or encountered. 

• Fire Departments should perform a thorough risk assessment, including an evaluation of 

structural conditions, when switching from a defensive strategy back to an offensive strategy. 

Additionally, governing municipalities (federal, state, regional, and local) should: 

• Consider upgrading access to narrow roadways in 19th century neighborhoods or restrict 

parking so access is maintained for modern fire apparatus. 

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

03

July 30, 2020

Career Lieutenant Killed in Building Collapse While Fighting Row 

House Fire—Pennsylvania 

Introduction 

On January 6, 2018, a 42-year-old Lieutenant was killed in a structural collapse while fighting a fire in 

an 1800’s era row house. 

On January 7, 2018, the U.S. Fire Administration notified the National Institute for Occupational 

Safety and Health (NIOSH) of this incident. On February 8, 2018, the Fire Department contacted the 

NIOSH Firefighter Fatality Investigation and Prevention Program and requested assistance with an 

independent investigation of the incident. A number of phone conversations were held to exchange 

information and arrange the on-site investigation. On March 9-14, 2018, a Safety and Occupational 

Health Specialist and a General Engineer with the NIOSH Firefighter Fatality Investigation and 

Prevention Program traveled to Pennsylvania to investigate this incident. The NIOSH investigators met 

with the Fire Commissioner and senior staff officers from the fire department, including the Deputy 

Chief of Health and Safety and members of the Health and Safety Office After Action Review Team. 

NIOSH investigators also met with the fire department’s Deputy Chief of Training and representatives 

of the International Association of Firefighters (IAFF) Local 22. The NIOSH investigators met with 

and interviewed the career firefighters and officers involved in the incident. 

The NIOSH investigators visited the incident scene, examined and photographed building materials, 

and also obtained wood joist samples from the fire department’s Health and Safety office and brought 

them to the West Virginia University School of Wood Science for identification. Additionally, mortar 

samples were obtained and sent to NIST for identification analysis. NIOSH investigators worked with 

the department’s Health and Safety Office After Action Review Team and a SCBA manufacturer’s

representative to obtain information from the victim’s electronic data logger. NIOSH investigators also 

accompanied fire department Health and Safety office representatives to Intertek labs in New York 

state to perform a pneumatic evaluation on the victim’s SCBA. NIOSH obtained and reviewed fire 

department breathing air compressor service records, department training requirements, standardoperating procedures, incident scene photographs and drawings, and victim training records and 

medical records. On March 27-28, 2018, the NIOSH investigators returned to Pennsylvania to conduct 

additional interviews. 

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 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 
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2,707 uniformed. In FY 2017, the department responded to 314,722 incidents. Of these, 267,266 were 

EMS incidents and 47,456 were fire incidents, 2,506 of which were working structure fires.

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. 

Over the previous 5 years, the fire department has undergone many changes. At the time of this 

incident, there were four major operating sections: Operations; Logistics; Planning/Risk Reduction; 

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

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

for Logistics commands: 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 commands: Fire Prevention, Fire 

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

Information Systems. The deputy commissioner for Finance/Administration commands: Fiscal and

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 added a new division with an additional division chief and two additional 

battalion chiefs. A Division Chief is responsible for each division. 

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

city. 

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).

Training and Experience

The Commonwealth of Pennsylvania does not have pre-requisite 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 [NFPA 2018a]. 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 fire-fighting 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 as per NFPA 1001, Standard for Firefighter Professional 

Qualifications [NFPA 2013b], Firefighter I and Firefighter II; Hazardous Material Awareness and 

Hazardous Materials Operations certification; NFPA 1035, Standard on Fire and Life Safety Educator, 

Public Information Officer, Youth Fire-setter Intervention Specialist and Youth Fire-setter Program 

Manager Professional Qualification [NFPA 2010]; and as a state-certified emergency medical 

technician/basic (EMT/B).

A probationary firefighter is assigned to the Operations Division on either an engine company or a 

ladder company. As an EMT/B, firefighters are also assigned as needed to work on basic life support 

(BLS) and advance life support (ALS) medic units. During the probationary period, the probationary 

firefighter is tested by the fire academy staff at 9 months (written and practical examinations) and 12 

months (written examination). Recertification for an EMT/B and paramedics (EMT/P) is every 2 years, 

which requires 18 hours of continuing education for EMT/B and 24 hours for EMT/P. 

Members assigned to the Operations Division are required to complete at least 1 hour of training per 

shift. Also, fire officers and firefighters are required to complete 170 hours of training annually.
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Additionally, the department has a procedure that personnel are trained on for emergency situations. 

When any member is in distress, lost, trapped, or injured, they are trained to depress the emergency 

activation button on their portable radio and announce “Mayday” 3 times followed by their location, 

identification and problem. This emergency activation overrides all other radio traffic on that 

frequency and provides several seconds of undisturbed radio transmission by the member on the 

frequency (hands free). As noted in the equipment and personnel section, this department provides 

portable radios to all members.

Equipment and Personnel

Emergency calls are answered by the city’s police dispatch center. If a 911 call is for a fire or a 

medical emergency, the call is then routed to the fire department’s Fire Communications Center 

(FCC). The FCC is operated by non-uniformed members of the fire department, consisting of a shift 

supervisor, four call takers, four dispatchers, and one relief person. The FCC is overseen by the Deputy 

Commissioner of Logistics, who directs all staff and support functions for the fire department and 

reports to the fire commissioner. In the event of a structure or building fire, the FCC assigns the 

appropriate number and type of fire companies to the incident. All incidents are assigned a box number 

based upon the location of street boxes that were previously used as a method of transmitting alarms to 

the FCC. The fire department communicated information from an incident to the FCC by a street box, 

which was done primarily before the radio system came into existence. All of the street boxes have 

been removed from service, but their locations are maintained within the FCC computer system.

The FCC sends four assignment levels to reported or confirmed structure fires: Tactical Box Alarm, 

Box Alarm, High-rise Box Alarm, and Major Incident Response Assignment.

A Tactical Box Alarm is assigned for reports of fires in appliances, chimneys, and outside rubbish 

fires. If multiple calls are received, people are reported trapped, severe weather conditions are in effect, 

or the first engine arrives on-scene with fire showing, the incident is upgraded to a Box Alarm 

Assignment. Note: If a report of nothing showing is given by the first arriving engine, dispatch issues a 

reduce speed directive to other responding units.

A Tactical Box Alarm dispatches:

• 2 Engines

• 2 Ladders

• 1 Battalion Chief

A Box Alarm is assigned for single family dwelling fires, fires in commercial or industrial buildings, 

factories, warehouses, educational buildings, or multiple-family dwellings fewer than seven stories in 

height, and dispatches:
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Career Lieutenant Killed in Building Collapse While Fighting Row 

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• 4 Engines

• 2 Ladders

• 2 Battalion Chiefs

• 1 Advanced Life Support (ALS) medic unit

A High-rise Box Alarm is assigned for fires in buildings seven stories in height or higher, and 

dispatches:

• 4 Engines

• 3 Ladders (1 for lobby control)

• 2 Battalion Chiefs

• Rescue company (Rescue 1)

• 1 ALS medic unit

A Major Incident Response is assigned to large-scale events, and dispatches:

• 5 Engines

• 4 Ladders

• Deputy Chief

• 3 Battalion Chiefs

• 2 Rescue companies

• 1 Squad

• 1 EMS command officer

• 3 ALS medic units

• 1 Air unit

When the incident commander is assigned to a Box Alarm Assignment and advises the FCC that “all 

hands are working,” the FCC will dispatch an additional ladder company to serve as the rapid 

intervention team (RIT), a squad company (either Squad-47 or Squad-72), the rescue company (Rescue 
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Career Lieutenant Killed in Building Collapse While Fighting Row 

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company, if they are not already assigned), and a medic unit. Note: Squad-47 and Squad-72 are engine 

companies trained and equipped in technical rescue and hazardous materials mitigation.

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

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 are assigned a staff assistant or chief’s aide. They are designated by position on the 

apparatus, for example Engine-45 Officer, Engine-45 DPOP (Driver/Pump/Operator/Pump), Engine45 Pak and Engine-45 Tip (Pak and Tip denote responsibilities for advancing hoselines [Pak] and 

responsibility for advancing and operating the nozzle [Tip]. These terms are used throughout the report 

to identify personnel by position. 

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 FCC 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.

Since this incident the department added a Battalion chief to the Health and Safety office. 

Additionally, the department has 4-field Deputy Chiefs that serve as operational Incident Safety 

officers. They work shifts and respond to “All Hands” notification or greater fires.

In this incident, the first alarm and special units (through Mayday response) and their reported times to 

the fire were:

First Alarm (Box)

Engine-45, dispatched at 0851:43, en-route 0852:48, on-scene 0854:32

Engine-13, dispatched at 0851:43, en-route 0852:51, on-scene 0858:55

Engine-34, dispatched at 0851:43, en-route 0853:52, on-scene 0859:24

Engine-59, dispatched at 0851:43, en-route 0852:27, available 0856:05 (replaced Engine 50)

Ladder-14, dispatched at 0851:43, en-route 0852:44, on-scene 0855:05

Ladder-12, dispatched at 0851:43, en-route 0852:34, on-scene 0855:42
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Career Lieutenant Killed in Building Collapse While Fighting Row 

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Battalion-8, dispatched at 0851:43, en-route 0852:31, on-scene 0855:47

Battalion-3, dispatched at 0851:43, en-route 0852:27, on-scene 0854:27 

Medic-25, dispatched at 0851:43, en-route 0853:56, on-scene (not reported, however they arrived and 

worked)

Engine-50, (additional) dispatched at 0854:09, en-route 0854:35, on-scene 0857

2 and 2 Response:

Ladder-3, dispatched at 0856:21, en-route 0859:15, on-scene 0904:19, assigned as RIT (on a 2 and 2 

response, a ladder and a medic are automatically dispatched as RIT)

Medic-31, dispatched at 0856:21, en-route 0857:35, on-scene 0905:48 (assigned as RIT medic unit)

ES-9 (EMS Supervisor) dispatched at 0856:21, en-route 0858:14, on-scene 0906:34

Squad-72 (1st response), dispatched at 0856:21, en-route 0858:19, response canceled and available 

0902:24

Rescue-1, dispatched at 0902:06, en-route 0902:31, on-scene 0916:45

All Hands Response:

Squad-72, 2nd dispatch at 0907:44, en-route 0908:40, on-scene (not reported, however they arrived and 

worked)

Deputy Chief-2, dispatched at 0907:44, en-route 0943:14, on-scene 1002:42

Incident Safety Officer, dispatched at 0907:56, en-route 0909:05, on-scene 0931:18

ES-1 (EMS Supervisor), dispatched at 0907:44, en-route at 0910:12, on-scene 0923:08

ES-3, (EMS Supervisor) dispatched at 0908:06, en-route at 0910:34, on-scene 0929:56

Fire Marshal-13, dispatched at 0914:09, en-route at 0914:09, on-scene at 0948:00

Fire Marshal-15, dispatched at 0900:22, en-route at 0900:22, on-scene at 0900:22 (reported)

Medic-36, dispatched at 0913:06, en-route at 0914:36, on-scene at 0920:36

Special Call:

Engine-59, dispatched at 0914:49, en-route 0915:27, on-scene at 0918:00
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Career Lieutenant Killed in Building Collapse While Fighting Row 

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Engine-29, dispatched at 0914:48, en-route 0915:56, on-scene at 0918:30

Medic-34, dispatched at 0916:30, en-route 0917:02, on-scene at 0929:24

Medic-44, dispatched at 0916:30, en-route 0917:46, on-scene at 0930:02

Second Alarmers-10, dispatched at 0927:15, en-route 0927:15, on-scene at 0933:57

Mayday Response:

Engine-55, dispatched at 0936:22, en-route 0937:12, on-scene 0940:17

Engine-43, dispatched at 0937:02, en-route 0941:59, on-scene 1000:00

Ladder-8, dispatched at 0936:22, en-route 0940:33, on-scene 0950:01

Battalion-4 dispatched at 0936:22, en-route 0936:39, on-scene 0943:57

Medic-13, dispatched at 0936:22, en-route 0937:41, on-scene 0943:50

Medic-15, dispatched at 0936:22, en-route 0938:56, on-scene 0945:56

AU-1 (Air Unit-1), dispatched at 0937:02, en-route 0942:02, on-scene 1000:00

PN-10 (Fire Prevention), dispatched at 0949:09, en-route 0949:09, on-scene 1015:09

Car-1, (Fire Commissioner) dispatched at 0942:13, en-route 0942:13, on-scene 0947:44 

Second Alarm Units

Engine-20, dispatched at 0952:09, en-route 0952:49, on-scene 0952:50

Engine-9, dispatched at 0952:09, en-route 0952:20, on-scene 1002:51

Engine-35, dispatched at 0952:09, en-route 0953:27, on-scene 0958:22

Engine-25, dispatched at 0952:09, en-route 0954:00, on-scene 1000:41

Engine-28, dispatched at 0952:09, en-route 0953:32, on-scene 1001:31

Ladder-10, dispatched at 0952:24, en-route 0952:5026, on-scene 0959:03

Ladder-18, dispatched at 0952:37, en-route 0954:41, on-scene 0958:42

Battalion-9 dispatched at 0952:09, en-route 0952:50, on-scene 1008:45
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Battalion-11 dispatched at 0952:09, en-route 0955:00, on-scene 1010:00 

Battalion-1 dispatched at 0952:09, en-route 0952:15, on-scene 1006:04 

Battalion-10 dispatched at 0952:37, en-route 0952:42, on-scene 1002:37 

Timeline 

The following timeline is a summary of events that occurred as the incident evolved. Individual unit 

times are noted above, however unit arrival times and actions may also be noted in the timeline below. 

Not all incident events are included in this timeline. The times and actions were obtained by studying 

department reports, dispatch records, audio recordings, witness statements, and other available 

information. All times are approximate and rounded to the closest minute. 

Incident Conditions Time Response & Fireground Operations

Box Alarm for dwelling fire, 4 

Engines, 2 Ladders, 2 Battalion 

Chiefs and Medic unit dispatched. 

0851 Engine-45, Engine-13, Engine-34, 

Engine-59, Ladder-14, Ladder-12, 

Battalion Chief-8, Battalion Chief-3 

and Medic 25 respond Engine-50 

added. 

Dispatch advised report of people 

inside (dwelling). 

0853 Dispatch updated possible address. 

Engine-45 arrived on scene (victim’s 

engine). 

Ladder-12, Battalion Chief-8 arrived. 

0854-

0855 

Engine-45 officer gave initial arrival 

report, 2 story, 15’ x 35’ middle of the 

row dwelling, fire showing first floor. 

Bravo and Delta (exposures) same size 

and dimensions all occupied. 2N2 in 

service, (denotes 2 engines and 2 

ladders will be working). The stretch 

from Engine-45 to front of dwelling 

was approximately 260 feet (15 row 

homes in). 

Battalion Chief-8 established 

command. 

0856 Command called Ladder-14 officer and 

advised that a report of a civilian 

inside. 
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Incident Conditions Time Response & Fireground Operations

Command called dispatch and 

provided the correct address, updated 

to heavy fire conditions first floor.

Command told Engine-34 to bring 1

3⁄4” handline and check exposure 

Delta.

0856

Engine-34 officer acknowledged.

Engine-45 Pak called Engine-45

DPOP and told him to send water (to 

their 1 3⁄4” handline).

0856 Very narrow street didn’t allow for 

heavy fire apparatus to access side A. 

The crew from Engine-45 hand 

stretched to the dwelling. Pump 

operator hand stretched to hydrant. 

Hydrant possibly frozen.

Command called Engine-13 for their 

arrival order.

Command Called Engine-50 and told 

them to stretch 1 3⁄4” and back up 

Engine-45 going in the front door.

0857 Engine-13, advised of their arrival 

order, 

Engine-50 acknowledged.

Command aid called dispatch. Aid 

was in the vehicle and Battalion-8 

(command) was outside and in front 

of the fire dwelling. Note: Resident

cars were parked on one side of the 

narrow snow-filled street.

0858 Battalion-8 aid, radioed dispatch and 

advised 3N2 in-service (3 Engines, 2 

Ladders working) for a middle of the 

row, occupied dwelling 15’ x 35’, 

heavy fire first floor, Exposures Bravo 

and Delta same dimensions.

Command radioed Ladder-12 officer

and told him to search and ventilate 

exposure Bravo.

0858-

0859

Ladder-12 officer acknowledged, then 

radioed command that they were in 

Bravo and that original dwelling had 

smoke on 1st and 2nd floors (rear).
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Incident Conditions Time Response & Fireground Operations

Engine-45 officer radioed command 

with a broken transmission, (that they 

were bringing out a...) command was 

in visual with Engine-45 officer and

acknowledged over the radio and told 

dispatch to send a medic unit 

immediately with stretcher to front of 

the fire dwelling.

0900 Civilian located on first floor and

removed from fire building (Deceased).

Charlie division (Battalion Chief-3)

radioed command to report he had fire 

in the breezeway and needed a line 

stretched.

0900 Command acknowledged.

Command called Ladder-14 officer.

Command called Engine-45 officer 

and request a progress report on the 

interior.

Command called Engine-45 officer 

and told him fire had extended to 

second floor and Engine-50 would be 

coming in behind him on first floor.

0901-

0902

Ladder-14 officer reported back that 

primary is on the way.

Engine-45 officer radioed back but 

transmission unreadable.

Victim’s data logger showed

PASS/SCBA turned on (note: the time 

information is from the internal clock 

on PASS device a different time 

source from other entries in the 

timeline).

0902 (Electronic data log work sheet 

provided in Appendix 1)

Engine-45 DPOP radioed Engine-45 

officer.

0903 Engine-45 DPOP advised that he had a 

new hydrant and that water is coming 

now.
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Incident Conditions Time Response & Fireground Operations

Command called Engine-45 officer 

and advised of the fire conditions on 

second floor and he (Engine-45) had 

Engine-50 coming in behind him and 

needed them to make the second 

floor.

0905 Engine-45 officer acknowledged and 

told command of trouble making stairs 

due to the debris inside.

Command told division Charlie that 

he had Engine-13 stretching a line to 

him.

0905

Engine-45 officer called Engine-45 

DPOP.

Engine-34 officer told Engine-34 

DPOP to send water.

0906 Engine-50 DPOP told Engine-50 

officer that he had a bad hydrant.

Battalion Chief-8 aid gave progress 

report of “all hands in-service, heavy 

fire, first and second floors” and 

confirmed the incident address with 

dispatch.

FCC provided information to 

Battalion Chief-8 aide and command 

regarding information that someone in 

the building (exposure Delta) cannot 

get out of their property.

0907 Battalion Chief-8 aide acknowledged,

and Command acknowledged and said 

that he would send someone in.

Command told all companies 

operating-exit the building they 

were going to switch to a defensive 

attack.

0907 Command repeated this defensive 

command twice.

All hands response dispatched: 

Deputy Chief-2, Incident Safety 

Officer, Emergency Service-1, and 3,

Fire Marshal-13, and 15, Medic-36.

0907 Deputy Chief-2 responded at 0943 and 

arrived at 1002. Note: Deputy Chief-2 

response and arrival were delayed due 

to a communication issue.
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Incident Conditions Time Response & Fireground Operations

Command called Division Charlie and 

told him that they were pulling 

everyone out of the building and to 

get a PAR, (Personnel Accountability 

Report) then they would regroup and 

go back inside.

0908 Division Charlie gives PAR for Ladder 

12 and told Command he was still 

waiting for a hoseline to come to the 

rear.

Command called Engine-45 officer 

and told him to exit the building and 

bring his members outside and 

standby for a PAR and then gave the 

same message to Engine-50 officer.

0908 Battalion Chief-8 aide gave FCC a 

report of an exterior attack and that 

they were doing a PAR.

Victim’s helmet camera shows that he 

is outside on side Alpha.

0908

Command called Engine-34 officer 

and told him to make sure and back 

out your crew and standby for a PAR.

0909 Engine-50 DPOP radioed Engine-50 

officer and told him they had a second 

bad hydrant.

Command called Engine-45 officer.

Command called Engine-50 officer.

0909 Engine-45 officer confirmed he had a 

PAR outside the structure.

Engine-50 officer responded that they 

were making their way out.

Command called Engine-13 officer

then called Ladder-14 officer.

0910-

0911

Engine-13 officer acknowledged PAR 

and Ladder-14 officer (told his 

members to do a face to face out front 

and acknowledged PAR.

Battalion Chief-8 aide told FCC 

that they were in an exterior attack 

and all members accounted for.

0911 FCC acknowledged the Battalion 

Chief-8 aide and advised of elapsed 

time of 20 minutes, Battalion Chief-8

was not aware on the tac channel.
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Incident Conditions Time Response & Fireground Operations

Engine-45 officer’s PASS data logger 

shows several sensing to pre-alarm 

entries.

0911-

0916

These are likely lack of movement logs 

(the victim was recorded outside by his 

helmet cam at 0908) and reset by user 

and turned off at 0916.

Command called Division Charlie and 

asked for status.

Command acknowledged Division 

Charlie and asked FCC to send utility 

company.

Command requested 2 more engine 

companies special call.

0913 Division Charlie reported he was in the 

rear with Engine-13 and Ladder-12 still 

waiting on water and that fire was 

extending to exposure Delta and that he 

needed the electric utility company in 

an emergency response.

Operations change back to offensive

Command called Division Charlie and 

told him that they had Engine-34 back 

on the first floor and that they were 

having water problems in the front as 

well.

0914 Division Charlie said they would help 

him (Command) out as soon as they 

could get water.

Special call for Engine-59, Engine-29 

and Medics 34, 44 transmitted.

0914 Engine-59, Engine-29 both arrived 

0918, Medics 34, 44 arrived 0929-

0930.

Engine-50 officer called Engine-50

DPOP and told him that he needed 

water.

Engine-13 officer called Engine-13 

DPOP and told him to send water.

Command told FCC to advise the first 

additional engine that arrived to assist 

Engine-50 DPOP to establish a water 

supply.

0915-

0916

Engine-50 DPOP told him that he was 

working on getting a hydrant that 

works. He was working on his third 

hydrant (frozen).

Engine-45 DPOP called another Engine 

and told him to send water (to Engine45).

Dispatch acknowledged and advised 

that Engine-59 and Engine-29 were the 

additional units dispatched.
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Incident Conditions Time Response & Fireground Operations

Engine-13 Tip radioed that they were 

ready for water and leaving shortly.

Battalion Chief-8 Aide advised 

dispatch that Engine-59 to assist 

Engine-50 DPOP with water supplyacknowledged.

0916 Command called division Charlie and 

told them that Engine-34 would be 

coming through exposure Delta with a 

charged hoseline and that he had 

Engine-45 operating in the front with a 

charged hoseline.

Engine-45 DPOP called Engine-45 

officer and told him he had a good 

water supply.

Engine-13 DPOP told his officer that 

he had water.

0917-

0918

Engine-45 officer acknowledged.

Engine-13 officer relayed to his tip 

man that water was coming.

Command asked Engine-50 officer 

what the fire conditions were on the 

first floor.

Command asked division Charlie for 

a report.

Command acknowledged and told 

him they had Engine-50 on the first 

floor.

0919-

0920

Engine-50 officer told command that 

there was a lot of trash inside and then 

the radio transmission cut off.

Division Charlie reported he had 

Engine-13 and Engine-34 and knocking 

down the fire impinging on exposure 

Delta.

FCC advised command that there was 

a female in distress in a nearby 

structure.

0924 Command acknowledged and asked 

emergency medical supervisor (ES-9)

to check on it.

Engine-45 officer’s Data logger 

shows the PASS unit being powered 

back on.

0925

Command called Engine-50 officer 

for a report on how they are doing on 

the first floor.

Command acknowledged.

0925 Engine-50 officer told command that 

Engine-45 had the hoseline and that he 

was on his way out to change his 

cylinder, he also said that Engine-45 

had a positive water supply.
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Incident Conditions Time Response & Fireground Operations

Command called Engine-45 officer 

for a progress report on first floor.

0925-

0926

Engine-45 officer radioed back that 

they had their hoseline on the first 

floor, lots of debris inside the dwelling 

and they were going to make an 

attempt to reach the second floor.

Command called Division Charlie and 

told them to take a line from the rear 

to the first floor and back up E-45 

while they went to second floor.

Command acknowledged Division 

Charlie and then told Engine-50 

officer that they were charging a line 

for him and they would be good to go 

(back up Engine-45).

Command called Engine-45 officer 

and told him that Engine-50 had water 

and would be coming in behind him.

0927-

0929

Division Charlie told command they 

couldn’t because Engine-13 did not 

have water. Engine-34 had water (in 

the rear) but they were needed due to 

fire impinging on exposure Delta.

Engine-45 officer acknowledged.

Command told Engine-45 officer to 

hold the first floor and that Engine-50 

would be (unintelligible) the second.

0931 Safety Officer arrived 0931.

Engine-45 officer’s Data logger 

showed the PASS indicating sensing 

to pre-alarm.

0926-

0939

No reset indicated by PASS data logger 

from 0926.40 through 0939.02 (a total 

of 7 data log entries indicating sensing 

to pre-alarm with no further step up to 

full alarm motion until log entry at 

0939).

Collapse Occurred

Command orders all units to exit the 

building and that they were going 

defensive.

0933 Command told all units to stand by for 

a PAR.
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Incident Conditions Time Response & Fireground Operations

Command called FCC and told them 

to sound the emergency evacuation 

signal.

Engine-50 officer activated his 

emergency button (portable radio).

0934 FCC acknowledged, and told 

Command that they had an emergency 

activation signal coming from Engine50 Pak (portable radio emergency 

button).

Mayday-Mayday-Mayday, Engine-50 

officer, radioed he couldn’t find 

Ladder-12 Pak and that they were on 

the second floor.

0934-

0935

Command asked Engine-50 officer for 

his location, then Ladder-12 Pak

radioed that he had made it out the rear.

Division Charlie radioed Command 

that he had accountability for Engine50 Pak.

Command called for all units to 

standby for a PAR.

Command called for Engine-45 

officer.

0936 FCC sounded emergency evacuation 

signal over the radio.

Command told all units to standby 

unless they had a priority.

Command called Engine-45 officer 

twice.

Command told dispatch that they 

were still looking for Engine-45 

officer.

Command called Engine-45 officer.

Command called Engine-50 officer 

for PAR.

0937-

0938

0939

No response from Engine-45 officer.

No response from Engine-45 officer.

Division Charlie told Command they 

had PAR in the rear with Engine-34 

and Engine-13.

Engine-50 acknowledged and said he 

had PAR.

Engine-45 officer’s Data logger 

showed the PASS indicating prealarm to alarm. (see Appendix 1)

0939 This data logger entry at 0939.14 to 

full alarm was by motion not manual 

alarm.
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Incident Conditions Time Response & Fireground Operations

Last recorded entry from electronic 

data logger occurred at 0939.14.(see 

Appendix 1)

0939 Note: Engine-45 officer’s SCBA had to 

be cut when he was extricated. The 

wires for the integrated PASS were 

also cut and there was considerable 

effort by the manufacturer and the Fire 

Department’s Health and Safety office 

to remove/replace parts to read the data 

from the requested date.

Mayday response was dispatched. 0936 Engine-55, Engine-43, Ladder-8, 

Battalion Chief-4, Medics 13, 15.

Command radioed Ladder-14 officer 

for PAR.

Command ordered Engine-55 and 

crew to front of the dwelling.

0940-

0941

Ladder-14 officer confirmed PAR.

Engine-55 acknowledged.

Car 1 dispatched (Fire 

Commissioner).

0942 Car 1 on scene 0947.

Command asked Division Charlie if 

he could place a line to the second 

floor from the rear.

0944 Division Charlie radioed, negative, 

they had a unstable kitchen floor and 

partial collapse and extension in the 

rear.

Squad-72 roof radioed command that 

they had a partial collapse in the rear 

and to pull anyone out if they were in 

there.

Command radioed FCC and 

advised that they had all companies 

out of the building, but they had 

one member unaccounted for, start 

the collapse unit and send a 2nd

alarm.

0947 Command acknowledged.
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Incident Conditions Time Response & Fireground Operations

FCC tells Battalion-8 aid of the 2nd

alarm chiefs.

Battalion-8 aid acknowledged and 

updated that they were still in a 

defensive mode and that they had one 

member they were trying to remove 

from the building.

0952-

0955

Second alarm units dispatched 

Battalion Chief-9, Battalion Chief-11, 

Battalion Chief-1, Engine-20, Engine35, Engine-25, Engine-28 and 

responded.

Additional units were Ladder-10, 

Ladder-18, Battalion Chief-10, Car-5.

RIT group radioed Command to tell 

him that they shut hoselines down 

inside and to request quiet on the 

fireground.

0955-

0958

Command called all companies to shut 

their hoselines down and requested

quiet on the fire scene.

Squad-72A officer reported during 

NIOSH interviews that he heard a

PASS sounding.

Squad-72A officer reported that when 

they located Engine-45 officer and took 

his facepiece off, there was an air 

sound and the vibration alert was 

sounding from the victim’s SCBA.

RIT group radioed command that they 

were going to fog out the first floor 

(use the hoseline to help ventilate).

0958 Command acknowledged.

Deputy Chief-2 arrived and asked for 

a progress report.

1002 Command told him that they had 

evacuated the building of all members 

and Engine-45 officer was not 

accounted for, but they had eyes on 

him and Rescue-1 and Squad-72 were 

trying to remove him.

Operations Division established. 1007
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Incident Conditions Time Response & Fireground Operations

Operations Division gave an update to 

Command. 

1010- 

1011 

RIT group supervisor reported that 

there had been an interior collapse and 

parts of the building were unstable and 

they were in the process of shoring and 

the rescue operation. 

Collapse unit arrived. 

Command gave a progress report to 

FCC. 

1022 Report - Crews had shored up the 

collapse on the first floor and located 

the downed firefighter and that they 

were in the process of extricating him 

to the exterior of the building.

Car-5 assumed command. 1027 

1035 Victim extricated, operations called 

command and advised that they 

extricated the firefighter (Engine-45 

officer) and they were on their way 

out.

Building Construction and History

Note: Much of the following building construction description and history for the fire structure is 

based on a NIOSH funded expert review and report provided by Chief Christopher J. Naum, SFPE 

(NY). His full review report of the incident is included in Appendix 2. 

Additionally, the Fire department’s Health and Safety Office After Action Review Team investigated 

this fatality and provided NIOSH with extensive information, including the fire department’s history of 

fighting fires in highly congested urban areas such as this row house community. The fire department’s

Health and Safety Office After Action Review Team completed a comprehensive review and

investigation of this incident and many of the findings, resources and references have been referenced 

and/or included in this report. 

There was additional analysis needed for building material identification used during the period of 

construction. West Virginia University analyzed wood joist samples in their wood science laboratory 

and identified them as Eastern Hemlock. 
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Additionally, samples of the brick mortar were analyzed by the National Institute of Standards and 

Technology (NIST) and noted that they lacked Portland cement as an ingredient. Appendix 3 contains 

the findings by NIST. 

The fire structure was a 2-story, approximately 1,038 square feet, single family, occupied residential 

row house of ordinary construction (Type III) masonry, brick and wood joist built between 1880 and 

1888 (see Photo 1 and floor layout in Diagrams 1 through 5). It was located on a narrow street 

comprised of thirty-four attached row house buildings that spanned the city block. Similar row houses 

made up the exposures on all four sides. Side Charlie had a slight buffer area for utilities, but not 

enough room for access by fire department vehicles or equipment.

Photo 1. Side Alpha of incident dwelling, including view of exposures Bravo and Delta. 

(Photo Courtesy of Google Earth)
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Diagram 1. Sketch of first floor layout. 

Note: there was severe clutter conditions not depicted in this sketch. 

(Diagram courtesy of fire department Health and Safety Office) 
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Career Lieutenant Killed in Building Collapse While Fighting Row 

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Diagram 2. Sketch of second floor layout. 

Note: there was also severe clutter conditions not depicted in this sketch. 

(Diagram courtesy of fire department Health and Safety Office) 
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Career Lieutenant Killed in Building Collapse While Fighting Row 

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Diagram 3. Cross-Section of Row house. Red dotted circle indicates where second floor joists 

framed up to the stairwell opening 

(Graphic Courtesy of Buildingsonfire.com | C.J. Naum) 
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Diagram 4. Row house Floor Joist Plan-Second Floor. Detail A indicates gas piping run in joists. 

Detail B indicates second floor joists extend from bearing wall to bearing wall. Detail C indicates 

joists terminating at stairwell opening.

 (Graphic Courtesy of Buildingsonfire.com | C.J. Naum) 
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Diagram 5. Stairwell Opening Framing and Second Floor Joists. 

(Graphic Courtesy of Buildingsonfire.com | C.J. Naum) 
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The building’s style and design are commonly referred to as a row house or Workingman’s House with 

defining characteristics that include:

• Two-floors of occupied space (approximately 519 square foot per floor) with a limited window 

basement below grade

• Masonry brick bearing-party walls with masonry front facades and narrow windows (a party 

wall is a wall that is shared by two occupancies)

• 3-inch x 7.5-inch wood floor joists as structural support pocketed into the masonry bearing 

walls (WVU wood science division identified the floor joist as Eastern Hemlock wood with a 

moisture content of 3.6%). 

• Eastern Hemlock is moderately light weight, and moderately weak in strength, moderately 

weak in bending strength and moderately low in splitting resistance. Hemlock is similar to 

Spruce in appearance but is considered inferior and used almost exclusively as a cheap roughframing timber [Naum 2014]. 

• A unique feature of this row house (as well as the exposure structures and likely in other 

surrounding row houses) was a 1-inch by 1-inch notch cut in the upper top portion of the wood 

joists to allow for a gas pipe when gas service was provided in the late 1800’s. These notches 

are in every joist in a line from Side A inward approximately 20 feet (see exemplar from 

exposure in Photo 2).

• Plaster and lath over wood framing interiors.

• Single sloping timber rafter roof with wood deck and covering with a brick cornice on Side A. 

• Masonry walls on Bravo and Delta Exposure (party walls), brick wall on Side A and wood 

frame backing on Side C.

• Access from street via a vestibule (Side Alpha).

• Single run stairway located adjacent to the left along the wall just after the vestibule.

• Flooring consisted of material over 3-inch x 1-inch planking.

• Indoor kitchen, plumbing and heating (this unit was equipped with gas lighting at one time and 

the gas feed pipe was run through a cut in the floor joists as seen in Photo 2).

• The row house was in a poorly maintained condition with structural deterioration and 

excessive clutter and heavy contents with hording like conditions.
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• Narrow utility alley (no access for vehicles) on side Charlie with partial fencing and 

overgrown vegetation restricting access to a working area.

• The department reported that although the dwelling was occupied, (a deceased civilian was 

located and removed early in the fire), it may not have had an operable fixed heating system. 

The dwelling had roof and wall deterioration, and open areas directly exposed to the 

environment [Naum 2019].

• The department reported evidence that significant clutter conditions of materials by the 

occupant over time and a significant degree of clutter that was present and encountered by 

operating FD companies throughout the rooms and floors of the structure that imposed critical 

operational impediments and may have affected the structure during the early development 

stages of the fire within the room compartments [Naum 2019].

• Occupied row houses on either side (see Photo 1).
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Photo 2. Exposure row house exemplar photo showing the floor joists cut to allow for gas pipe and 

the gas pipe drop for the light fixture. Electric light fixtures were attached to these pipes in later 

years. 

(Photo courtesy of fire department Health and Safety Office) 
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Personal Protective Equipment

Engine-45’s officer was wearing full personal protective equipment (PPE) including NFPA compliant 

coat, bunker pants, helmet, gloves, boots and a 2013 Edition, 5500 psi, 1800-liter, Self-Contained 

Breathing Apparatus (SCBA). The NIOSH Division of Safety Research sent the victim’s SCBA to 

Intertek labs in New York for a Posi-check pneumatic flow performance test. The testing was witness 

by the Health and Safety Office personnel from the department. There were no issues found with the 

SCBA’s pneumatic performance. 

The victim’s integrated personal alert safety system (PASS) device was examined and the electronic 

data logger was downloaded courtesy of a manufacturer’s vendor due to significant damage to the 

PASS housing. A partial PASS electronic data log was collected, and a marked version is included in 

Appendix 1 of this report. This SCBA with integrated PASS did not have pneumatic data logging 

capability, just the electronic PASS data.

The PASS device electronic data log indicated the victim initially turned on the SCBA at 0902:34 

(according to the PASS internal clock). The Engine-45 officer likely changed his cylinder out when the 

PASS device recorded a sensing to off at approximately 0916:40. This may have been during the time 

the strategy had changed from offensive to defensive. At approximately 0925:04, the Engine-45 

officer’s PASS data log indicated an Off to Sensing mode indicative of the SCBA being turned back 

on. The Engine-45 officer’s data logger showed the PASS device indicating sensing to pre-alarm from 

0926:40 to 0939:02 with a total of 7 data log entries with no reset. At 0939:14 (internal PASS clock) 

the Engine-45 officer’s data logger indicated pre-alarm to full alarm motion. It is important to note 

that the alarm was motion and not manual, which indicates the alarm sounded due to a lack of motion 

by the officer and not by him manually activating it. 

The last entry in the data logger was the final log of 0939:14 which showed the PASS going into full 

alarm by lack of motion (not manual). The victim’s SCBA was cut off while he was being extricated 

which also cut the electronic wires for the PASS device. This may have damaged the internal 

electronics and made downloading the stored information difficult. It is also the likely reason for the 

missing electronic data logs that would have followed (i.e., alarm reset, alarm to off or low battery). 

The manufacturer provided considerable assistance to NIOSH investigators to obtain the information 

stored in the PASS device. This involved considerable and delicate technical work to gather basic 

information from the PASS device. The limited data that was able to be removed from the device 

appeared to be reliable. 

The department’s SCBA breathing-air compressor maintenance records were checked by NIOSH 

personnel. The SCBA in use by the department at the time of the incident were only one year old and 

there were no reported problems. 

Although not considered a contributing factor in the line-of-duty-death in this incident, the 

investigation by the fire department’s Health and Safety Office noted a need to update the training on 

SCBA filling of the newer high pressure (5500 psi) cylinders. This was also noted by NIOSH 
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investigators when reviewing the initial on-air times for the first crews in and early end-of-servicetime-indicator (EOSTI) activation. 5500 psi cylinders require a full charge to deliver the 1800 liters

that provide a rated service time of 45 minutes. Note: a rapid fill (sometimes referred to as a hot fill) 

will result in a loss of pressure after the cylinder cools. It is important to follow the manufacturer’s 

instructions on the rate of fill to achieve the proper operating pressure. Some cylinders may require 

slower fill rates and/or the ability to top off after they have cooled down. Firefighters need to 

understand that a rapid fill may result in an 1800-liter, 5500 psi cylinder having only a partial fill to 

capacity after it has cooled down. To obtain the 45-minute rated capacity of 1800 liters, the cylinder 

needs to be slowly filled to an operating pressure of 5500 psi. 

The department’s Health and Safety Office did a considerable amount of work to identify typical fill 

rates and how to reduce the “hot fill” air loss which can be significant in a small volume/high pressure 

cylinder. Their work is noted in Recommendation 13 in this report. Although the cylinder pressure and 

air usage was not considered a contributing factor in this fatality, NIOSH provided a recommendation 

on filling SCBA air cylinders as a best safety practice for the fire service. This can be useful to other 

departments who have upgraded to higher pressure 5500 psi SCBA and may not be aware of the need 

to alter fill procedures, upgrade breathing air compressors and/or increase the number of fill sites in the 

operations area to reduce out of service time. 

Weather and Road Conditions

The weather was a primary contributing factor in this incident. Firefighters experienced significant 

interruptions in water supply with as many as 6 inoperable (possibly frozen) fire hydrants as well as a 

frozen nozzle tip and difficulties with personal protective equipment including SCBA (frozen head 

straps and a head net in a SCBA facepiece). They also faced extreme cold, snow and ice in the 

response roadways and a narrow street that had cars parked on one side of the street, making it 

impossible for heavy fire apparatus to access the front of the fire building. Crews had to hand stretch 

handlines 260 feet past 15 row houses from intersecting larger streets that could accommodate engines 

and ladders (see Photos 3 and 4). 

At approximately 0854 hours on January 6, the weather in the immediate area (Airport) was reported 

to be 9 degrees Fahrenheit, with a dew point of -7 degrees Fahrenheit, and the relative humidity was 

48%. Wind conditions were up to 20 miles per hour (mph) from the west, and within the hour having 

gusts from the WNW at 35 mph. [Weather Underground 2019]. 
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Photo 3. Red pin and horizontal arrow point to incident structure, vertical white arrows indicate the 

narrow access to side A due to narrow roadway and on street parking and very limited access to the 

utility alley on side C. 

(Photo courtesy of Google Earth)

Photo 4. 1800’s era row homes with dense construction and narrow streets. Incident location noted 

with red pin and exposures noted. 

(Courtesy of Google Earth. Analysis Diagram Courtesy of Buildingsonfire.com | C.J. Naum) 
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Investigation

On January 6, 2018, a 42-year-old Lieutenant (Engine-45 officer) was killed after becoming trapped in 

an interior structural collapse while fighting a fire in an 1800’s era row house. 

At approximately 0851 hours a box assignment was dispatched for a reported dwelling fire in a middle 

of the block row house in an older section of the city. Dispatched to the box assignment were Engine45, Engine-13, Engine-34, Engine-59, Ladder-14, Ladder-12, Battalion Chief-8 and Battalion Chief-3 

and Medic-25. Engine-50 was out on another assignment, but cleared and was added to the dispatch 

assignment. Firefighters arrived to find a two-story row house heavily involved in fire in the middle of 

the block. The narrow streets and resident parking prevented fire apparatus from accessing the front of 

the dwelling and there was no access to the rear of the dwelling except through an alleyway

overgrown with vegatation.

En-route to the fire, firefighters had a report of possible victims trapped in the structure. Engine-45 was 

the first engine to arrive and parked on the main street. Engine-45’s officer instructed his crew to 

stretch a 3-inch line connected with a gated wye to a 1 3⁄4 inch handline and for Engine-45 to find a 

hydrant to secure a water supply. The Engine-45 officer sized up the incident and gave his initial 

arrival report of a two story, 15 feet by 35 feet middle of the row dwelling with fire showing on the 

first floor (see Photos 5 and 6). 

The Engine-45 crew (Pak and Tip1) hand stretched approximately 300 feet of 3-inch hoseline along 

with 150 feet of attack line to the middle of the block (15 row homes in) from Engine-45’s location 

approximately two hundred and sixty feet down a snow and ice covered street to the front of the fire 

dwelling (see Photos 5 and 6).

1 In this jurisdiction there are four firefighters assigned to an engine. An officer, Driver/Pump/Operator/Pump (DPOP), and 

the PAK firefighter and TIP Firefighter. The position of a PAK is to assist in hose advancement to the seat of the fire and 

the TIP firefighter is the nozzleman.
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Photo 5. Fire conditions pre-arrival of fire department time: 08:55:20. 

(Photo courtesy of fire department from resident video)
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Photo 6. Initial fire department operations. 

(Photo courtesy of fire department from video taken by area resident across the street)

Battalion Chief-8 (BC-8) arrived and assumed Command Note: Battalion Chief-8 would become the 

incident commander. He was an experienced fire officer with 28 years of service in busy companies, 

with 4 years as a Battalion Chief. Prior to this incident, he had sent out a notice at the beginning of the 

shift warning of icing conditions, “slick streets” and the possibility of frozen hydrants. 

Battalion Chief-8 reported during interviews that he observed smoke at the roof top on arrival then 

heavy fire at the 1st floor windows. The Battalion Chief-8’s aid was able to drive up the narrow street 

with his SUV. Battalion Chief-8 advised the Fire Communications Center (FCC) of heavy fire 

conditions on the first floor of the dwelling and placed 3 engines and 2 ladders in-service. Command 

then ordered Engine-34 to go to the Delta Exposure with a 13⁄4-inch hoseline and check for fire 

extension. Command told Engine-50 to stretch a 13⁄4-inch line via side Alpha and back up Engine-45. 

Engine-45’s Driver/Pump/Operator/Pump (DPOP) charged the 3-inch and 13⁄4-inch hoseline off the 

Engine-45 internal tank. The Engine-45 officer directed the Engine-45 Tip to flow water from the 

outside, but no water would come out. During interviews, the Engine-45 Tip stated that the nozzle was 
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frozen. Engine-45’s officer instructed the Engine-45 Tip to remove the stream straightener off the 

nozzle and this allowed water to flow. This did knock the fire down on the first floor (see Photo 6). 

The initial 2 engines, 2 ladder trucks and Battalion Chief-8 began initial fire suppression and rescue 

efforts. The crews making entry found excessive clutter (hoarding conditions) that hampered their 

ability to enter and search. Battalion Chief-3 arrived and was assigned Division Charlie.

The Engine-45 Pak reported during interviews that after they stretched hoselines to the dwelling

(Engine-45 officer, Engine-45 Pak and Engine-45 Tip), located a civilian behind the door and removed 

him to the street. The crew was still operating off internal tank water from Engine-45, and re-entered 

the structure and tried to locate the stairs to the second floor. Engine-45’s Tip reported that they flowed

water into the living room area until they ran out of water and exited the structure. Command ordered 

Ladder-12 to exposure Bravo to search for any other occupants and fire extension.

Ladder-14 reported they were conducting a primary search. Division Charlie advised Command that 

there was fire in the breezeway (area at the corner of side C and side D) and that they would need a 

hoseline stretched to side C. Command acknowledged and advised dispatch that the fire had extended 

to the 2nd floor and then radioed the Engine-45 officer with the same information. Command told the 

Engine-45 officer that Engine-50 would be coming in behind him on the 1st floor and for Engine-45 to 

go to the 2nd floor. The Engine-45 officer told Command that he was having difficulty getting to the 

stairs due to excessive clutter. Engine-50 entered the dwelling to back up Engine-45. Engine-45’s

DPOP radioed that he had a bad hydrant and was waiting for water while Engine-50 operated their 

hoseline.

An “All Hands” message was transmitted at 0907. This meant that 4 engines and 2 ladders were 

working (in-service) and the protocol was that a Deputy Chief, Incident Safety Officer, EMS Division 

Chief and Squad-72 were dispatched. All Hands units responded and arrived, except for Deputy Chief 

2 who was delayed and didn’t respond until 0943.

Interruptions in water supply hampered fire-fighting efforts and forced a change in strategy until a 

reliable supply was established. At approximately 0906, Engine-50’s crew reported that they had lost 

water on their hoseline. At approximately 0908, Command ordered all units to exit the building and 

that they were switching to a defensive attack. Engine-45’s crew exited and changed out SCBA 

cylinders. Engine-45 officer’s helmet camera recorded his exit. Command told Charlie division of the 

strategy change and for Charlie division to report back with a Personnel Accountability Report (PAR)

on their companies. Charlie division reported back with PAR complete on his companies. 

Engine-50’s DPOP then reported that he had a second bad hydrant, and approximately 1 minute later, 

Engine-34’s officer reported to Engine-34 DPOP that he had lost water pressure on his hoseline. The 

last member to exit the structure was Engine-50’s officer at approximately 0910. Command told FCC

that they were in a defensive strategy and all members were accounted for at approximately 0911. FCC

acknowledged and replied with a 20-minute elapsed time notification. 
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At approximately 0913, Charlie division notified Command of fire extension to exposure Delta and 

that he needed a water supply, and to contact the electric utility company to cut-off power to the 

structure due to the live wires arching. Command then contacted dispatch to call for 2 additional 

engine companies (Engine-59 and Engine-29). The Engine-13 crew stretched a hoseline from side 

Alpha to Charlie via the Delta exposure. Engine-45 reported that he had re-established a water supply 

and re-charged the 3-inch line that Engine-45 had stretched.

Once the water supply was re-established, crews re-entered the structure to continue to extinguish fire. 

At approximately 0916, Command radioed Charlie division and advised him that Engine-34 was 

coming to the rear with a charged hoseline and that Engine-45 was operating in the front of the 

dwelling with their hoseline. At approximately 0917, Engine-45’s DPOP advised the Engine-45 officer 

that he had a good water supply. Engine-13’s DPOP then radioed his crew that water was on its way.

When Engine 45’s PAK Firefighter returned to the front of the fire dwelling (he was previously told by 

Engine-45’s officer to return to the apparatus to assist Engine-45’s DPOP), Engine-45’s officer gave 

him Engine-45’s hoseline and instructed him to continue discharging water onto the first floor. The

Engine-45 PAK said he still had air remaining in his SCBA cylinder and re-entered the dwelling just 

inside the front door. When the Engine-45’s Tip firefighter returned to the front of the dwelling (he 

was previously instructed by the Engine-45’s officer to return to the apparatus and bring back 

additional full SCBA cylinders), the Engine-45’s Pak exited the dwelling to change his SCBA 

cylinder. While replacing his SCBA cylinder, Engine-45’s officer gave Engine-45’s nozzle to Engine50’s officer. The Engine-50 officer along with the Engine-45 Pak re-entered the structure from side 

Alpha and used Engine-45’s hoseline to continue to knockdown the kitchen area. Division Charlie had 

Engine-34 and Engine-13 working from the rear with a hoseline flowing on the fire that was extending 

to the exposure.

The Engine-45 officer and Engine-45 Tip re-entered the structure from side Alpha where they joined 3 

other members of Rescue-1 (search man), Squad-72’s officer and Engine-50’s Pak. The Engine-50 

officer and Engine-45 Pak exited for new air cylinders. The Engine-45 officer now had the nozzle and 

with Engine-45 Tip, they continued to knock down fire. The Engine-45 officer called Command and

told him they were trying to make it to the 2nd floor, however there was a lot of debris hampering their 

efforts. The Engine-45 Tip reported that they made it approximately one third the way up the stairs 

with the Engine-45 officer on the nozzle and they were flowing water on the 2nd floor.

The Engine-45 Pak and Ladder-12 Pak were outside of the structure on side Alpha. Engine-45’s 3-inch 

line had water, so they used Engine-50’s hoseline connected to Engine-45’s gated wye and got a 

second line in operation from side Alpha. The Engine-50 officer was told by Command to take this 

second line to the 2nd floor. Command told the Engine-45 officer to hold the 1st floor and that Engine50’s crew was coming in and would make the 2nd floor. At this time, there were a total of 5 firefighters 

on the first floor (Engine-45 Officer, Engine-45 Tip, Engine-50 Pak, Squad-72 Officer, and Rescue-1 

Search) with 2 additional firefighters (Squad-72 Tip man and Pak man) in the vestibule area at the 

front door.
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The Engine-50 crew, which consisted of 3 firefighters (Ladder-12 Pak on the nozzle, backed up by the 

Engine-45 Pak, followed by the Engine-50’s officer) entered the building and advanced up the stairs to 

the second floor. The Engine-50 officer reported that his SCBA head webbing and straps were frozen 

and that he was slightly delayed in entering the building. There were now two hoselines in operation 

inside the dwelling. Ladder-12 Pak reported that he made it to the 2nd floor and was in the hallway just 

off the top of the stair landing. He was flowing the nozzle towards the rear (side Charlie, 2nd floor), 

then turned and flowed water toward the other rooms in the direction of side Alpha (see Diagram 6).

The Engine-45 officer gave the nozzle to the Engine-45 Tip and they continued to flow water in the 1st

floor living room area that kept flaring up. Visibility was reported as zero from different companies

during interviews. The Rescue-1 Search firefighter was just inside the 1st floor area and reported that 

he told the Engine-45 Tip that there was an area of fire towards the front (1st floor) in the living room.

The Engine-45 Tip and Engine-45 officer then made their way toward the front and started flowing 

water. The Engine-45 Pak reported that the collapse occurred approximately 30 seconds after he 

started hitting the fire in the front of the 1st floor living room (see Diagram 7). The Engine-45 Tip 

stated that a Rescue-1 member grabbed him and told him to get out.

The crew on the second floor reported that they experienced a shift in the floor and the Ladder-12 Pak 

yelled to the crew on the stairs that he felt the floor sag. During interviews, he reported the floor 

sagged approximately 2 inches. The Engine-50 officer ordered the Ladder-12 Pak man off the 2nd

floor; however prior to getting back to the stairs, the 2nd floor collapsed into the first floor.
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Diagram 6. Location of members on floor 2 at time of collapse. 1 = Ladder-12 Pak, 2 = Engine45 Pak, 3 = Engine-50 Officer. 

(Diagram courtesy of fire department Health and Safety Office, After Action Review Team) 
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Diagram 7. Location of members on floor 1 at time of collapse. 1 = Engine-45 Officer (victim), 2

= Rescue-1 Search, 3 = Engine-45 Tip, 4 = Squad-72 Officer, 5 = Squad-72 Search, 6 = Squad72 Pak, 7 = Engine-50 Pak. 

(Diagram courtesy of fire department Health and Safety Office, After Action Review Team) 
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At the time of collapse the following members and companies were inside the structure:

• 2nd floor: Ladder-12 Pak, Engine-45 Pak, Engine-50 Officer

• 1st floor: Engine-45 Tip, Engine-45 Officer (victim), Rescue-1 Search, Squad-72 Officer, 

Squad-72 Pak, Squad-72 Tip, Engine-50 Pak 

Squad-72’s officer reported hearing a loud crack and went to the front door (side Alpha) and told 

Command to get everyone out. At approximately 0933 a V-shaped collapse occurred trapping several 

firefighters. Command ordered an evacuation of the building and a PAR and notified everyone that 

they were going defensive.

Two firefighters who were on the stairs leading to the second floor (Engine-45 Pak and Engine-50 

officer) were trapped. Engine-50’s officer activated the emergency button on his portable radio. FCC

received this transmission and relayed the information back to Command. Command then had the 

dispatcher sound the emergency evacuation signal. The Engine-50 officer then transmitted a Mayday 

for Ladder-12’s Pak (who had been above him on the 2nd floor). The transmission was successful, and 

he told Command the Mayday was for Ladder-12’s Pak. The Engine-50 officer reported during 

interviews that he was unable to free himself but was able to assist the Engine-45 Pak and get him free 

from the entrapment. Rescue-1 Search was able to grab the legs of the Engine-45 Pak and free him and 

direct him to safety. 

The Ladder-12 Pak reported during interviews that when the floor collapsed, he slid down to the first 

floor and was trapped in debris, and both of his legs were pinned. His SCBA facepiece became 

dislodged. He was able to place it back on his face and attempted to transmit a Mayday over the radio, 

but was not successful. The Engine-50 officer heard the Ladder12-Pak call the Mayday and transmitted 

a Mayday on his radio for Ladder-12’s Pak. The Ladder-12 Pak reported during interviews that he was 

able to free one leg and then able to remove his foot from his other boot and self-extricate. He saw an 

area of light and made his way toward the light (which was side Charlie). He radioed that he had made 

it out of the structure and Charlie division called Command to let him know that Ladder-12 Pak was 

accounted for in the rear. 

Rapid Intervention Team (RIT) Operation

A RIT group was established with Rescue-1, Squad-72 and other fire department members, including 

the collapse unit. The extensive rescue and extrication involved heavy shoring, cutting, jacking and 

stabilizing in hot, smoky conditions. The RIT group worked in these conditions while using SCBA 

until they could ventilate by fogging out (hydraulic ventilation) and using fans on side Charlie to 

remove smoke and provide air. Overhaul and extinguishing spot fires were still being performed 

throughout the RIT operation. At one point in the RIT operation, crews had to suspend water flow for 

the RIT group and keep an eye out for further collapse onto the RIT group. The rescue/removal 
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operation took just over an hour. The incident safety officer controlled access (accountability) at the 

front doorway due to a threat of further collapse.

The victim (Engine-45 officer) was trapped by heavy second floor joists, building materials and debris

(see Photo 7). Squad-72’s officer reported that he heard a PASS device sounding and was able to 

locate the Engine-45 officer. They had to crawl through extensive debris and follow the Engine-45 

hoseline in the contour of the collapse towards Delta wall (simultaneously, Engine-50 and other crew 

members searched the Bravo side wall). The Squad-72 officer reported that he heard a PASS device 

and crawled toward the noise. When they found the Engine-45 officer, he was heavily entrapped with 

his SCBA jammed in-between the floor joists and his leg pinned underneath debris. He was trapped 

between the two floor joists in a seated position facing the Delta side. Rescue-1’s officer reported that 

they couldn’t move him. Squad-72’s officer reported that he removed the victim’s face piece and air 

flow was heard along with the EOSTI (vibrating alert) on the victim’s regulator, however the victim 

was not breathing. They silenced the victim’s PASS device and turned off his cylinder. Squad-72 and 

Rescue-1 worked to free the officer using power cutting and spreading tools, hand tools, and 

shoring/cribbing, stabilizing, and jacking equipment.

The Engine-45 officer was eventually removed by the RIT group. Fire department paramedics began

Advanced Life Support (ALS) measures which continued during transport. He was transported to a 

local trauma hospital and later pronounced dead. He died of positional asphyxia with superheated gas 

and smoke inhalation (see Diagram 8 and Photo 7).
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Photo 7. Arrow indicating victim’s SCBA and approximate location where Engine-45’s Lieutenant 

was located and extricated by Fire Department RIT crews. 

(Photo courtesy of the Fire Department)
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Diagram 8. Cross-Section of Second Floor Collapse. 

(Graphic courtesy of Buildingsonfire.com C.J. Naum) 
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Fire Behavior

The origin and cause have not been released by the Fire Marshal at the time of this report. 

Contributing Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key 

events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH 

investigators identified the following items as key contributing factors in this incident that ultimately 

led to the fatalities:

• Extreme cold weather, water supply (6 inoperable hydrants). 

• Inherent building characteristics and unique row house variation.

• Structural overloading, excessive clutter and deteriorated building conditions. 

• Risk assessment that included a structural condition evaluation after strategy change (fire 

severity on primary building materials and extension within ceiling spaces). 

Cause of Death

According to the Medical Examiner’s Report, the medical examiner listed the victim’s cause of death 

as Positional Asphyxia with Superheated Gas and Smoke Inhalation.

Recommendations 

Recommendation #1: Fire Departments and Authorities Having Jurisdiction (AHJ’s) should 

consider increasing emergency response capabilities during extreme weather. 

Discussion: Fire departments can be challenged to perform seemingly standard life saving and fire 

suppression operations during periods of extreme weather, such as extreme cold, heat and/or severe 

flooding. 

Fire departments and authorities having jurisdiction should consider pre-planning and pre-staging 

resources, assets and additional emergency personnel to best suit their local geographic and population 

density challenges during severe weather sitations. Severe weather can impact emergency response and 

block or restrict access to assets such as fire apparatus and emergency medical vehicles and law 

enforcement support to best perform the needed missions such as fire and rescue services. 

Critical functions of emergency operations can be assisted by increasing resource and the response 

capabilities during severe weather operating periods. Additional personnel called back or held over are 

considerations for increasing staffing assets, however this should be pre-planned and then implemented 

in stages with forecasting and planning. 

Firefighters were hampered with frozen nozzles, inoperable/frozen hydrants, frozen PPE and extreme 

freezing temperature conditions. They supplied handlines remotely by stretching supply and hand 
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lines 260 feet to the front of the structure due to the turn of the century narrow streets and civilian 

parking that restricted access by modern fire apparatus. Recognizing problematic type hydrants and 

planning for additional maintenance can help to ensure operation during extreme weather conditions. 

For example, if problematic hydrants can’t drain properly or leak past the valve seats, they should be 

identified and repaired or replaced. Additionally, if a certain tamper proof type of hydrant is identified 

as problematic during severe weather conditions, they should be planned for repair or replacement. 

Recommendation #2: Fire Departments should consider defensive operations when a dependable, 

continuous water supply is lost or not available and the building’s primary building materials may

have been subject to severe fire conditions.

Discussion: As part of the initial size up and continuously throughout the incident, once the search and 

rescue of civilians has been completed, incident commanders should consider defensive fire operations 

when a continuous water supply is not available or is limited. Firefighters and officers need to 

communicate bench marks to the incident commander. It is also important to communicate when those 

benchmarks have not been or cannot be completed. 

Benchmarks such as water on the fire (or lack of knock down), primary search complete, excessive 

clutter or hoarding limiting firefighter access, water supply established (or water supply difficulties), as 

well as scene access are important benchmarks that the incident commander uses along with many 

other factors (such as resource availability) to establish or change the strategy and tactics. When one or 

more of the bench marks are not accomplished or may be delayed, incident commanders should 

consider a defensive strategy and alter the tactics. 

When the water supply is limited or insufficient for fireground operations, incident commanders 

should ensure this issue is factored into the strategy and incident action plan [NIOSH 2018]. Incident 

commanders should consider a defensive strategy whenever water supply is or becomes a factor. 

Adequate water supply during fire attack operations has a critical impact on fire control outcomes. 

Delayed or limited water supply and inadequate fire flow leads to delayed fire control, increased risk to 

firefighters, victims, and greater fire loss. 

Command is ultimately responsible for managing attack positions in either offensive or defensive 

locations. The key to effective attack positioning is WATER. Water not only extinguishes the fire, but 

water protects firefighters from the lethal products of combustion [MABAS 2015]. 

As an incident commander develops a strategy and incident action plan for an incident, the issue of 

water supply factors into this process. Incident commanders should have an acute awareness of the 

following water supply factors: 

• What are the required fire flows for the incident 

• What is the projected fire flows we can produce 

• Do we have enough water to safely extinguish the fire 
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• Where is the water supply coming from 

• Are the key tactical areas adequately supplied with water

• What units have/need a water supply 

• How many handlines can the supplied pumper(s) charge and pump 

• How many large-diameter openings can the supplied pumper(s) charge and pump 

• Is there a need for pumped supply lines? [MABAS 2105] 

If there is insufficient or an inadequate water supply or if the water supply is interrupted, incident 

commanders should make a decision to operate in a defensive strategy, especially if the fire has been 

burning for a considerable time prior to the arrival of the fire department. 

In this incident the elapsed time from arrival to collapse was 37 minutes. The strategy was changed 

from offensive to defensive due to critical water supply interruptions, and back to offensive once a 

stable water supply was established. Hoarding conditions with heavy content, and likely added water 

weight, combined with age, weather-related deteriorated structural conditions, and prolonged fire 

exposure all contributed to the V-shaped collapse originating from the notch cut in the floor joists for 

the gas piping. 

Firefighters were hampered with frozen nozzles, frozen hydrants, frozen PPE and extreme freezing 

temperature conditions. They supplied handlines remotely by stretching supply and handlines 260 feet 

to the front of the structure due to the turn of the century narrow streets and civilian parking that 

restricted access by modern fire apparatus. Despite these obstacles, the firefighters were still able to 

locate and remove a fire victim (who was deceased) utilizing internal fire engine tank water. The water 

supply was re-established and interrupted numerous times, however quick thinking and skilled DPOPs 

(driver/pump/operator/pump) members were successful in communicating the water supply issues to 

officers or their interior crews. 

Recommendation #3: Fire departments should ensure that firefighters are trained to understand the 

influence of inherent building performance characteristics, unique row house variation 

(modifications and construction) on structural collapse and consider defensive operations when

dilapidated/excessive clutter conditions are encountered. 

Discussion: Firefighters are at significant risk for injury or death due to structural collapse during firefighting operations. Between the years 1979 and 2002 there were over 180 firefighter fatalities due to 

structural collapse, not including those firefighters lost in 2001 in the collapse of the World Trade 

Center Twin Towers. Structural collapse is an insidious problem within the fire fighting community. It 

often occurs without warning and may result in multiple fatalities. As part of a larger research program 

to help reduce firefighter injuries and fatalities, the U.S. Fire Administration (USFA) funded the 

National Institute of Standards and Technology (NIST) to determine if there were trends or patterns 
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that could be detected in firefighter fatalities due to structural collapse [NIST 2003]. In 2020, NIOSH 

released a fact sheet with specific information on row house features and helpful firefighting tactics for 

consideration. [NIOSH 2020]

Fire departments should ensure that officers and firefighters are trained in legacy and modern building 

construction techniques to gain a better understanding of collapse potential. Structural collapse often 

results in firefighter injuries and fatalities. While structural collapse is a significant cause of injury and 

death to firefighters, the potential for a structural collapse is one of the most difficult circumstances to 

predict. The structure’s age, use, design and modifications along with the construction all have a 

significant effect on the building’s structural integrity. The extent, intensity, location of the fire and 

burn time are significant factors that command and all fire officers need to keep in mind.

In his report to NIOSH on this incident [Appendix 2], Chief Naum stressed the importance of 

understanding the specific row house building performance under fire conditions. Type III (ordinary 

construction) row houses have a recognizable predictability of expected building performance under 

fire conditions. This predictability is also based on inherent building anatomy, design, compartment 

fire dynamics in the building and the actions of fire fighting forces (intervention, time and 

effectiveness). They are prone to interior collapse and perimeter wall collapse within short operational 

periods based on influencing fireground factors such as fire severity, degraded building, component or 

structural conditions or heavy content that may have adverse effect on structural integrity or weight 

carrying capacity [Naum 2019]. 

In situations when suspected or actual degradation of the structure are observed, or excessive content 

clutter or observations indicate excessive live or dead loads may have an adverse effect on structural 

strength or stability, immediate actions need to take place to ensure fire fighting forces are able to 

communicate the risks to the incident commander and an effective strategy is selected.

When confronted with active fire conditions within a Type III row house, the size up considerations, in 

addition to life safety, should include building performance issues such as fire location and severity 

and length of burn time or duration, building age, occupancy (excessive clutter), structural 

condition(s), access, and availability of fire fighting resources to engage and stop the advancement of 

fire.

Inherent building characteristics and unique row house variations can contribute to the risk of collapse 

during a fire. In this incident, uniqueness and variances for this row house included material 

degradation and legacy notching of floor joists, as well as possible degraded load carrying capacity of 

the existing wood floor joists due to age, creep, the effects of loss of moisture content or cyclical 

exposure to environment elements [Naum 2019]. The inherent legacy notching of the existing wood 

floor joists (see Diagrams 9 and 10) was a primary contributor that created an existing floor system 

that was highly susceptible to being affected by a structural fire or affected by the addition of live or 

dead loads. 
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The 1-inch x 1-inch notch was cut into the upper top portion of the wood joist to accommodate the 

installation of a pipe run into the occupancy for gas service to the residence in the late 1800’s. These 

cut notches and legacy gas pipe runs continued in each wood floor joist inward from the Alpha side 

wall area interior along a center-line approximately 20 ft. or more in length (see Diagram 11). There 

are additional details included in the expert analysis report attached in Appendix 2. 

Many times, these factors are not known to first arriving companies and may not be able to be factored 

into the initial size up. Altered, dilapidated and or deteriorated structural building members should be 

reported to the incident commander as soon as possible so he/she can factor them into the size-up and 

risk assessment. Severe clutter conditions can add considerable weight that perhaps wasn’t considered 

in the design of the original construction. Clutter conditions can also contribute to trapped water 

adding significant weight applied during a fire fighting operation. Additionally, severe clutter makes 

search and rescue operations very difficult. Just getting access to areas for a search can be challenging 

and very time consuming (as was experienced very early in this incident by the victim and other 

crews). 

Fighting fire in a cluttered occupancy adds additional hazards to all areas of search, rescue and 

extinguishment. Occupants can be harder to locate, access in and around rooms and to stairways may 

be blocked, extreme overloading of structural members can occur as well as the possibility of clutter 

adding tremendous amount to a fuel load unexpected in a residential setting. Fire departments should 

ensure that their members are trained to recognize and report these conditions to the incident 

commander for consideration during size-up. 

Diagram 9. Typical Wood Floor Joist. Uniqueness and variances for this row house included, 

possible degraded load carrying capacity of the existing wood floor joists due to age, creep, the 

effects of loss of moisture content or cyclical exposure to environment elements [Naum 2019]. 

(Graphic Courtesy of Buildingsonfire.com | C.J. Naum) 
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Diagram 10. Gas-line & Notch. The inherent legacy notching of the existing wood floor joists was a 

primary contributor to create an existing floor system that was highly susceptible and prone to be 

affected by an interior compartment or structural fire or affected by existing or in the addition of 

live or dead loads [Naum 2019]. 

(Graphic Courtesy of Buildingsonfire.com | C.J. Naum) 
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Diagram 11. Joists numbered from side Alpha toward side Charlie detailing the joist breaking points 

along the notched cut out for the gas pipe installation. 

(Photo courtesy of fire department and analysis diagram courtesy of Buildingsonfire.com, C.J. Naum) 
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During initial size-up and ongoing fire-fighting operations, incident commanders need to consider 

many variables to determine the integrity of a burning structure. Understanding the influence of 

building design, condition, age and construction on structural collapse has a direct correlation to safe 

fire-fighting operations and firefighter survivability. In many cases, structural collapse results from 

damage to the structural system of the building caused by the fire or by fire-fighting operations 

[NIOSH 2013]. The longer a fire burns in a building, the more likely the building will collapse.

“The predictability of a building’s performance and risk to structural collapse, compromise or failure 

should be foremost in the development and execution of incident action plans (IAP) with collapse 

precursors or indicators identified, monitored and managed by incident commanders, supervisors and 

operating companies.” [Naum 2014, NIOSH 2016]

Based upon continuous risk assessments being conducted, coupled with pre-incident planning 

information, a collapse zone or exclusion zone should be established when factors indicate the 

potential for a building collapse. Fire departments should not rely solely on the amount of time a fire 

has been burning as a collapse indicator. An external load—such as a parapet wall, steeple, 

overhanging porch roof, awning, sign, or large electrical service connections—may cause a structural 

collapse. Additionally, excess water from fire fighting operations can add significant weight to upper 

floors, especially after switching from a defensive operation back to an offensive, or overhaul 

operation. Other factors to consider include:

• fuel loads (including excessive debris beyond the structure’s design)

• fire behavior and building ventilation characteristics

• fire duration (burn time), size and location

• pre-existing structural damage/deterioration

• renovation/modifications to structure

• height and age of the building

• types of doors and windows

• engineered load systems/lightweight truss construction

• roof design and covering

• fire protection features such as sprinkler systems, standpipe systems, automatic fire alarm system 

[NIOSH 2014a].

Construction features, combined with fire factors, indicate the most probable type of structural failure 

[Klaene and Sanders 2007]. Given the fact that the incident commander is always working with 
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incomplete and imperfect information, it is impossible to accurately predict the type of collapse and 

resultant collapse zone. 

Whenever the incident strategy has changed (from offensive to defensive or even back to offensive for 

overhaul), a risk assessment needs to be performed. A collapse or exclusion zone should be established 

for any areas identified by the risk assessment. Many times, after a defensive fire is knocked down, the 

strategy is changed again so crews can overhaul or knock down remaining pockets of fire. If the 

strategy is changed back to offensive, significant attention must be given to the structural integrity and 

any areas identified as exclusion zones should be communicated to all operating companies prior to the 

entry of firefighters for overhaul.

A risk-versus-benefit analysis is essential in the risk assessment of the structure. The crucial question 

that any incident commander must ask is:

• What could I potentially save in relation to the risk being taken? 

• Obviously, no building is worth a firefighter’s life; therefore, imminent risk to a firefighter’s 

life to save a building is unacceptable. 

• When a defensive operation represents a reasonable risk, positions at the corners of the 

buildings are normally safer than those on the flat side of a wall. 

• Consideration should also be given to using unstaffed ground monitors to reduce the risk of 

placing personnel in exposed positions. 

• When total collapse is imminent, collapse zones represent exclusion zones that no one is 

permitted to enter or re-enter regardless of the level of protective clothing [Klaene and Sanders 

2007].

In this incident, there was heavy fire involvement for a significant amount of time prior to the collapse. 

There was an extreme amount of clutter that added to the weight of the dilapidated dwelling along with 

likely additional water weight from defensive operations. This was further compounded by critical 

interruptions of water supply (frozen hydrants, and a frozen attack nozzle). Despite all of the 

difficulties, the initial arriving crews were able to locate and remove a civilian victim in very 

challenging removal conditions from the first floor of the 125-year-old dilapidated structure. 

Water supply issues continued after the civilian victim removal. The strategy was changed from 

offensive to defensive and all interior crews removed, and exterior streams applied after 16 minutes 

due to water supply interruptions. After approximately 6 minutes, water supply was re-established. The 

collapse occurred approximately 19 minutes after the re-entry. Elapsed time from arrival to collapse 

was 37 minutes. Hoarding conditions with heavy content, and likely added water weight, combined 

with age, weather related deteriorated structural conditions, and prolonged fire exposure all contributed 

to the V-shaped collapse originating from the notch cut in the floor joists for the gas piping.
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Recommendation #4: Fire departments should ensure that Incident Commanders establish a 

stationary/expandable command post, which includes the use of a tactical worksheet and effective 

fireground communications. 

Discussion: When a Chief Officer (e.g., Battalion Chief, District Chief, Deputy Chief) arrives on 

scene, he/she should automatically assume a standard stationary, exterior, and remote command 

position and immediately assume “Command” and begin functioning as the Incident Commander. 

Command officers generally establish and continue command and control functions inside their 

vehicles or at the rear of the vehicle, which has a command board and/or a tactical worksheet. This 

stationary command post can allow for expansion of an effective command team if the incident 

expands beyond initial responding units. 

NFPA 1561 Standard on Emergency Services Incident Management System and Command Safety, 

5.3.1 states, “The incident commander shall have overall authority for management of the incident.” 

The incident commander must establish and maintain a command post outside of the structure in order 

to assign companies, delegate functions, and continually evaluate the risk versus gain of continued 

firefighting efforts [NFPA 2014].

When establishing a command post, the Incident Commander should ensure the following: 

• The command post is located in or tied to a vehicle to establish presence and visibility

 

• The command post includes radio capability to monitor and communicate with assigned 

tactical, command, and designated emergency traffic channels for that incident

 

• The location of the command post is communicated to the communications center

 

• The Incident Commander, or his/her designee, is always present at the command post 

 

• The command post should be located in the incident cold zone [NFPA 2014].

In order to effectively command an incident, incident commanders must be in the most advantageous 

position possible. The best position is a fixed, visible, and accessible location at the command post. 

This can be accomplished by utilizing the incident commander’s staff vehicle, a designated command 

vehicle, or fire apparatus. An acceptable alternative is utilizing the rear area of a sport utility vehicle or 

pick-up truck type vehicle. This method will provide the incident commander with an area that may be

quieter and free of distractions from which to command an incident. It is also vital for the incident 

commander to be able to hear all radio transmissions, especially from those operating on-scene. The 

best way to accomplish this is through the use of a radio communication headset. This will enable the 

incident commander to be in the best position possible to hear critical radio transmissions. The incident 

command post also should be visible and recognizable. This can be accomplished by displaying a 

colored light, flag, banner, or other symbol to mark the location. Where special command post vehicles 
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are used, such vehicles are usually marked with distinctive identification to make the command post 

recognizable [NFPA 2014]. 

A tactical worksheet is a critical piece of equipment because it helps the incident commander organize 

tasks by providing reminders, prompts, and a convenient workspace for tracking companies and 

apparatus. It allows them to better manage a large, multi-alarm incident. The worksheet can be used on

large complex and small fires as well as EMS incidents, to help develop proficiency and to record vital 

information that may aid future operational decisions. By documenting the assignments of 

division/group officers and division/group resources, the incident commander creates a visual 

reference of the overall fireground organization and deployment [Los Angeles Fire Department 2011]. 

A tactical worksheet is also an excellent tool when the passing of command must occur. On the 

fireground, the officer taking over command can quickly check the worksheet and obtain a good 

understanding of the initial deployment of resources, the need for additional apparatus and equipment, 

and the status of units in the staging area. 

Some advantages of using a tactical worksheet are: 

• Includes a location to quickly note individual assignments

• Provides prompts for the incident commander, such as time, air management, and strategy

• Provides tactical benchmarks, such as primary search complete, fire knocked down, fire under 

control

• Facilitates consistent, organized information

• Documents assignments and responsibility

• Expedites passing of command or support for the incident commander

• Provides resource status [NFPA 2014]. 

When a division or group is implemented, a fire department should provide a dispatch channel, a 

command channel, and a tactical channel. A fire department should provide the necessary number of 

radio channels with multiple tactical channels, depending on the type of incident and the complexity of 

the incident. The fire department should have procedures for the announcement of emergency 

conditions, using the term “emergency traffic” as a designation to clear radio traffic” [NFPA 2018].

Emergency traffic should be declared by the Incident Commander, tactical level management unit, or 

member who identifies a high-risk situation on the fireground (e.g. power lines down, signs of 

impending collapse) and should be used to alert members that the Incident Commander is ordering the 
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evacuation of the building. The term “Mayday” should be reserved for only those situations where a 

firefighter or firefighters is/are in trouble or facing a life-threatening emergency. 

Another element that is essential to the success of the personnel accountability system is effective 

fireground or incident scene communications. The function of resource accountability should be 

assigned to a member, such as a chief’s aide, who is responsible for maintaining the location and status 

of all assigned resources at an incident. This is separate from the role of the incident commander. The 

incident commander is responsible for the overall command and control of the incident. Due to the 

importance of responder safety, this function should be assigned to an accountability officer or 

resource status officer. Several members could function in this role including an incident command 

technician, chief officer, apparatus driver/operator, or other responder. There are several methods of 

accounting for resources including tactical worksheets, command boards, apparatus riding lists, 

company responder boards, a passport system, and electronic bar-coding systems, depending on 

whether equipment or personnel are being tracked. These components can be used in conjunction with 

one another to facilitate the tracking of responders by both location and function. The components of 

any resource accountability system should be modular and expand with the size and complexity of the 

incident [NFPA 2014]. 

Recommendation #5: Fire departments should consider the capacity and capability of the dispatch 

process to ensure response accountability and prevention of a single source failure in the response 

matrix. 

Planning, accounting for, and assigning assets/resources is important at all stages of incident command 

or incident management development and begins with the communications center or dispatch agency. 

When assets and/or resources are delayed by factors including traffic, weather and or road conditions, 

being involved in a crash, assigned to other incidents or failure to arrive to an incident, dispatch should 

have a system to account for those units and replace or modify the notification as necessary [NIOSH 

2017]. 

In a recent NIOSH investigation that occurred in MD, a fire department safety officer was unaccounted 

for and units cleared the scene without knowing he was still in an exposure building after a fire and 

died from smoke inhalation. The safety officer was a single person emergency response vehicle. It was 

not realized he was unaccounted for until the following morning when his vehicle was spotted outside 

of the original fire building. To prevent this, fire communications centers, chief officers and 

supervisors and EMS supervisors, as well as dispatchers, should have a system to recognize when a 

unit or a resource doesn’t answer a call to respond and anytime a unit never clears the scene. This can 

be accomplished in many ways at all accountability levels (task, tactical and strategic) through 

electronic accountability systems that also have a back up system when other systems are not 

successful [NIOSH 2015]. 

In this incident, the initial incident commander was the Engine-45 officer for just over 1 minute. 

Battalion Chief 8 arrived at the same time as Engine-45 and maintained Command for approximately 

one hour and 10 minutes. The Deputy Chief dispatched to this incident had a delayed response due to a 
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breakdown in the notification system by radio. The Deputy Chief didn’t arrive until 55 minutes after 

being dispatched. Delayed arrival of command staff may interrupt the building of an effective 

command staff in large or complex incidents. 

Battalion Chief-8’s aide stayed in the SUV while Battalion Chief-8 stood in the snow- and ice-covered

street in command in the sub-freezing conditions until well after the collapse when he was relieved by 

Deputy Chief 2. After the arrival of Car-5, the incident command was expanded to add an operations 

division (Deputy Chief 2). 

Recommendation #6: Fire departments should ensure that fire officers and firefighters are trainedin and practice situational awareness, and personal safety. 

The book Essentials of Fire Fighting and Fire Department Operations [IFSTA 2008] defines situational 

awareness as an awareness of the immediate surroundings. On the fireground, every firefighter should 

be constantly alert for changing and unsafe conditions. Even though a safety officer may be designated 

for an incident, it is the obligation of all personnel to remain alert to their immediate surroundings. 

They should maintain their situational awareness and be alert for unsafe conditions. This applies not 

only to the conditions found within a burning structure, but to the exterior fireground as well [Clark 

2008]. In virtually every case, structural collapse results from damage to the structural system of the 

building caused by the fire or by fire-fighting operations [NIOSH 2013]. The longer a fire burns in a 

building, the more likely the building will collapse. 

One of the most critical aspects of coordination between crews is maintaining situational awareness. 

The opposite of situational awareness is tunnel vision where the firefighters become so focused on fire 

fighting or other operational assignments that they fail to sense changes in their environment. 

Firefighters can maintain their situational awareness by looking up, down, and around as well as 

listening for new or unusual sounds and feeling vibrations or movement. Firefighters and officers 

should communicate any changes in their environment to other members as well as to the incident 

commander.

The International Association of Fire Chiefs (IAFC), Safety, Health and Survival section developed the 

“Rules of Engagement for Structural Fire Fighting.” The rules of engagement have been developed to 

assist both the firefighter and the incident commander as well as command team officers in risk 

assessment and “Go” or “No-Go” decisions. The fireground creates a significant risk to firefighters and 

it is the responsibility of the incident commander and command organization officers to minimize 

firefighter exposure to unsafe conditions and stop unsafe practices [IAFC 2013].

The rules of engagement can assist the incident commander, company officers, and firefighters who 

are at the highest level of risk in assessing their situational awareness. One principle applied in the 

rules of engagement is that firefighters and the company officers are the members most exposed to the 

risk for injury or death and will be the first to identify unsafe conditions and practices. The rules 

integrate the firefighter into the risk assessment/decision making process. These members should be 

the ultimate decision makers as to whether it’s safe to proceed with assigned objectives. Where it is not 
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safe to proceed the rules allow a process for that decision to be made while still maintaining command 

unity and discipline [IAFC 2013].

The Firefighter’s Rules of Engagement for Firefighter Survival:

• Size-up your tactical area of operation. This causes the company officer and firefighters to pause for a 

moment, look over their area of operation, and evaluate their individual risk exposure to determine a 

safe approach for completing their tactical objectives

• Determine the occupant survival profile. Occupant survival should be considered as part of the 

individual firefighter’s risk assessment and action plan development

• Do not risk your life for lives or property that cannot be saved. This includes fire-fighting operations 

that may harm firefighters when fire conditions prevent occupant survival and significant or total 

destruction of the building is inevitable

• Extend limited risk to protect savable property. Risk exposure should be limited to a reasonable, 

cautious, and conservative level when trying to save a building

• Extend vigilant and measured risk to protect and rescue savable lives. Search and rescue operations 

should be managed in a calculated, controlled, and safe manner while remaining alert to changing 

conditions during high-risk primary search and rescue operations where lives can be saved

• Go in together, stay together, and come out together. Two or more firefighters should operate as a 

team. Maintain continuous awareness of your air supply, situation, location in the building, and fire 

conditions. Situational awareness is knowing where they are in the building and what is happening 

around them and elsewhere that can affect their risk and safety

• Constantly monitor fireground communications for critical radio reports

• You are required to report unsafe conditions or practices that can harm you. Stop, evaluate, decide. 

This prevents firefighter exposure to unsafe conditions or practices that can harm them, allows any 

member to raise an alert about a safety concern without penalty, and mandates the supervisor address 

the question to ensure safe operations

• You are required to abandon your position and retreat before deteriorating conditions can harm you. 

Firefighters must remain aware and exit early to a safe area when they are exposed to deteriorating 

conditions, unacceptable risk, and a life-threatening situation

• Declare a Mayday as soon as you think you are in danger. This ensures the firefighter is comfortable 

with declaring a Mayday as soon as they think they are in trouble [IAFC 2013].

The Incident Commander’s Rules of Engagement for Firefighter Safety:
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• Rapidly conduct or obtain a 360-degree situational size-up of the incident. Determine the safest 

approach to tactical operations as part of the risk assessment plan and action development plan before 

firefighters are placed at substantial risk

• Determine the occupant survival profile. Consider fire conditions in relation to the potential for 

occupant survival of a rescue event before committing to a high-risk search-and-rescue operation 

• Conduct an initial risk assessment and implement a safe action plan. This rule causes an incident 

commander to develop a safe action plan by conducting a size-up, assessing the survival profile, and 

completing a risk assessment before firefighters are placed in high-risk positions on the fireground

• If you do not have the resources to safely support and protect firefighters, seriously consider a 

defensive strategy. This rule prevents the commitment of firefighters to high-risk tactical objectives 

that cannot be accomplished safely due to inadequate resources on the scene

• Do not risk firefighter lives for lives or property that cannot be saved. Seriously consider a defensive 

strategy. This rule prevents the commitment of firefighters to high-risk fire-fighting operations that 

may harm them when fire conditions prevent occupant survival and significant or total destruction of 

the building is inevitable

• Extend limited risk to protect savable property. The incident commander should limit risk exposure to 

a reasonable, cautious, and conservative level when trying to save a building that is believed, following 

a thorough size-up, to be savable

• Extend vigilant and measured risk to protect and rescue savable lives. The incident commander 

should manage search and rescue and supporting fire-fighting operations in a highly calculated, 

controlled, and cautious manner while remaining alert to changing conditions during high-risk searchand-rescue operations where lives can be saved

• Maintain frequent two-way communications and keep interior crews informed of changing 

conditions. The incident commander should obtain frequent progress reports, keeping all interior crews 

informed of changing fire conditions observed from the exterior that may affect crew safety

• Obtain frequent progress reports and revise the action plan. Frequent progress reports enable the 

incident commander to continually assess fire conditions and any risk to firefighters and to regularly 

adjust and revise the action plan to maintain safe operations

• Ensure accountability of every firefighter’s location and status. The incident commander and 

command organizational officers must maintain a constant and accurate accountability of the locations 

and status of all firefighters within a small geographic area of accuracy within the hazard zone and an 

awareness of who is presently in or out of the building
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• If after completion of the primary search, little or no progress towards fire control has been achieved, 

seriously consider a defensive strategy 

• Always have a rapid intervention team in place at all working fires. 

Recommendation #7: Fire Departments should consider increased staffing and/or capacity of 

specialized rescue companies in dense urban areas or in targeted areas to assist in highly technical 

rescue capabilities and prevent a single source failure in response.

Discussion: A number of resources, such as the International Association of Firefighters, the National 

Fire Protection Association, and the National Institute of Standards and Technology (NIST), can assist 

policy makers and fire service leaders in planning for adequate resource deployment in their 

community to ensure that firefighter intervention in a risk event occurs in a timely and coordinated 

manner to limit risk escalation and negative outcomes. Additionally, specialized resource staffing and 

deployment are an important consideration in dense urban areas and/or in jurisdictions with specialized 

target hazards.

In basic firefighting, interdependent and coordinated tasks of all deployed fire-fighting personnel are 

required to meet standard fire fighting strategy and tactics (the incident action plan). These tasks (e.g., 

stretching a hoseline to the fire, ventilation, search and rescue) can be conducted simultaneously, 

which is the most efficient manner, or consecutively (one after the other), which delays some task(s) 

perhaps allowing a risk escalation to occur. The specialized rescue companies should have their 

staffing and assets identified and available for timely deployment to assist on incidents such as 

building collapse, technical rescue-high angle rescue, trench rescue, confined space rescue, water 

rescue and SCUBA operations as well as hazardous materials teams. 

Departments should understand and plan to maintain these capabilities in the event of a single asset 

source failure, e.g., a deployment delay due to inadequate number and location of assets, a response 

delay due to traffic congestions and long response routes, frequency of need for specialized assets and 

a delay due to over burden. 

In the case of building collapse, specialized heavy rescue assets (staffing and equipment) are likely to 

be needed quickly without waiting for a developed response from mutual aid or members being 

notified and responding from remote locations. In dense urban or targeted areas, pre-planning a likely 

response is key. 

NFPA 1710 Standard for the Organization and Deployment of Fire Suppression Operations, 

Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments 

contains recommended guidelines for minimum staffing of career fire departments [NFPA 2013, 

NIOSH 2014b]. NFPA 1710 recommends that the minimum staffing level for an engine company to 

perform effective and efficient fire suppression tasks is four firefighters. However, NFPA 1710 also 

recommends that large jurisdictions with tactical hazards, high hazard occupancies, high incident 
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frequencies, or other pertinent factors, should staff companies with a minimum of five or six on-duty 

members [NFPA 2013].

NFPA 1710 states the following: “On-duty fire suppression personnel shall be comprised of the 

numbers necessary for fire-fighting performance relative to the expected fire-fighting conditions.” 

These numbers shall be determined through task analyses that take the following factors into 

consideration:

• Life hazard to the populace being protected

• Provisions of safe and effective fire-fighting performance conditions for the firefighters

• Potential property loss

• Nature, configuration, hazards, and internal protection of the properties involved

• Research by NIST and Underwriters Laboratory on methods for strategically ventilating and isolating 

fires to delay or prevent flashover by use of manual door control (requires additional staffing)

• Types of fireground tactics and evolutions employed based on standard operating procedures, 

staffing, type of apparatus used, and results expected to be obtained at the fire scene [NFPA 2013,

NIOSH 2014b].

Following a community hazard/risk assessment, fire service leaders prepare a plan for timely and 

sufficient coverage of all hazards and the adverse risk events that occur. This plan is often referred to 

as a “standard of response coverage.” Standards of response coverage can be defined as those written 

policies and procedures that establish the distribution and concentration of fixed and mobile resources 

of an organization [NIST 2013a]. Additionally, fire departments and AHJ’s should plan for specialized 

resource equipment needs, staffing and deployment such as heavy rescue companies as they are an 

important consideration in dense urban areas and/or in jurisdictions with specialized target hazards.

Resource distribution is associated with geography of the community and travel time to emergencies. 

Distribution is typically measured by the percent of the jurisdiction covered by the first-due units 

within a specified time frame [NFPA 2013, NIOSH 2014b]. Concentration is also about geography and 

the arranging of multiple resources, spacing them so that an initial “effective response force” can arrive 

on-scene within the time frames established by community expectations and fire service leadership. 

Response time goals for first-due units (distribution) and for the total effective on-scene emergency 

response force (concentration) drives fire department objectives like fire station location, apparatus 

deployed, and staffing levels. 

The service-level objectives established in any community drives response time performance by all 

responding resources and the assembly of effective on-scene fire-fighting response force and heavy 

rescue capabilities. Both response time performance and assembly times subsequently drive resource 
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distribution and concentration. If response times and force assembly times are low, it is more likely 

that sufficient resources have been deployed, which is associated with more positive outcomes from 

risk events. Conversely, if response times and force assembly times are high, or a single source 

specialty company is delayed it is more likely that insufficient resources have been deployed or 

planned for which may be associated with negative outcomes. Fire service leaders should consider 

several other factors when preparing standards of response coverage. These considerations should 

include an assessment of the probability or likelihood that an event will occur [NFPA 2013a, NIOSH 

2014b] and the effect on operations when a single source failure may occur (asset response). 

Urban fire departments should staff companies commensurate with the tactical hazards, high-hazard 

occupancies, high incident frequencies, geographic restrictions, and other pertinent factors that are 

common in urban environments. For example, the Fire Department of New York (FDNY) staffs rescue 

companies and ladder companies with a minimum of one officer and five firefighters. FDNY engine 

companies are staffed with one officer and four firefighters. The Chicago Fire Department staffs rescue 

companies with one officer and five firefighters. Also, Chicago Fire Department ladder companies and 

engine companies are staffed with one officer and four firefighters [NIST 2013a, NIST 2013b].

Recommendation #8: Fire departments should ensure that fire officers and firefighters are trainedin and practice accountability.

Discussion: Although there is no evidence that this recommendation would have prevented this 

fatality, it is being provided as a reminder of best safety practice for the fire service. A fire department 

should develop its own system and standardize it for all incidents. All fire officers and firefighters 

operating at an incident should maintain accountability, situational awareness and conduct a 

continuous risk assessment throughout the incident, reporting unsafe or changing conditions to the 

incident commander. Firefighters need to understand the importance of and practice accountability, 

situational awareness and personal safety on the fireground. The fireground dangers and hazards can 

and do change as the incident becomes larger and the event duration increases. 

Accountability on a fireground means identifying and tracking all personnel working at the incident. 

Accountability on the fireground can be maintained by several methods: a passport system, a system 

using individual tags assigned to each firefighter, a riding list provided by the company officer, a 

SCBA tag system, or an incident command board [IFSTA 2008, NFPA 2014]. 

Some SCBA and personal alert safety system (PASS) devices incorporated into SCBA have the ability 

to communicate automatically with a command/control module at the incident command post, 

establishing an automatic accountability system. NFPA 1500 Chapter 8, Section 8.4, and NFPA 1561, 

Chapter 4, Section 4.5, contain guidelines for the development of an accountability system for 

fireground and other emergency operations [NFPA 2014, 2018]. 

As the incident escalates, additional staffing and resources will be needed, adding to the burden of 

tracking personnel accountability. A tactical worksheet should be established at this point with an 
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assigned accountability officer or chief’s aide. In large incidents, this can also be used at the division 

level, with resources assigned to that division being assigned and tracked at the division level.

Accountability begins at the individual and task level with the company level officer. Accountability 

also occurs at the tactical level and this accountability is typically at the division level. Finally, overall 

accountability is established and maintained at the command level. This can be performed by the 

incident commander or designated to a member of the command team once the incident escalates and 

more companies are involved. One of the best training methods for incident scene accountability is 

repetitive skill training at the task, tactical and command levels (much like repetitive skill training for 

SCBA). The skills for effective incident scene accountability can be enhanced with frequent use. 

Frequent use of accountability on incidents such as “smells and bells”, fire alarms and smaller 

incidents prepare and get all firefighters and officers in the habit of the accountability portion of 

incident command. 

As stated above, ultimately overall accountability is the responsibility of the incident commander. 

However, this responsibility can be delayed or overlooked by task saturation at the command level. 

Building the command team with additional responding chief officers can help to ensure that the 

important functions of accountability and safety are covered. 

Positive accountability is established by the fire arriving units and then transferred to an arriving 

battalion level chief. Some departments use a riding list or a passport system on the apparatus that is 

later collected and transferred to command. There are new electronic accountability systems that 

identify firefighters and officers electronically and the information is coordinated by an accountability 

officer for the incident commander. When a member is found to be in alarm, a signal goes to the 

accountability officer and the member or company is checked on. Command can also evacuate 

individual members or companies from areas or even a full evacuation can be sent via the 

accountability system. Once the incident escalates the company officers report accountability to the 

tactical level (e.g., Side Charlie or vent group) and then to incident command or strategic level. The 

incident commander then relies on his/her division officers to maintain accountability in those 

divisions. There are many systems available to fire departments to increase their effectiveness in 

personnel accountability. The most important aspect of any accountability system is training in the use 

of their system and then frequent repetition to ensure all fire officers and firefighters are comfortable 

and competent with their system.

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

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

requested by the incident commander [NFPA 2018]. The use of a personnel accountability system is 

recommended by NFPA 1500, Standard on Fire Department Occupational Safety and Health Program 

[NFPA 2018] and NFPA 1561, Standard on Emergency Services Incident Management System and 

Command Safety [NFPA 2014]. A functional personnel accountability system requires the following:

• Development of a departmental SOP
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• Training all personnel 

• Strict enforcement during emergency incidents 

The control of the personnel accountability system should be assigned to an individual responsible for 

maintaining the location and status of all assigned resources (resource status) at an incident. This is a 

separate role from the duties of the incident commander. The incident commander is responsible for 

overall command and control of the incident. Due to the importance of responder safety, this function 

would be assigned to a personnel accountability officer or resource status officer. This function can be 

staffed by the chief’s aide, staff assistant, field incident technician, chief officer, or other responder 

familiar with the department’s accountability system [NFPA 2014]. 

Recommendation #9: Fire departments should have a deployment strategy for rapid intervention 

crews/teams (RIC/RIT) which includes the initial dispatch and all working incidents. This strategy 

should incorporate all critical components of an appropriate response of structural collapse rescue 

capabilities and address strategic as well as tactical needs for RIC/RIT and escalation to heavy 

rescue. 

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Fire 

departments need to have a strategy for deployment of traditional rapid intervention teams and the 

critical components of response in an escalation to heavy rescue assets for structural collapse and other 

complex incidents. 

Beginning with considerations for a standard structural fire incident, there is a narrow window of 

survivability for a firefighter who is out of air or trapped. On the task level, individual firefighters or 

company officers should not delay reporting to Command if they become lost, trapped, or are 

otherwise in need of assistance. Company officers or firefighters must not delay reporting to Command 

that they cannot account for members of their crew. Command officers must always assume that the 

missing firefighter is lost in the building until they can be located. 

At all fireground operations, a rapid intervention team (RIT) or crew (RIC) should be designated and 

available to respond during all fireground operations. [NFPA 2018, IFSTA 2008, NFPA 2014] The 

rapid intervention team should report to the Incident Commander and be available within the incident’s 

staging area. The size and complexity of an incident will ultimately determine the number of rapid 

intervention crews needed. 

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness Program, 

Chapter 8.8, Rapid Intervention for Rescue of Members, provides detailed guidelines for the 

deployment of rapid interview crews at emergency incidents. Chapter 8.8.1 states “The fire department 

shall provide personnel for the rescue of members operating at emergency incidents.” Paragraph 

8.8.1.1 of NFPA 1500 states, “Personnel assigned to perform the function of the initial rapid 
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intervention crew (IRIC) or the rapid intervention crew (RIC) shall be trained on the requirements of 

NFPA 1407, Standard for Training Fire Service Rapid Intervention Crews.”

On a tactical level, the rapid intervention mission can be separated into two categories. The first 

category is defined as the Standby Mode or preparation for Rapid Intervention as a precautionary

measure (most frequent mode). The second category is the Deployment Mode or immediate rescue 

upon arrival at, or during the incident.

• STANDBY MODE or preparation for rapid intervention – In this category of rapid intervention 

the resources assigned as a RIC have time to gather equipment, perform reconnaissance, and 

liaison with the Command Post. Company Commanders need to stay vigilant and be prepared 

to initiate a rescue mission at a moment’s notice. The same intervention configuration should 

apply in either rescue mission. The difference is in how much time you and your company will 

have to prepare for this most important mission. In this category of rapid intervention, the 

resources assigned as RIC should monitor the following radio channels:

o Dispatch Channel 

o Command Channel

o Incident Tactical Channel(s)

• DEPLOYMENT MODE or immediate rescue – Companies dispatched or assigned rapid 

intervention may find themselves involved in the immediate rescue of members upon arrival on 

scene of an incident. For this reason, the following RIC operations shall be followed and/or 

considered:

o In the event of a Mayday, the RIC or rescue group will operate on the tactical channel that 

the lost, missing, or trapped firefighter(s) were assigned. 

As the incident expands in size or complexity, which includes an incident commander's requests for 

additional resources beyond a fire department's initial attack assignment, the following should be 

considered [NFPA 2018]. The initial rapid intervention crew is most likely a single resource (e.g. 

engine, truck, or heavy rescue) recommended to be comprised of four personnel but with a minimum 

of three personnel. 

An example could be the fourth due (to arrive) engine is designated as the initial rapid intervention 

crew. Also, the initial rapid intervention crew can be on-scene members designated and dedicated as a 

RIC. RIC is assigned from the resources that make up the initial alarm assignment to achieve the RIC

capability. The trigger for the creation of the initial rapid intervention crew capability is an incident 

dispatch potentially requiring operation within an immediately dangerous to life and health (IDLH) 

atmosphere. 

When an incident is declared a “working fire”, the rapid intervention crew process is upgraded to at 

least one engine company and truck company or one heavy rescue company. These units are in 

addition to the units assigned to the initial box alarm and should be given priority in the dispatch 

sequence of any additional alarms. Once a working structure fire is confirmed by units on scene, this 
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level shall be requested by the initial IC or the first due command officer to augment the initial rapid 

intervention crew.

The rapid intervention team should be comprised of RIT trained, well-rested firefighters, and be 

positioned and ready to respond when a firefighter(s) is down or in trouble [NFPA 2018]. 

NFPA 1500, Chapter 8.8, Rapid Intervention for Rescue of Members, provides detailed guidelines for 

the deployment of rescue teams at emergency incidents. Chapter 8.8.1 states “The fire department shall 

provide personnel for the rescue of members operating at emergency incidents.” During the initial 

stages of an incident, the rescue crew members may be engaged in support operations outside the 

structure. Once the incident expands in size or complexity and the IC requests additional resources, the 

rescue crew must be dedicated to stand-by in case rescue operations are needed [NFPA 2018].

The rapid intervention team function should be incorporated into the department’s incident 

management system and the personnel accountability system (PAR) [NFPA 2018]. Critical fireground 

operations and staffing needs should be continuously evaluated. Resource assignments should be made 

with the goal of having the RIT function in place at all times. 

When the Incident Commander needs additional resources, the consideration of deploying the rapid 

intervention team for an operational assignment without additional resources on scene to function as 

RIT should be carefully assessed [NFPA 2018]. The following restrictions regarding the use of RIT 

should be considered by the Incident Commander during fireground operations: 

• The RIT should not be used for fire-fighting operations. The RIT is dedicated to assist, and if 

necessary, rescue members who become trapped, distressed or involved in other serious lifethreatening situations

• When the Incident Commander orders the RIT to work, the Incident Commander shall immediately 

assign another on-scene company to stand by as the RIT. If no units are available, the Incident 

Commander must assign at least two members to act as a rapid intervention team while waiting for 

additional resources to serve as a RIT to arrive. An engine company may be designated as the RIT 

pending arrival of an additional ladder company or rescue company. This ensures compliance with 

OSHA’s “Two In/Two Out” rule under 29 CFR 1910.134, Respiratory Protection [OSHA 1998]

• The RIT should not be used to provide relief for operating companies until the fire/incident has been 

declared “Under Control” by the “Command” 

• If assigned by a superior officer to other than RIT duties, the RIT unit officer should remind such 

officer of RIT designation [Toledo Fire Department 2012, Township of Spring Fire Rescue 2014].
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On a strategic and tactical level, fire departments should consider a defined response plan for the 

dispatch of an additional company (engine, truck, squad, or heavy rescue company) to respond to an 

incident and standby as the rapid intervention team. 

Based upon the complexity, magnitude, configuration of the structure, or geographical layout of the 

incident, the Incident Commander may deploy additional rapid intervention teams by location or 

function. [NFPA 2014] Fire departments should also ensure members are trained on a standard 

operating procedure for Rapid Intervention Team (RIT) operations including the RIT bag, tools, rescue 

equipment and how and where to get specialized equipment and personnel for collapse incidents. 

Additionally, RIT crews on all incidents should train to identify means of providing breathing air to 

trapped members. 

Upon arrival or upon appointment, the RIT officer should confer with the Incident Commander. The 

RIT officer should establish an area to stage the rapid intervention team and the necessary RIT 

equipment. The RIT equipment should include: 

• A tool staging tarp 

• Rescue SCBA (RIT Pack) 

• Forcible entry tools such as a Halligan bar or other pry tool 

• Stokes basket 

• 150’ long rope for search and rescue 

• Wire cutters 

• Saws 

• Thermal Imaging Camera 

• Emergency strobe lights

• Rebar cutter 

• Life Saving Rope/Life Belt 

• Elevator keys for buildings with elevators [Toledo Fire Department 2012, Township of Spring Fire 

Rescue 2014, FDNY 2011] 

It is important to stage all necessary RIT equipment in an expedient manner. The RIT officer, 

accompanied by one member of the RIT, should perform an incident scene survey while the remaining 

RIT members assemble the RIT equipment. If the size of the structure negates a 360-degree survey of 

the building, this should be relayed to the Incident Commander as soon as possible. This should be a 

benchmark for “Command” to designate another RIT in order to effectively cover all sides of the 

building. 

During this survey, the RIT officer and members should look for ways in and out of the structure, 

window configuration, fire escapes and construction features. The RIT officer should note the 

feasibility for placement of ground ladders for rescue or escape purposes. The RIT officer shall be 

responsible for setting up and securing a suitable secondary egress for interior crews. This may include 

laddering multiple sides of the structure. Once the RIT has determined the need for an egress ladder the 
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window opening shall be cleaned of glass. This should only be done after conferring with “Command” 

that the removal of the window will not affect fire-fighting operations. Once approved by “Command”, 

the egress ladder should be placed at the window. The location of the egress ladder(s) should be 

announced over the radio by the RIT Officer. 

The RIT Officer should then radio “Command” that a 360-degree survey is complete, and the RIT is 

ready to engage, if necessary. Once the incident scene survey has been completed and the RIT’s 

equipment is in place, the entire RIT should be in an area immediately accessible to the building in 

order for rapid deployment plus maintaining radio contact with the Incident Commander. The RIT 

officer shall brief all members of the RIT as to the results of his/her incident scene survey. RIT 

members should take turns periodically doing 360-degree surveys throughout the incident for changing 

conditions and updating the team. The RIT should operate as one unit unless multiple RITs are 

required due to size, complexity or engagement of a RIT.

In the event of a complex incident such as a major collapse, large geographic area, multiple floor highrise incidents or shipping, rail or tunnel incident, additional crews may be added to or in support of the 

initial team as necessary. When more than one company is added as part of the rapid intervention team, 

a rescue group should be formed with a rescue group supervisor [Toledo Fire Department 2012].

Another consideration for “Command” is to request the response of an advanced life support (ALS) 

engine company or truck company as a component of the RIT Group. The members of the ALS 

company should be trained to operate in an Immediately Dangerous to Life or Health (IDLH) 

atmosphere, and function as part of the RIT, and provide advanced life support to affected firefighters 

[FDNY 2011].

The RIT officer and RIT members should coordinate with the Incident Commander to formulate rescue 

plan contingencies and continue to monitor the radio and fire ground conditions. RIT protection is not 

a passive assignment. This is a process of ongoing information gathering and diligent scene monitoring 

until the unit is released by the Incident Commander. The RIT is a critical component for firefighter

safety [NIOSH 2014b].

On the strategic level, Authorities Having Jurisdiction (AHJ’s) and fire departments should plan-ahead 

for considerations for major Heavy Rescue or collapse needs. An important part of the strategic 

assessment for structural collapse and heavy rescue considerations is identifying pre-planned assets for 

heavy rescue and structural collapse companies or resources. They should be identified and formally 

brought into the response matrix whether they be internal or outside mutual aid for larger collapse 

operations.

In some localities, there may not be enough assets or resources to staff heavy rescue and/or collapse 

units and the specifically trained personnel who perform these missions. Identifying the assets ahead of 

time with a formal mutual aid agreement or participation on regional response teams can help localities 

and their departments respond sooner rather than later. However, the AHJ and fire department need to 
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consider a possible delay in on-scene capabilities when the assets are not available or able to respond 

early in an incident, or be adequately staffed when a major collapse has occurred. 

Recommendation #10: Fire departments and municipalities should consider upgrading access to 

narrow roadways in 19th century neighborhoods or restrict parking so access is maintained for 

modern fire apparatus. 

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Modern fire 

apparatus should have access to buildings to effectively save lives and fight fire. This includes access 

for hoselines and ladder trucks as well as access for ground ladders in the narrow alleyways. It is 

important that fire departments and communities pre-plan operations and remove or alter parking on 

narrow streets to allow for heavy fire apparatus to access the buildings. 

Restricting parking on one or both sides of the street, special access routes, specialized equipment and 

operations training are some remedies for existing clusters of buildings (such as these row homes). 

Additionally, the local fire marshal’s office and administration should work with planners to identify 

and address fire department access for high density, multi-family areas.

In this incident, the neighborhood was established (buildings, roads and alleyways) between 1884 and 

1888. This construction era would have preceded motorized fire apparatus and on street parking. The 

fire department was very experienced in fighting row house fires and were aware of the challenges 

presented by limited access. The fire department had a policy of keeping the heavy apparatus on the 

main streets and crews were trained to stretch hoselines to the dwellings with long hose drags. 

The first arriving officer (victim), sized up the fire structure and identified the fire structure in his 

arrival report as a two story, 15’ x 35’, middle of the row, dwelling with fire showing from the first 

floor and then gave the size and dimensions of the two exposures in his size up. Engine crews had to 

stretch handlines 260 feet (15 row houses in) to get to side Alpha of the fire dwelling. There were no 

fire hydrants on the dwelling street (only at the main cross streets). 

Ladder trucks were not able to access the dwelling with the aerial and had to hand carry ground ladders 

to the dwelling and exposures. Additionally, all equipment such as spare SCBA cylinders, hand tools, 

saws, shoring equipment, and extrication equipment had to be carried longer distances due to the very 

narrow streets and resident parking. 

Recommendation #11: Fire departments should consider identifying and pre-planning emergency 

operations in target areas that present access problems or are known to have poorly maintained or 

abandoned/dilapidated structures. 

Discussion: Although there is no evidence that the following recommendation would have prevented 

this fatality, it is being provided as a reminder of best safety practice for the fire service. Fire 

departments, municipalities and local authorities having jurisdiction should consider developing 
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strategies for the identification, prevention of and the remediation of vacant/abandoned structures and 

for hoarding prevention and have programs in place to address fire and emergency response in those 

target areas. Fire departments don’t typically pre-plan residential structures, however groups of target 

hazards (such as row houses, town homes with limited access or unique multifamily garden 

apartments) can be identified and emergency response (including access) can be pre-planned. 

Additionally, AHJ’s should consider programs to identify and plan for structures that are experiencing 

severe clutter or are in dilapidated conditions.

Poorly maintained, dilapidated and excessive clutter can have a substantial effect on the expected 

building performance under fire conditions. Many firefighters and officers may think that the expected 

building performance for a contents fire in an older row house can be compared or gauged by past fire 

experience in these type occupancies. In fact, experience in fighting fire in specific occupancies can 

provide great assistance to the firefighters in sizing up and preparing to fight a fire. However, 

firefighters and officers need to use knowledge gained in target hazard identification such as open 

roofs, excessive clutter, hoarding conditions, dilapidated structural conditions in their training to size 

up each fire building on its on merits and adjust the strategy accordingly.

There can be many challenges for fire departments and emergency response agencies in areas such as 

older neighborhoods with very narrow streets and limited access, densely populated areas, and areas 

that contain neglected/poorly maintained, abandoned/derelict, or vacant structures. Many of these 

challenges can be identified and planned for by addressing the problem through targeted hazard 

identification and/or pre-planning. Targeted hazard identification can be specific to one or more 

properties such as a closed down or abandoned factory, or a grouping of target occupancies such as 

vacant commercial buildings on a waterfront. A targeted hazard identification program can then allow 

a department to pre-plan a response that is likely to occur. Assets and resources, such as specific 

apparatus, additional manpower, specific emergency vehicle routing, and closing or re-routing traffic 

patterns to allow for emergency vehicle access are all factors in a pre-planned emergency response to a 

targeted hazard.

Additionally, a targeted hazard program can be a formal program of cooperation between other city 

agencies and the fire department. For example, when a fire inspector, police unit, or EMS unit observes 

a severely deteriorating living and/or building condition while performing their mission, a cooperative 

program that notifies social services as well as agencies like the building officials office and fire 

department that may be able to provide assistance or direction. Additionally, social service agencies 

may be able to notify other agencies (such as fire departments) that have a need to know of structurally 

deficient conditions such as a hoarding condition in combination with neglected structural conditions. 

Utility companies can also be a part of the program and provide information in cases where they 

observe dangerous living conditions while servicing electric, gas or water customers. This kind of a 

program ideally should be overseen in the AHJ’s building department in close cooperation with the 

local fire inspections/fire marshal’s office.

In this incident, the first arriving fire units performed a very difficult offensive rescue operation and 

firefight with severely limited water supply in extreme weather conditions to rescue a trapped civilian. 
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The civilian was pronounced dead after they removed him from the fire building. There was reported 

to be extensive clutter and hoarding conditions which added to an excessive strain on the dilapidated 

structure. It is unknown if the excessive clutter contributed to the civilian’s inability to escape, 

however the excessive clutter contributed to the conditions that resulted in the Lieutenant being 

trapped and killed after a collapse occurred later in the fire. 

Fire fighting suppression efforts also added weight from water used to extinguish the fire as well as 

firefighters and equipment. The excessive clutter could have easily slowed or prevented water runoff 

from the 2nd floor. Additionally, the structure itself was severely neglected with openings in the roof 

that allowed extensive degradation of the structure. 

The department in this incident recognized the access issues with the narrow streets and had a planned 

response that kept heavy apparatus out on the main highways. This however resulted in long stretches 

of hose (which also means that additional equipment and ladders must be carried in) and a very limited 

access to side Charlie.

Recommendation #12: Fire Departments, water and utility department and authorities having 

jurisdiction should consider increased fire hydrant maintenance programs and identify and replace 

“problematic” type fire hydrants. 

Discussion: Fire departments can be challenged to perform at even smaller residential structure fires 

when the domestic water supply is not available due to frozen or out of service fire hydrants. Most 

cities that experience cold temperatures utilize underground fire mains with dry barrel hydrants 

designed to keep the barrel and the valves of the hydrant dry. When the stem is operated a valve down 

below the street opens and fills the barrel, and then exits the steamer and/or 2 1⁄2” threaded caps. When 

the hydrant is shut down, there is a drain system in place that drains the remaining water in the barrel, 

keeping the barrel dry for the next use. 

Fire hydrants need maintenance and one important part of the maintenance is ensuring the hydrant 

drains after use. It is also recommended that hydrants that show a history of operational issues due to 

weather are identified and replaced when they are shown to be less effective or dependable. 

In this incident, a number of the inoperable hydrants were identified to be of a similar type. In fact, five

of the first six fire hydrants would not operate for engine crews. They were accessed only to find they 

would not supply water due to being frozen or broken. It was reported during interviews that one 

specific type of hydrant was problematic on this incident due to the tamper proof mechanism becoming 

frozen. Initial crews relied on apparatus tank water for an extended period of time including the 

removal of the civilian fire victim.

Fire departments, water/utility departments and AHJ’s should ensure that fire hydrants are checked and 

maintained annually. 
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Recommendation #13: Fire departments should ensure that SCBA are stored fully charged to obtain 

full use and capacity as well as sufficient emergency reserve air, and cylinder pressure is checked 

during daily equipment checks. 

Although there is no evidence that the following recommendation would have prevented this fatality, it 

is being provided as a reminder of best safety practice for the fire service. Many new SCBA cylinders 

have a larger capacity in liters than older SCBA that is achieved by higher cylinder pressures. As an 

example, a department may have new 1800-liter SCBA 5500 psi, 45 minute rated vs. older 1800-liter

SCBA 4500 psi, 30 minute rated. Some departments may have up upgraded to higher pressure SCBA 

cylinders with the same capacity (1800 liters for example) but the cylinder size is now smaller.

For example, changing from an 1800 liter at 4500 psi to an 1800 liter at 5500 psi can result in a smaller 

profile size of the cylinder. The cylinder size may be smaller than the older cylinders, however the 

amount of breathing air in liters is achieved by an increase from 4500 psi to 5500 psi. The user will

only get the 1800 liters when the SCBA is properly filled (at the fill rate specified by the manufacturer) 

to capacity or 5500 psi (after cooling). 

There was also a change in the EOSTI (End-Of-Service-Time-Indicator) setting that came with the 

2013 edition SCBA, and that was the increase from 25% +/- 2%, which means the EOSTI could have 

activated anywhere between 27 and 23% in the past to 33%. The new standard has the EOSTI 

minimum activation at 33% so the EOSTI will sound sooner. This was changed to provide firefighters 

more emergency reserve air by sounding the EOSTI sooner in the use period [NFPA 2013c]. 

The normal breathing rate (non-working) for many firefighters, and the rate at which the SCBA receive 

their NIOSH certification rating, is 40 liters per minute. However, firefighters frequently will use more 

than 40 liters per minute and in some cases upwards of 100 liters per minute when performing heavy 

fire work. The user’s breathing rate has the most significant effect on the service time of an SCBA; 

however if departments have recently switched over from 1800 liter, 30 minute, 4500 psi cylinders to 

5500 psi, 1800 liter cylinders, they should understand the limitations of older compressors and fill sites 

that may have been set up to fill the smaller and/or and lower pressure cylinders. Fully charging the 

5500 psi cylinders can take longer periods, especially with older compressors that were designed to 

primarily fill 4500 psi cylinders. 

Like SCUBA diving with compressed air, using SCBA in the fire service is a critical component of 

firefighter PPE in order to work in IDLH environments. Individual air management and repetitive 

skills training with SCBA can improve a firefighters individual and company level air management 

and usage. Understanding the capacity ratings and how they are arrived [at] is important to 

understanding what the SCBA can do for the user. Additionally, understanding the capabilities and 

limitations of the SCBA is essential for the firefighter get the most out of his/her SCBA.

In this incident, the Engine-45 officer’s SCBA vibrating EOSTI was heard sounding during a radio 

transmission after only approximately 10 minutes on the scene. 
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Chart 1 is an exemplar chart provided by the department’s Health and Safety office team. It depicts a 

heavy usage of an SCBA and the beneficial effect of having a full cylinder to start the job. This chart 

uses 100 liters per minute as an example. Most firefighters would start off using well below that rate, 

however as the work demands climb, so does the rate of usage and rates approaching 80-100 liters per 

minute are easily attained and common in fire fighting.

In this incident, the fire department’s Health and Safety office was clearly proactive and provided this 

information to the field units since the new higher-pressure cylinders were new to the department. This 

chart very clearly illustrates the relationship between the cylinders beginning pressure and service 

time.

It is critically important to completely fill SCBA cylinders to the manufacturer’s recommended 

pressure. It is also important to note that there is a correlation in the rate of fill to heat produced and 

ultimately the ending fill pressure. High pressure cylinders, such as those rated at 5500 psi, require 

slower fill rates and higher compressor capacity to completely fill to a cooled down working pressure.

Fire departments should strictly follow SCBA and compressor manufacturers filling rates and ensure 

only trained operators perform the fills. Hot filling or rapid filling a cylinder during routine (nonemergent) filling should be discouraged due to a resulting lower pressure after cooling (if not topped 

off). Care must be taken not to over pressurize (routinely quickly filling with excessive pressures to 

allow for a cool down working pressure). Instead, SCBA cylinders should be filled at the 

recommended rate which may take longer filling periods with older breathing air compressors and 

cascade systems. 

In this incident, Engine-45’s officer and Engine-45 Tip firefighter both had their SCBA’s EOSTI 

sounding approximately 10 minutes after arrival. It is suspected that their SCBA (5500 psi, 1800 liter) 

may not have been completely topped off to 5500 psi. No one interviewed recalling any large air loss 

of any of the members during the initial operations. This department had recently upgraded their 

SCBA to a 2013 edition SCBA with the same capacity of 1800 liters, but smaller cylinders (profile 

size) at a higher pressure (5500 psi). The EOSTI was also changed in the 2013 edition from 23-27% of 

4500 psi (1800 liter) to 33% of the cylinder pressure. So, if a group of 5500 psi 1800-liter cylinders 

were filled with older breathing air compressors and cascade systems that were adjusted up from 4500 

to 5500, it could take longer to fill multiple cylinders to the full mark of 5500 psi cold pressure. 

One of the most important components of properly filling SCBA is understanding of and training in the 

manufacturer’s instructions.

Fire departments should consider the breathing air compressor assets whenever they upgrade or 

consider changes to their SCBA as part of their overall respiratory protection program.
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Chart 1. SCBA Air Usage chart developed and used by the fire department health and safety office. 

Figures have not been validated and are for demonstrative purpose. They reflect this department’s 

ambient conditions, equipment, experience and calculations. 

(Exemplar chart provided to NIOSH courtesy of the fire department’s Health and Safety Office 

After Action Review Team)
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References 

Weather Underground [2019]. Weather history for Philadelphia, January 6, 2018 

https://www.wunderground.com/history/daily/KPHL/date/2018-1-

6?req_city=Philadelphia%20International&req_state=PA&req_statename=Pennsylvania&reqdb.zip=1

9113&reqdb.magic=6&reqdb.wmo=99999. Date accessed: November 25, 2019. 

Clark BA [2008]. Leadership on the line: firefighter Mayday doctrine—where are we now? Firehouse, 

September 23, http://www.firehouse.com/podcast/10459336/leadership-on-the-line-firefightermayday-doctrine-where-are-we-now. Date accessed: May 2020. 

FDNY [2011]. Fire Fighter Assist and Search Team, Managing Members in Distress, Chapter 2. 

November 2011. Fire Department of New York, New York, NY. 

Harms, T. [2010]. Using tactical worksheets, tactical worksheets help maintain control at 

the scene. FireRescue Magazine. April 2010. 

https://www.firerescuemagazine.com/articles/print/volume-5/issue-4/news/using-tacticalworksheets.html. Date accessed: December 2019. 

Klaene B, Sanders R, NFPA [2007]. Structural firefighting strategy and tactics. 2nd ed. Sudbury, MA: 

Jones & Bartlett Learning.

IFSTA [2008]. Essentials of fire fighting, 5th ed. Stillwater, OK: Fire Protection Publications, 

International Fire Service Training Association. 

IAFC [2013]. Rules of engagement for structural firefighting. Fairfax VA: International Association of 

Fire Chiefs, Safety, Health and Survival Section http://iafcsafety.org/rules-of-engagement/ Date

accessed: January 2020. 

Los Angeles Fire Department [2011]. Los Angeles Fire Department Command Post Training. 2011 ed. 

Los Angeles, CA: Los Angeles Fire Department.

MABAS [2015]. MABAS Division 201, operations manual. Mishawaka, IN: Mutual Aid Box Alarm 

System.

Naum C [2014]. Building construction analysis and insights report. Prepared for NIOSH Fire Fighter 

Fatality Investigation and Prevention Team, November 8, 2014. 

Naum C [2019]. INSIGHTS ON BUILDING PERFORMANCE DURING FIRE OPERATIONS;

Residential Row House Fire & Collapse, Expert report, June 2019. 
Page 76

Career Lieutenant Killed in Building Collapse While Fighting Row 

House Fire—Pennsylvania

Report # F2018-03

NFPA. [2010]: NFPA 1035, Standard for professional qualifications for fire and life safety educator, 

public information officer, and juvenile firesetter intervention. 2010 ed. Quincy, MA: National Fire 

Protection Association.

NFPA [2018a]. NFPA 1582, Standard on comprehensive occupational medical program for fire 

departments. Quincy, MA. National Fire Protection Association.

NFPA [2013]. NFPA 1710, Standard for the organization and deployment of fire suppression 

operations, emergency medical operations, and special operations to the public by career fire 

departments. Quincy, MA. National Fire Protection Association.

NFPA [2013a]. Fire service deployment: assessing community vulnerability. 2nd ed. High-rise 

implementation guide. Quincy, MA: National Fire Protection Association.

NFPA. [2013b]: NFPA 1001, Standard for fire fighter professional qualifications. 2013 ed. Quincy, 

MA: National Fire Protection Association.

NFPA [2013c]. NFPA 1981, Standard on open-circuit self-contained breathing apparatus (SCBA) for 

Emergency Services. 2013 ed. Quincy, MA: National Fire Protection Association.

NFPA [2014]. NFPA 1561, Standard on emergency services incident management 

system. 2014 ed. Quincy, MA: National Fire Protection Association.

NFPA [2017]. NFPA 1142, Standard on water supplies for suburban and rural fire fighting. Quincy, 

MA: National Fire Protection Association.

NFPA [2018]. NFPA 1500, Standard on a fire department occupational safety and health 

program. 2018 ed. Quincy, MA: National Fire Protection Association.

NIOSH [2013]. Career lieutenant and fire fighter killed and two fire fighters injured by wall collapse at 

a large commercial structure fire—Pennsylvania. By Miles S.T., Merinar T, Loflin M., Morgantown, 

WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health, F2012-13, 

http://www.cdc.gov/niosh/fire/reports/face201213.html.

NIOSH [2014]. NIOSH workplace solution: preventing deaths and injuries to fire fighters by 

establishing collapse zones at structural fires. Cincinnati, OH: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health.

NIOSH [2014a]. Career Captain Dies Conducting Roof Operations at a Commercial Structure Fire –

Pennsylvania. By Bowyer M, Loflin M., Morgantown, WV: U.S. Department of Health and Human 
Page 77

Career Lieutenant Killed in Building Collapse While Fighting Row 

House Fire—Pennsylvania

Report # F2018-03

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, FACE Report F2013-07. https://www.cdc.gov/niosh/fire/reports/face201307.html .

NIOSH [2014b]. Career Female Fire Fighter Dies After Becoming Lost and Running Out of Air in a 

Residential Structure Fire--Pennsylvania. By Bowyer M, Miles S.T., Morgantown, WV: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Institute for Occupational Safety and Health, F2014-25, 

https://www.cdc.gov/niosh/fire/pdfs/face201425.pdf

NIOSH [2015]. Shift Safety Officer Falls through Hole in Floor into Basement of

Vacant Row House and Dies from Smoke Inhalation – Maryland. By Merinar T., Loflin M. 

Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, F2014-24, 

https://www.cdc.gov/niosh/fire/pdfs/face201424.pdf

NIOSH [2016]. Career Probationary Fire Fighter Runs Out of Air and Dies in Commercial Structure 

Fire—Michigan. By Miles S.T., Tarley, J., Morgantown, WV: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, FACE Report F2013-14 https://www.cdc.gov/niosh/fire/pdfs/face201314.pdf .

NIOSH [2017]. Career Fire Fighter Killed and Volunteer Fire Fighter Seriously Wounded When Shot 

during a Civilian Welfare Check—Maryland. By Miles S.T., Merinar T., Morgantown, WV: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Institute for Occupational Safety and Health, F2016-06, 

https://www.cdc.gov/niosh/fire/pdfs/face201606.pdf

NIOSH [2018]. Volunteer Assistant Chief Killed and One Fire Fighter Injured by Roof Collapse in a 

Commercial Storage Building—Indiana By Miles S.T., Loflin M., Morgantown, WV: U.S. Department 

of Health and Human Services, Centers for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, F2014-18, https://www.cdc.gov/niosh/fire/pdfs/face201418.pdf 

NIOSH [2020]. NIOSH Fact Sheet: Row House Firefighting Tactics. Cincinnati, OH: U.S. Department 

of Health and Human Services, Centers for Disease Control and Prevention, National Institute for 

Occupational Safety and Health. https://www.cdc.gov/niosh/docs/2020-117/pdfs/2020-

117.pdf?id=10.26616/NIOSHPUB2020117

NIST [2013a]. Report on high-rise fireground field experiments, fire fighter safety and deployment 

study. Gaithersburg, MD: By Jason D. Averill, Lori Moore-Merrell, Raymond T. Ranellone Jr., Craig 

G. Weinschenk, Nicole Taylor, Randy Goldstein, Robert Santos, Doug Wissoker, Kathy Notarianni, 

Kathryn M. Butler. National Institute of Standards and Technology.

https://www.nist.gov/publications/report-high-rise-fireground-field-experiments (date accessed 

January 2020)
Page 78 

Career Lieutenant Killed in Building Collapse While Fighting Row 

House Fire—Pennsylvania 

Report # F2018-03

NIST [2013b]. Wind driven fires. Gaithersburg, MD: By Madrzykowski, D., Kerber, S. National 

Institute of Standards and Technology, https://www.nist.gov/publications/fire-fighting-tactics-underwind-driven-conditions-laboratory-experiments (date accessed January 2020)

NIST [2003]. Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002, Gaithersburg, 

MD: By Brassell, L D, Evans D D. National Institute of Standards and Technology, 

https://www.nist.gov/publications/trends-firefighter-fatalities-due-structural-collapse-1979-2002 

(updated 2009, date accessed January 2020). 

OSHA [1998]. 29 CFR Parts 1910 and 1926 Respiratory Protection; Final Rule. Federal Register 

Notice 1218-AA05. Vol. 63, No. 5. January 8, 1998. U.S. Department of Labor, Occupational Safety 

and Health Administration. Washington DC. 

Toledo Fire Department [2012]. Rapid Intervention Team (RIT) Standard Operating Procedure C82. 

November 2012. Toledo Fire Department, Toledo, OH. 

Township of Spring Fire Rescue [2014]. Rapid Intervention Team Interim Procedure 2014-003.

Investigator Information

This incident was investigated by Stephen T. Miles, Investigator/Safety and Occupational Health 

Specialist, and Matt Bowyer, Investigator/General Engineer with the Fire Fighter Fatality Investigation 

and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, 

NIOSH located in Morgantown, West Virginia. A technical review was also provided by the National 

Fire Protection Association, Public Fire Protection Division. Some text provided by expert reviewers 

was incorporated into the final report. 

An independent identification and analysis of a wood floor joist sample was performed by Dr. 

DeVallance, Division of Wood Science, West Virginia University, Morgantown, WV. Assistance with

a structural mortar sample analysis was performed by Mr. Paul Stutzman, Inorganic Materials Group, 

Materials and Structural Systems Division, Engineering Laboratory, National Institute of Standards 

and Technology, Gaithersburg, MD 20899-8615. Additionally, the United States Department of 

Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), provided extensive information 

that was utilized in the timeline with information taken from police body cameras, civilian cell phone 

video and other sources. 

NIOSH funded an evaluation of the victim’s SCBA for pneumatic performance by Intertek Labs, 3933 

Cortland NY. The victim’s PASS device was evaluated with the assistance of the manufacturer. 

An expert technical review was provided by Chief Christopher J. Naum, SFPE (NY) (Command 

Institute). Chief Naum provided information on building construction, historical data and structural 

collapse hazards. His full report is included in Appendix 2. Additionally, much of the building 
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construction description and history for the fire structure is based on a review and material provided by 

Chief Naum. Some identifiers in this report have been removed by NIOSH. 

Additionally, the Fire Department’s Health and Safety Office put together an after-action review team

consisting of a Deputy Chief, 2 Captains and a Lieutenant assigned to investigate this fatality. The Fire 

Department’s Health and Safety Office after-action review team completed a lengthy and 

comprehensive incident review and many of the findings, resources and references have been included 

in this report. The Fire Department’s Health and Safety Office after-action review team provided 

NIOSH with extensive information, including the fire departments history of fighting fires in highly 

congested urban areas such as this row house community. The Fire Department’s Health and Safety 

Office after-action report identified contributing factors and developed changes based on lessons 

learned from this incident.

Additional information on row house firefighting considerations and tactics can be found at DHHS 

(NIOSH) Publication Number 2020-18 https://www.cdc.gov/niosh/docs/2020-118/default.html. 

Disclaimer 

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

Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC). In 

addition, citations to websites external to NIOSH do not constitute NIOSH endorsement of the 

sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the 

content of these websites. All web addresses referenced in this document were accessible as of the 

publication date. 
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Appendix 1, Engine 45 Officer’s Electronic PASS Data Log Record 

Victim’s Partial Electronic Data Log. The PASS device sustained significant damage; however, the 

manufacturer provided assistance in obtaining this data. 

(Data log information markings and highlighting by NIOSH Investigator - NIOSH worksheet 

provided with permission by the department) 
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Appendix 2

Special Expert Building Construction Report

Prepared by:

Christopher J. Naum, SFPE, CUSA 

Fire Protection Analysis & Fire Management Consultant

Technical Advisor & Subject Matter Expert

Syracuse, New York USA 

INSIGHTS ON BUILDING PERFORMANCE DURING FIRE OPERATIONS;

Residential Row House Fire & Collapse

 January 6, 2018

ANALYSIS REPORT

NIOSH F2018-03 

This Analysis Report was provided to NIOSH Firefighter Investigation and Prevention Program 

Investigative Team in support of the Technical Review and SME Support provided for Report 

F2018-03, which is based on the Final Executive Report of the comprehensive findings and 

insights issued to the Philadelphia Fire Department Health & Safety Office

Privileged and Confidential

The Contained Information of this Report is confidential and privileged and is intended for use, dissemination and 

review purposes solely with the City of Philadelphia Fire Department (PFD), The Office of the Fire Commissioner, 

Safety Investigation Team, NIOSH and other designated parties authorized by and at the discretion of 

the City of Philadelphia Fire Department and in cooperation with the author. 

The submission to NIOSH Firefighter Investigation and Prevention Program Investigative Team grants authorization to 

share this material in full support of Report F2018-03 as deemed in the best interest of the Fire Service to support insights, lessons, learnings, 

recommendations and best practices in LODD reduction and prevention. 

 
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INSIGHTS ON BUILDING PERFORMANCE DURING FIRE OPERATIONS;

Residential Row House Fire & Collapse

January 6, 2018

ANALYSIS REPORT

NIOSH F2018-03

I. Scope of Insights

II. Executive Summary

III. Building Construction and Occupancy Profile

a. Overview

b. Layout and General Features

c. Building Construction and Occupancy

d. Building Anatomy and Profile

IV. Anatomy and Mechanism of Floor Compromise and Collapse

a. Occupancy Risk Profile

b. Mechanism of Floor Compromise and Collapse

c. Operational Perspective

d. Uniqueness & Variations for this Row house Occupancy

V. Graphics and Diagrams

VI. References

VII. Appendix
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I. Scope 

The purpose of this report was to provide insights on Building Performance during fire suppression 

operations derived from the inherent and as-found building conditions, occupancy risk and incident fire 

suppression operations conducted at the residential row house fire that occurred on January 6, 2018 

that resulted in the Line-of-Duty Death (LODD) of a Lieutenant, Fire Department. 

Technical support was requested by the Fire Department’s Health and Safety Office to support and 

supplement the scope and objectives of the Fire Department’s After-Action Report for incident lessons, 

learning and insights. 

The insights, observations, assessment and opinions expressed directly or indirectly by this report are 

based on a review of general information, documents and visual media provided by designated and 

authorized representatives from the Fire Department and are postulated, formulated and articulated 

based on generally accepted fire protection engineering, fire and emergency services, fire incident 

management & operations and occupational safety & health principles, practices and methodologies. 

This report and its observations shall not be construed to be a result of an in-depth technical analysis of 

the events or conditions leading to or resulting from the Fire Department as referenced in this report. A 

review of media and documents provided by the Fire Department were used in the preparation of this 

report. The author assumes no liability for opinions expressed. 

II. Executive Summary 

The structure fire, occurring on January 6, 2018 at the residential property consisted of a single-family 

residential occupancy row house was a structure fire that the Fire Department encounters with both 

regularity, consistency in building and fire performance and conditions that have led to the 

development of proficiencies, skills sets and protocols for the incident management and tactical 

mitigation of these incidents and the protection of life for the affected occupants that reside in these 

occupancies. 

The row house building type is synonymous and defined in the history of the City as is the Fire 

Department’s response, control and mitigation of fire incidents in these building and occupancy types. 

This single-family residential occupancy row house sustained a fire within the structure that 

communicated throughout the building, (causal factors of which are under investigation), culminating 

in a catastrophic second floor collapse of that area, which resulted in the line of duty death on-scene of 

Lieutenant and other subsequent firefighter personnel injuries. The originating fire within this occupied 

structure resulted in the fatality of the single row house occupant. 

It is suggested and highly probable the second-floor collapse was triggered by; 

• Overloading and excessive stress and loss of load transfer or carrying capacity of the existing 

structural wood floor joist assembly on the Second Floor from existing hoarding, heavy loads 

and clutter; The center bedroom area’s floor area appears to have had significant live loading 

added based on occupant hording, heavy loads and clutter that placed additional stress and load 
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transfer as fire extension or exposure from the first-floor fire resulting in probable building 

component and assembly compromise, deterioration and failure that lead to the V-shaped 

collapse along a vulnerable inherent condition. 

• the ensuing compromising floor conditions lead to interior V-shaped floor collapse and the 

progressive succession of compromise of the floor diaphragm commencing from second floor 

bedroom inwards towards the second-floor center bedroom area. 

• This resulted in a compromising floor condition at the front second floor bedroom, progressing 

towards the full collapse of the most susceptible second floor area within the center part of the 

second-floor resulting in a V-shaped collapse configuration bring both structural floor joists, 

flooring, partition and hoarding condition, heavy contents from the rooms above downward 

into the V-shaped collapse and onto the first floor. 

• The central area of the second floor had a series of shorter floor joists that terminated at a 

framing joist that in turn framed the stairwell opening and did not extend to or were pocketed 

into the masonry bearing wall (Bravo Division) 

• Wood floor joist #11 progressing from the front of the building inward was the last floor joist 

to full span from each bearing wall. 

• The predominate compromising conditions that followed the legacy notch lines in the wood 

joists from building front- inward exhibited signs of load stress, failure and compromise; 

exhibited by the splitting and cracking of the wood joists. The line of structural compromise 

and failure followed the existing gas line and joist notching coincided with an apparent 

structurally weak area and aligned with the axis of the subsequent V-shaped collapse (versus a 

more common single-sided lean-to collapse of the floor diagram and assembly.

• Fire severity (unquantifiable) and extension within the interior ceiling spaces; within the joist 

channels or possible direct impinged from room and contents fire conditions in the absence of 

some of the existing plaster and lath ceiling may have had a contributing effect on the wood 

joists due to fire exposure to increase susceptibility of floor joist compromise with diminishing 

load carrying capacity due to loss of wood mass (material charring and burn) coupled with the 

inherent characteristics of the aged wood. 

• It is postulated and suggested that the addition of water introduced from the application of 

exterior hose streams into the upper interior from the street on the Alpha Division during a brief 

defensive tactical time period may have added additional live load (weight) that fall-out rates 

(non-evaporation) of water from the hose streams, would have soaked or saturated into porous 

or other soak-prone clutter and hoarding materials, thus increasing overall live loads that 

further exasperated floor structural stability, increased floor deflection and loss of load transfer 

and load carrying capacity that precipitated the compromise and resulting catastrophic collapse. 

• The existing wood joist notches, creating a vulnerable condition on multiple adjacent floor 

joists, excessive hording and heavy clutter adding significant live load to an aged existing floor 

assembly and a varying degree of fire within the interior compartment and structural void space 

area suggest an apparent and highly probable series of conditions that aligned in such an 

manner at this row house fire that provided the sequence of events and mechanism of collapse 

that had adverse consequences to operating companies within the structure. 
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Uniqueness and Variances for this Row house and Fire 

• The inherent legacy notching of the exiting wood floor joists was a primary contributor to 

create an existing floor system that was highly susceptible and prone to be affected by an 

interior compartment or structural fire or affected by existing or in the addition of live or dead 

loads.

• Existing Hoarding, Heavy Contents and Clutter introduced to the rooms by the occupant 

significantly contributed towards the potential for floor instability and compromise. 

• Deterioration and exposure of the interior rooms and occupancy to environmental exposure and 

elements and their suggested impacts on the building structural components, materials and 

systems may have had a contributing effect on structural stability and integrity of building 

components. Possible degraded load carrying capacity of the existing wood floor joists due to 

age, creep, the effects of loss of moisture content or cyclical exposure to environment elements.

• The small size of the row house structure, when impacted by unstable or compromising 

structural stressors may not have the resiliency or resistance to recover from those conditions or 

allow for load transfers and still maintain its structural stability and integrity. 

The alignment of seven separate conditions correlated in this row house occupancy to create a 

variance an irregularity that made this incident and fire operation unique that contributed to the 

collapse conditions and outcome;

• The Existing Hoarding, Heavy Contents and Clutter

• The presence of the legacy notch lines in the wood joists from created an existing condition that 

made each of the floor joists highly susceptible and prone to the effects of fire, heat & failure. 

• Inherent building support systems (Wood joist) degrade or affected material conditions & 

postulated diminished structural integrity 

• Floor joist framing at the stairwell and floor area above that creates a susceptible and prone 

interior condition (to fire) that is inherent in all row houses of this layout type, floor plan and 

configuration (Workingman’s Row House)

• The suggested impact of water introduced during fire suppression affecting hoarding and clutter 

conditions

• The location and extent of fire

• The transitional tactics from Offensive to Defensive to Offensive may not have considered 

structural integrity of critical internal building systems or components that may have been 

subject to varying degradation, damage or compromise and the compounded effects of imposed 

loads on the building from hoarding, heavy content and clutter. 

The significance of interior compartment hoarding conditions, elapsed time of fire suppression 

operations and the varying degrees of fire involvement within the structure alone would highly suggest 
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that the elevating risk probability for a structural compromise or collapse could be highly expected and 

possibly imminent.

Whenever operations transition for Offensive-interior to Defensive-exterior and then back to 

Offensive-interior; The overall building risk profile and assessment must be made by Incident 

Command and a determination made on probable building integrity and operational benefits expected 

by placing companies back into a structure and compartments that have been subject to increased fire 

exposure and degradation, impacted by the introduction of large or small caliber hose streams during 

defensive operations and the potential effect of the water introduction, absorption, steam conversion 

and fall-out rate and run-off or containment in rooms, floors, voids or materials. 

III. Building Construction and Occupancy Profile 

Overview

The fire incident occurred within a densely populated neighborhood common to urban matrix of the 

City. The residential property consisted of a single-family residential occupancy row house that was 

located on a narrow street comprised of thirty-four (34) attached row house buildings that spanned the 

city block from a cross-street to the north street and a cross-street to the south. Similar row houses 

were present across the street from the residence and were found to the rear of the structure (Charlie 

Division- geographic West) along the adjacent city street and block, separated by a slight backyard 

buffer zone. 

The residential row house was built between 1880 and 1888 1 under the adopted building and 

construction standards in effect at that time. The structures were of Type III- masonry brick and wood 

joist construction 2 in accordance with recognized standards in that era and consistent with NFPA 220 

Standard 3.

The single-family residential occupancy row house sustained a fire within the structure that 

communicated throughout the building, (causal factors of which are under investigation), culminating 

in a catastrophic second floor collapse of that area, which resulted in a firefighter fatality and other 

subsequent personnel injuries. The originating fire within the occupied structure resulted in the fatality 

of the row house occupant. 

Progressive fire extension and further structural collapse and compromise occurred throughout the 

interior occupancy of the building during fire suppression operations. There was some damage to the 

adjoining residential properties on both the Bravo Divisions (Geographic South) and the Delta 

Divisions (Geographic North). The single-family residential occupancy row house was the 15th unit 

inward along North Colorado Street from the intersection of West Dauphin Street. 

The row house was found to have evidence of physical, material and maintenance neglect and 

progressive physical building and structure deterioration. The building did not have an operable fixed 

heating system1

, had roofing and perimeter wall deterioration and had direct open areas to the 

environment with direct exposure and susceptibility to seasonal environmental cycles and conditions.
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There was evidence that significant hoarding conditions of materials and a significant degree of clutter 

was present throughout the rooms and floors of the structure that imposed critical operations 

impediments and highly suggest; affected the structure during the early development stages of the fire 

within the room compartments and within concealed and exposed area of the building structural 

components, systems, assemblies and materials. These hoarding, heavy content and clutter conditions 

also had significant contributions towards building compromise, collapse and concurrent and 

subsequent Fire Department fire suppression operations, mitigation efforts and resulting fire service 

personnel extrication and rescue effort resulting from the structural floor collapse. 1, 17 

Appendix Photo 1. Street Photo: Analysis Diagram Courtesy of Buildingsonfire.com | C.J. Naum 

Map Courtesy of Bing Maps | Photo Courtesy of Google Earth
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Layout and General Features 

The residential property consisted of a single-family residential occupancy row house. The row house

style structure or commonly referred to as the row house, is typically a one to four-story residential 

house occupying a narrow street frontage and attached to adjacent houses on both sides. It evolved 

early in the city’s history. 4 

Lining the city’s straight, gridiron streets, the row house defines the vernacular architecture of the city. 

Row houses were built to fit all levels of taste and budgets, from single-room bandbox plans to grand 

town houses. The row house was easy to build on narrow lots and affordable to buy, and its 

pervasiveness resulted in Philadelphia becoming the “City of Homes” by the end of the nineteenth 

century. 

The row house became synonymous with the city and was the model for affordable housing throughout 

the Mid-Atlantic and New England states and cities in the late 1800’s and well into the early 20th

Century. 

From the city’s founding, the row house has served as an easy solution to housing the city’s residents. 

Streets, alleys, and courts were lined with relatively homogenous structures of predictable form and 

design. By the nineteenth century, the term “Philadelphia row” not only became synonymous with the 

landscape of the city, but it also became a term used elsewhere to describe orderly rows of regularized 

houses. 4, 5, 6 

The single-family residential property consisted of a two-story building located on a footprint of 

approximate 1,038 square feet. The building’s style and design are commonly referred to a 

Workingman’s House 4 with defining characteristics that included;

• Masonry Brick bearing-party walls with masonry front facades

• Adjoining occupied buildings (row houses) on either side of the occupancy 

• Wood Floor joists structural supports

• Plaster and lath over wood framing interiors

• Narrow Windows

• Single sloping roofs with modest ornate wood or brick cornice

• Front stoop (steps) accessing from street side, 

• Entry vestibule, 

• Two-floors of occupied space, 

• Single run stairway, 

• A basement with limited window(s) 

• Indoor kitchen, plumbing, service and heating

• Small rear yards with partial court-yard area (adjoining to adjacent property) 
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These row houses can be found throughout the neighborhoods and sections of the city consisting of 

1,000 – 1,600 sq. ft. on two-story homes. 4, 5, 6 

This row house style, configuration and layout was highly predictable in terms of expected 

performance under fire conditions and in typical fireground incident operations. These types of 

buildings and occupancies have consistently provided the Fire Department (FD) with extensive indepth experience and operational insights from hundreds of thousands emergency incident responses, 

row house building firefighting and fire incident management, tactical deployment and incident 

mitigation over the past 138 years. These buildings and occupancies have been fundamental in 

firefighting principles, practices and tactical methodologies in these residential occupancy types and 

occupancy risks. 

Building Construction and Occupancy

The building was a masonry constructed residential occupancy built in between 1880 - 1888.1

Constructed of Type III, ordinary construction, was two-stories in height and had a basement. The 

building had masonry party bearing walls located perpendicularly to the main street running east-west 

on the Bravo (South) and Delta (North) divisions, with in-fill non-bearing masonry walls on the west 

and east building face (Alpha and Charlie divisions respectively). Sited on a city block, the building 

was accessible on two of the four sides and had attached exposure structures of single use occupancy 

on the Bravo division and a building exposure across the alley on the Delta division. 

The residential property consisted of a single-family residential occupancy row house that was located 

on a narrow street (North Colorado Street) comprised of thirty-four (34) attached row house buildings 

that spanned the city block from a cross-street to the north (West Dauphin Street) and a cross-street to 

the south (West Susquehanna Ave.). 

Similar row houses were present across the street from the residence and were found to the rear of the 

structure (Charlie Division- geographic West) along the adjacent city street and block, separated by a 

slight backyard buffer zone. Type III, ordinary construction 2, 3 (also referred to as “Brick and Joist” 

construction) generally refers to a construction system that incorporates masonry perimeter wall 

construction with both fully supporting masonry bearing and non-bearing wall characteristics, fully 

dimensioned timber wood construction for structural supporting floor joists, roof rafters and 

assemblies and dimensioned wood framing for interior partitions. Interior wood framing is commonly 

present for wall and room partitions and compartmentation with plaster and lath construction for finish 

treatments. 

There was evidence that significant hoarding conditions of materials by the occupant over time and a 

significant degree of clutter that was present and encountered by operating FD companies throughout 

the rooms and floors of the structure that imposed critical operations impediments and highly suggest; 

affected the structure during the early development stages of the fire within the room compartments 

and within concealed and exposed area of the building structural components, systems, assemblies and 

materials. 1, 17
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These hoarding, heavy content and clutter conditions had significant influence and contributions 

towards subsequent building compromise, collapse and subsequent Fire Department fire suppression 

operations, mitigation efforts and resulting fire service personnel extrication and rescue effort resulting 

from the structural floor collapse. 

Appendix 2 Diagram 1. First-Floor Plan Graphic Courtesy of Buildingsonfire.com | C.J. Naum

First-Floor Plan: 15 ft. – 5 in. Front width x 37 ft. – 6 in. depth (10 ft. – 2 in. at rear width Kitchen) 

1,038 Sq. Ft. 
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• A: Front Sidewalk and stoop (stairs) 

• B: Entry Vestibule 

• C: Front Living Room 

• D: Straight Single-Run Stairs- UP to Second Floor

• E: Rear Kitchen with access to Rear yard (Charlie Division) 

• F: Exposure-B Row house

• G: Exposure-D Row house

• H: Adjacent Adjoining Court Yard 

Appendix 2 Diagram 2. Second Floor Plan (Adjacent Exposures shown) Graphic Courtesy of 

Buildingsonfire.com | C.J Naum
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Second-Floor Plan: 15 ft. – 5 in. Front width x 37 ft. – 6 in. depth (10 ft. – 2 in. width at rear 

Bedroom) 1,038 Sq. Ft. 

• A: Front Second Floor Bedroom (15’-2” x 12’-5”) 

• B: Middle Second Floor Bedroom (10’-0” x 10’-5”) 

• C: Rear Second Floor Bedroom (10’-2” x 9’-8”) 

• D: Straight Single-Run Stairs DOWN to First Floor and Second Floor Landing and Corridor 

• E: Second Floor Bathroom 

• F: Exposure-B Row house

• G: Exposure-D Row house

• H: Adjacent Adjoining Court Yard 

Building Anatomy and Profile 

• Constructed: circa 1880-1888 1,16, 17

• Occupancy: Single Family Residential

• Condition: Occupied and In-use; Hoarding Conditions along with Degraded Building 

Conditions and evidence of interior occupiable spaces exposed to environmental elements.

1,17,

o The row house was found to have evidence of physical, material and maintenance 

neglect and progressive physical building and structure deterioration. 

o The building apparently did not have an operable fixed heating system, had roofing and 

perimeter wall deterioration and had direct open areas to the environment with direct 

exposure and susceptibility to seasonal environmental cycles and conditions.

o There was evidence that significant hoarding conditions of materials and a significant 

degree of clutter was present throughout the rooms and floors of the structure that 

imposed critical operations impediments and highly suggest, affected the structure 

during the early development stages of the fire within the room compartments and 

within concealed and exposed area of the building structural components, systems, 

assemblies and materials. 

o These hoarding, heavy content and clutter conditions also had significant contributions 

towards building compromise, collapse and concurrent and subsequent Fire Department 

fire suppression operations, mitigation efforts and resulting fire service personnel 

extrication and rescue effort resulting from the structural floor collapse. 

• Construction System: Type III Ordinary Construction (based on National Building Code, 

circa 1900-1915 ed.) 

o Floor Joists: Full dimensioned 3 in. x 7.5 in. Floor joists were pocketed into the 

masonry bearing walls. There were no internal joint strap anchors or tie-backs to the 

masonry bearing or non-bearing walls. (no external spreader plates were used on the 

building facade) Bridging would not have been expected to be present between floor 
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joists based on the short spans. 

 

o Wood Joist: Eastern Hemlock (Tsuga canadensis)9,10 3 in. x 7.25 in 

The wood is moderately lightweight, (about 28 pounds per cubic foot at 12- percent 

moisture content), moderately weak in bending strength, moderately strong in end 

compression, low in splitting resistance, and average in nail-holding capacity, 

moderately low in strength, moderately stiff, and moderately low in shock resistance.9 

o Hemlock is similar to spruce in appearance, though much inferior as a building 

material. The wood is very brittle, splits easily, and is very liable to be shaky. Its grain 

is coarse and uneven, and though it holds nails much more firmly than does pine, the 

wood is generally soft and not durable. Hemlock is used almost exclusively as a cheap, 

rough-framing timber. 8 

o NOTE: A sample taken from the building by the PFD was identified to have a moisture 

content of 3.6%1,17

o Unique Feature of Note: Within the Joist Void consisting of the 2nd Floor wood floor 

system; Commencing proximal to the first wood joist an approx. 1-inch x 1-inch notch 

was cut into the upper top portion of the wood joist to accommodate the installation of a 

pipe run into the occupancy for gas service to the residence in the late 1800’s. These cut 

notches and legacy gas pipe run continues in each wood floor joist inward from the 

Alpha side wall area interior along an almost floor span center-line approx. 20 ft. or 

more.

o Stairwell Area: The Single-run stairway and stairwell was located directly adjacent to 

the interior Bravo Division wall and was accessible immediately upon entry through the 

front door and vestibule. The wood floor joists span fully wall to wall in all interior area 

except at the stairwell. An alternate method of assembly and structural system is present 

at this location 

o Flooring: 3-inch x 1-inch wood plank flooring is common for this building type and 

vintage consisting of a rough under floor planking attached to the wood floor joist, a 

finished upper flooring treatment was not apparent 

o Refer to Diagram for Typical Structural Floor System and Masonry Perimeter Wall and 

Floor Joist Orientation and Column Support Plan 

• Size: Two Stories, with a full basement 

o Height: Curb line to Cornice- approx. 20 feet 

• Floor Area: 37 feet approx. x 15 feet approx. [519 square feet per floor] 

o Total Floor Area: 1,038 Square feet est. 

o Closed- Compartmented Floor Plan 
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• Interior Compartments: Two (2) occupant spaces-rooms on the 1st Floor. Four (4) occupant 

spaces-rooms on the 2st Floor. Full basement; open space.

o Compartment framing, wood timber construction, original plaster and lath wall 

treatment (fully, partial or removed) 

o As-found evidence of physical, material and maintenance neglect and progressive 

physical building and structure deterioration

o Recommended practices and code ordinances at the time of the building’s construction 

(1880-1888) 

• Roof: Timber Rafters with Wood Deck and covering 

o The cornice had been modified and altered, with plywood panels partially installed to 

protect the roof cockloft void. Original brick and/or covering materials were absent at 

the time of the fire. 

• Masonry Perimeter Walls: Masonry Brick Wall Construction Party Bearing Walls (Bravo and 

Delta Divisions; Brick walls and wood frame backing on Alpha and Charlie Divisions 

o Evidence of masonry brick wall deterioration of mortar joints, brick facing and wall 

integrity; Exposed rear walls and court-yard shape, Charlie Division. 

o The Front façade did not appear to have an observable deteriorated or compromising 

condition. 

o Window Treatments: Conventional window treatment and sizing for residential 

occupancy spaces (Basement, 1st and 2nd floors). 

The building had vernacular architectural features in the use of masonry materials and construction for 

its perimeter enclosure walls which was common for buildings built in this timeframe (vintage and 

era). 8,11,12,13,21,28

Unreinforced Masonry—unreinforced masonry walls, when they are not veneers, are typically several 

wythes thick (a wythe is a term denoting the width of one brick). Therefore, header bricks will be 

apparent in the exposed surface. Headers are bricks laid with the butt end on the exterior face, and 

function to tie wythes of bricks together.

Brick header courses typically occur every six or seven courses as was found in the construction of the 

building’s walls. Sometimes, URM infill walls will not have header bricks, and the wythes of brick are 

held together only by mortar. The design and construction features, self-revealing of the building’s 

wall system suggests criteria was followed in combination with recognized recommended standards 

and regulatory insights of the time and incorporated common empirical design principles. 

Buildings of this and earlier vintage incorporated common empirical design principles, which is a 

procedure of proportioning and sizing unreinforced masonry elements based on known historical 

performance for a given application.
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Empirical provisions preceded the development of engineered masonry design, and can be traced back 

several centuries. This approach to design is based on historical experience in lieu of analytical 

methods. Using empirical design, vertical and lateral load resistance is governed by prescriptive 

criteria which include wall height to thickness ratios, shear wall length and spacing, minimum wall 

thickness, maximum building height, and other criteria, which have proven to be effective through 

years of experience.

Construction and Occupancy characteristic prevalent in this Heritage Vintage Row house

Building includes; 18,28 

• Type III Masonry- Ordinary Construction 

• Row house Design and Function with Vernacular (Philadelphia) style 

• Commonality of city block building occupancies and configuration 

• Common adjacent building exposures (attached) 

• Presence of Masonry Party Bearing walls 

• Degree of Masonry Party Bearing walls integrity and openness 

• Long, narrow streets

• Limited, rear yard-area accessibility 

• Longevity of building use, function and age and impacts 

• Compact semi-rectangular foot print (L-notch) 

• Fully dimensional lumber structural floor system 

• Limited Accessible and predicated floor plan 

• Compartmentation of rooms

• Limited number of rooms 

• Smaller room volume and square footage 

• Limited corridors (flow/vent paths) 

• Plaster and wood lath interior room finishes; wall and ceilings 

• Presence and influence of transom storefront design and subsequent ceiling voids

• Limited Concealed spaces with combustible treatments

• Limited allocation of exterior windows along perimeter walls

• Limited Building accessibility from street -curb side

• Probability of alterations, renovations, approved and non-approved changes/modifications over 

time

• Varying occupancy loading and degree of mobility 

• Age determinate & influential considerations 

• Unique gable architectural design features

• Front Brick Façades and varying conditions/treatments of roof Cornice 

• Occupant Hording, Heavy Contents, Clutter

• Occupancy use and habitability 
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Appendix 2 Photo 2. 2240 North Colorado Street, Photo Courtesy of Google Earth. Analysis 

Diagram Courtesy of Buildingsonfire.com | C.J. Naum
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• Front Street View looking north on Colorado Street, with Stoop and Sidewalk access 

• Bravo Division Two-story Brick & Joist Row house @ 2242 (Exposure- South side of 2240 

occupancy)

• Delta Division Two-story Brick & Joist Row house @ 2238 (Exposure- North side of 2240 

occupancy)

• Front Masonry non-bearing brick façade 

Appendix 2 Photo 3 & 4. 2240 North Colorado Street, Photo: Analysis Courtesy of 

Buildingsonfire.com | C.J. Naum, Photo Courtesy of Google Earth 

• The upper Second Floor windows are depicted for the Front Bedroom 

• All windows and doors: Masonry cut-stone lintels and sills 

• The modified remnants of the previous cornice are evident with the plywood panels applied and 

installed along the entire horizontal facia and cornice spanning both ends of the masonry 

bearing walls. Notice ornamental treatment of the masonry party walls on both sides 

• Upper second floor windows with narrow passageways 

• Front stoop (steps) 

• Two quarter sized windows at sidewalk grade with installed security bars 
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IV. Anatomy and Mechanism of Floor Compromise and Collapse

Occupancy Risk Profile 19,20,21

The inherent building, construction, design and characteristics in this row house structure have a 

recognizable predictability of expected building performance under fire conditions. 

The building’s anatomy and fire conditions upon arrival and during initial fireground operations have 

defined and expected performance, risks and hazards that define the conduct of fireground 

operations.18,19,21

This predictability of building performance has definable degrees of risk potential that once identified 

and assessed against an evolving fireground scenario can be aligned with recognized strategic and 

tactical measures that must be considered and assessed and possibly implemented in order to increase 

the probability of a safe and effective incident stabilization and mitigation. The time-demand 

identification and selection of tactical measures is borne with the arrival of the first-due company: the 

effectiveness and suitability of those tactical measures are validated or alter by the assuming command 

officer or incident commander.18,19,20

Understanding the building’s anatomy, its current occupancy use and the characteristic of the 

building’s internal compartments (occupied rooms and space use) are integral to effective and efficient 

firefighting operations within buildings on fire and are essential for all phases of fire engagement and 

suppression.18 Tactical Company actions may be subject to adjustment and change as conditions 

become evident, self-revealing, assumptions are validated or confirmed as well as when assumptions, 

projections or other unknowns continue to be questionable- prompt associated actions must be taken 

that will have a potential positive tactical outcome or risk reduction or elimination in order to maintain 

company integrity, overall incident safety and firefighter survival. 

Generally, when operating companies are confronted with intense fire conditions within a building of 

Type III construction with similar vintage, occupancy use and tenant space configuration; and those 

fire conditions have either impinged or propagated within or along concealed spaces, voids or 

compartment(s) for an extended period of time prior to arrival or during fireground operations, it is 

highly probable and predictable that the structural integrity of the various assembly, supports and 

structural floor joists and wall systems will be compromised and subject to varying degrees of 

degradation.28

Rapid or prolonged fire extension or exposure will result in probable building component and 

assembly compromise, deterioration, failure and collapse.29,30 This will directly affect structural 

integrity that will lead to a limited compromised assembly(ies), isolated or catastrophic collapse of 

critical building anatomy elements that may impact firefighting operations based on proximity, 

exposure and operational phases. This must be anticipated by safety officers, company officers and 

commanders and considered in tactical plans and task assignments both within the interior and exterior 

of the structure. The potential and probability of an isolated or catastrophic structural collapse of a 

masonry perimeter wall or facade, degraded bearing or party walls, degrade interior compartment or 
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ceiling or floor diaphragm would be considered a predominate building performance consideration and 

predictability variable for operations, if identified by command or company officers and assimilated as 

such into the initial on-scene size-up and incident risk assessment process during tactical plan 

development.24,29 

• Type III buildings have a distinctive predictability of performance under fireground operations 

based on inherent building anatomy, design, compartment fire dynamics in the building and the 

correlation of firefighting, intervention, effectiveness and time. They are prone to both interior 

floor collapse and perimeter wall collapse within short operational periods based on influencing 

fireground factors and variables.

• In situations when suspected or actual degraded building, component or structural conditions are 

observed or suspected; or when heavy content clutter, hoarding conditions are experienced or when 

observations indicate significant additional live or dead loads, staging or placement of materials, 

products, debris or other are present that may have an adverse effect on structural loading, integrity 

or structural stability, strength or weight carrying capacity or transfer; THEN immediate actions 

appropriate to the tactical stage(s) of incident operations should be initiated at the company or 

incident command level forthwith and with considerations to the promptness, severity and growth 

of the proceeding anticipated or preceding conditions. 

The on-going operations and concurrent tactical demands associated with incident priorities in 

complex and evolving incidents that involve escalating fire severity, undefined or invalidated fire 

location, extent or location(s) and concurrent demanding civilian life safety strategies, create a 

situation of decreasing managed defenses, high probability for error-likely conditions and operations 

proceeding into a high-risk environment. 

The need for a pronounced understanding of Type III building construction, features and risk profiling 

in reading a building integrated with fluid operational monitoring and assessment is crucial to 

firefighting operations in these building types and associated occupancy risks. This is applicable to row 

house occupancies and fire incidents with prolonged fire suppression activities and when structural 

stability conditions may be subject to adverse influence from identified or suspected conditions. The 

challenge for today’s incident commanders and operating companies on the modern fireground is to 

clearly recognize Type III building performance factors in both conventional Type III buildings and in 

applicable row house occupancies and inherent ordinary construction characteristics fundamental to 

the manner in which a building’s anatomy (and fire conditions) presents itself at an evolving incident 

and to ascertain and distinguish how it will subsequently perform during fire duress and the continuum 

of elapsed incident time.18,20,22,23

Although the size, footprint and design of row houses have lesser fireground complexities than 

typically encountered with larger sized and more complex Type III building and occupancies, 

nonetheless company and command level sensitivity of potential compromising and catastrophic 

structural conditions that may evolve with fire incidents that do not have clearly identified operational 

benchmarks or prompt declarations of fire conditions under control or extinguished must have diligent 

and timely monitoring and decision-making. 
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This is especially true for fireground operations involving transitions from offensive interior operations 

to defensive operational tactics and the transition back again to offensive interior or proximal building 

tactical engagements. These operational periods tend to lead to increasing risk severities and highly 

probable adverse conditions or events to occur that will impact the safety of fire companies and 

personnel. Predicting a potential structural collapse is one of the most challenging tasks facing an 

incident commander at a fire scene. Usually the lack of information on the construction of the building, 

fire size, fire location, fire burn time, condition of the building, fuel load, etc., makes the task nearly 

impossible. 

The incident parameters confronted by operating companies at the fire provided a clear indication of 

demanding operational priorities and task assignments, concurrent operational assignments and 

challenges with determination of fire location, propagation and extent and the effects of time 

compression on the operational period from arrival time at 08:51 hrs., to the time in which adverse 

building performance due to fire exposure precipitated the building collapse at 09:33:15 - :30 hrs.

The presence of observed or suspected heavy contents, hoarding and or clutter are clear signs that 

highly suggest deliberate actions and tactical assignments that maintain or enhance company integrity 

and firefighter safety during the evolving incident. 

Buildings on Fire Risk Assessment Matrix

Levels Severity of Risk

Catastrophic May Result in personnel Death; grave personnel injury; large 

scale destruction and perilous conditions

Critical May cause severe personnel injury, possible death; major 

property loss or significant degraded conditions

Marginal May cause or result in personnel injury, prominent property 

loss or degraded and compromised conditions

Normal

Hazards and conditions are consistent with generally accepted 

Fire Service work practices and operational parameters for 

adequately resourced and trained companies. Operations may

cause or result in some personnel injury; corresponding 

property loss or damage conditions consist with firefighting 

principle & practices

Negligible

Conditions have minimal threat to the safety and wellbeing of 

companies operating under generally accepted Fire Service 

work practices and parameters
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Appendix 2. Figure 1. Buildings on Fire Risk Assessment Matrix 18,19,25,26Courtesy of the 

Command Institute, Center for Fireground Leadership additional information can be accessed at 

http://buildingsonfire.com/buildings-on-fire-risk-assessment-matrix

The building’s anatomy, operational risk and probability of performance in a Type III Row house

structure for operating firefighting personnel and in the management of the incident is suggested as 

Marginal-Critical risk, with a slightly higher emphasis toward the Critical band primarily due to the 

inherent building’s anatomy, construction features and row house design and the increasing degree of 

fire severity and rapid escalation of the incident in a short time span and progression encountered. 

The presence of observed or suspected heavy contents, hording and or clutter are clear signs that 

highly suggest deliberate actions and tactical assignments that maintain or enhance company integrity 

and firefighter safety during the evolving incident. 
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The occupancy’s severity of risk would be considered normal-marginal with the operational 

probability of an adverse event to be Moderate (M) to High (H) resulting in a probability of Occasional 

to Likely event to occur during operational times. The severity and magnitude of fire, building volume 

and size and structural support system characteristics increase the occupancy risk.

The Identified Severity of Risk Level for postulated incident conditions for the fire building suggests a 

defined level of:

Normal-Marginal; Hazards and conditions are consistent with generally accepted Fire Service 

work practices and operational parameters for adequately resourced and trained companies. 

Operations may cause or result in some personnel injury; corresponding property loss or 

damage conditions consist with firefighting principle & practices | May cause or result in 

personnel injury, prominent property loss or degraded and compromised conditions. 25,26

NOTE: The tactical changes from Offensive to Defensive to Offensive however influence the risk 

severity and probability and may nudge it to Marginal-Critical with a Likely operation 

probability and severity. 

• The degree of fire involvement within a compartment(s) and first and second floors, concealed 

space or voids(s), the length of time of fire growth and impingement and concurrent fire 

suppression operations created building conditions that were highly predictable. 

• The probability of a collapse was foreseeable, should have been anticipated and operational task 

assignments adjusted based on the row house floor design, inherent stairwell design and fire 

intensity and influencing hording, heavy content conditions, however this may have been impeded 

by concurrent operational priorities, time compression and concurrent reflex and actions parallel to 

the self-revealing adverse building conditions 

• Structural stability & integrity must be closely monitored or considered a higher risk factor and 

overall operations conducted may be consider at-risk deployments that require fluid and concise 

risk-benefit assessment,

• Investigation or presumption of actual or projected supporting methods for beams, columns or 

secondary roof or diagram supports must be considered since building or structural integrity could 

be compromised. The need for concurrent tactical assignments to readily and promptly open up 

concealed spaces (ceilings, voids, transom areas etc.,) to determine identifiable structural 

assemblies, materials and systems and to determine the extent and severity of flame, heat or 

products of combustion that might be present. 

o This is especially difficult at small square footage row houses when interior room 

configurations and operating room is crowed at best and the primary tactical objective with 

the greatest degree of benefit is time and effective fire suppression to stabilize or mitigate 

the incident. 
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• Concise incident monitoring should be considered based on incident priorities, immediate or 

deferrable operational demands associated with life hazards and fire severity, growth or 

propagation. 

• Pre-incident information, pre-fire plans and building knowledge are mission critical- at a minimum 

for the first-due area response. Prior incident response and operations provide some building 

insight and “reconnaissance data” if it was recognizable and recollectable. 

• Understanding building construction, related engineering, reading key building indictors and 

having the skills to take those observations, comprehend, assimilate and apply predictive modeling 

and projected outcomes to tactical objectives and incident action plans thus increases exponentially 

the safety margin to have successful incident outcomes and not unexpected events. 

The structural collapse potential and probability would be considered a predominate building 

performance consideration and predictability variable for operations, if identified by command or 

company officers and assimilated as such into the initial on-scene size-up and incident risk assessment 

process during tactical plan development, the key is knowledge based reflex that lessens the time to 

recognize key attributes, process their relevancy and act upon the recognition of importance and 

influence on the evolving incident operation.19,22,28

Timeline17

08:50:44 First call 911 Call 

08:51:43 Time of Dispatch

08:55:57 On-location 

09:07:34* Lt. Confers w IC; Operations goes Defensive 

09:07:57 PD Cam: Hose Stream Water applied from Street to 2nd Floor 

09:10:37 PD Cam: NO Water is being applied from Street to 2nd Floor
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Predicting a potential structural collapse is one of the most challenging tasks facing an incident 

commander at a fire scene. Usually the lack of information on the construction of the building, fire 

size, fire location, fire burn time, condition of the building, fuel load, etc., makes the task nearly 

impossible. However, performance indicators, benchmarks and why-variables/determination support 

rapid assessment of assumed or actual factors that can support incident decision-making processes that 

are time-sensitive.22,28

09:10:26 PD Cam: Hose Stream Water applied from Street to 1st Floor 

09:13:45** Operations transition from Defensive to Offensive Interior 

09:33:15-09:33:30 Collapse 

10:48:58 Under Control 

• Initial Fire Suppression during Rescue Operations: 13 minutes: 37 seconds (approx.) 

• Water applied to 2nd floor during defensive OPS: 3 minutes: 53 seconds (approx. +plus)

• Transition to Offensive Interior OPS & Tactics: 19 minutes: 5 seconds (prior to collapse)

• Elapsed Operations time to Collapse: 37 minutes: 18 seconds

The elapsed time of Fire Suppression Operations, the magnitude, severity and degree of fire 

involvement within the structure alone would highly suggest that the elevating risk probability for a 

structural compromise or collapse could be highly expected and possibly imminent.

Whenever operations transition for Offensive-interior to Defensive-exterior and then back to 

Offensive-interior; The overall building risk profile and assessment must be made by Incident 

Command and a determination made on probable building integrity and operational benefits expected 

by placing companies back into a structure and compartments that have been subject to increased fire 

exposure and degradation, impacted by the introduction of large or small caliber hose streams during 

defensive operations and the potential effect of the water introduction, absorption, steam conversion 

and fall-out rate and run-off or containment in rooms, floors, voids or materials. 

The probability for an isolated or comprehensive structural compromise or collapse could be highly 

expected and possibly imminent must be recognized, considered and management based on incident 

priorities and operations demands. 
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Mechanism of Floor Compromise & Collapse, Operational Perspective 

Each building material and component is affected differently (over time) based on their material 

characteristics and fire resistance or vulnerability. This includes such factors as; applied structural load 

intensity, member/component type, member dimensions and boundary type, incident heat flux from the 

fire on the member or assembly, type of construction and effects of temperature rise within the 

structural member on the relevant properties of the member. Live loads introduced into the room 

compartments will also have an influence on fire propagation, severity and exposure on structural 

systems. 

The mechanism and sequence of collapse of the second floor along the approx. centerline of the row 

house and concentrated within the center of the building suggests with high probability the floor 

collapse was precipitated and triggered by the compromise of the interior supporting wood floor joist 

assemblies and the subsequent concurrent succession of collapse of the second floor area between the 

stairwell (Bravo side), the second floor central bedroom area and floor leading to the Delta side wall 

due to the inherent legacy condition of the upper notching of each floor joist, the additional live load 

imposed on the floor system from heavy content and clutter found in the second floor bedrooms, a 

degree of fire degradation of supporting systems from possible flame impingement and exposure and 

the probable addition of water loading from the application of exterior hose streams into the upper 

interior during a brief defensive tactical time period that precipitated the compromise and collapse. 

It is suggested and highly probable the second-floor collapse was triggered by; 

• Overloading and excessive stress and loss of load transfer and carrying capacity of the existing

structural wood floor joist assembly on the Second Floor from existing hoarding, heavy loads 

and clutter; The center bedroom area’s floor area appears to have had significant live loading 

added based on occupant hording, heavy loads and clutter that placed additional stress and load 

transfer as fire extension or exposure from the first-floor fire resulting in probable building 

component and assembly compromise, deterioration and failure that lead to the V-shaped 

collapse along a vulnerable inherent condition. 

• the ensuing compromising floor conditions lead to interior V-shaped floor collapse and the 

progressive succession of compromise of the floor diaphragm commencing from the from 

second floor bedroom inwards towards the second-floor center bedroom area. 

• This resulted in a compromising floor condition at the front second floor bedroom, progressing 

towards the full collapse of the most susceptible second floor area within the center part of the 

second-floor resulting in a V-shaped collapse configuration bring both structural floor joists, 

flooring, partition and hording condition, heavy contents from the rooms above downward into 

the V-shaped collapse and onto the first floor. 

• The central area of the second floor had a series of shorter floor joists that terminated at a 

framing joist that in turn framed the stairwell opening and did not extend to or were pocketed 

into the masonry bearing wall (Bravo Division) 
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• Wood floor joist #11 progressing from the front of the building inward was the last floor joist 

to full span from each bearing wall. 

• The predominate compromising conditions that followed the legacy notch lines in the wood 

joists from building front- inward exhibited signs of load stress, failure and compromise; 

exhibited by the splitting and cracking of the wood joists. The line of structural compromise 

and failure followed the existing gas line and joist notching coincided with an apparent 

structurally weak area and aligned with the axis of the subsequent V-shaped collapse (versus a 

more common single-sided lean-to collapse of the floor diagram and assembly.

• Fire severity (unquantifiable) and extension within the interior ceiling spaces; within the joist 

channels or possible direct impinged from room and contents fire conditions in the absence of 

some of the existing plaster and lath ceiling may have had a contributing effect on the wood 

joists due to fire exposure to increase susceptibility of floor joist compromise with diminishing 

load transfer and load carrying capacity due to loss of wood mass (material charring and burn) 

coupled with the inherent characteristics of the aged wood. 

• It is postulated and suggested that the addition of water introduced from the application of 

exterior hose streams into the upper interior from the street on the Alpha Division during a brief 

defensive tactical time period may have added additional live load (weight) that fall-out rates 

(non-evaporation) of water from the hose streams, would have soaked or saturated into porous 

or other soak-prone clutter and hoarding materials, thus increasing overall live loads that 

further exasperated floor structural stability, increased floor deflection and loss of load transfer 

and load carrying capacity that precipitated the compromise and resulting catastrophic collapse. 

• The existing wood joist notches, creating a vulnerable condition on multiple adjacent floor 

joists, excessive hoarding and heavy clutter adding significant live load to an aged existing 

floor assembly and a varying degree of fire within the interior compartment and structural void 

space area suggest an apparent and highly probable series of conditions that aligned in such an 

manner at this row house fire that provided the sequence of events and mechanism of collapse 

that had adverse consequences to operating companies within the structure. 

Uniqueness and Variances for this Row house and Fire 

• The inherent legacy notching of the existing wood floor joists was a primary contributor to 

create an existing floor system that was highly susceptible and prone to be affected by an 

interior compartment or structural fire or affected by existing or in the addition of live or dead 

loads.

• Existing Hoarding, Heavy Contents and Clutter introduced to the rooms by the occupant 

significantly contributed towards the potential for floor instability and compromise. 

• Deterioration and exposure of the interior rooms and occupancy to environmental exposure and 

elements and their suggested impacts on the building structural components, materials and 

systems may have had a contributing effect on structural stability and integrity of building 

components. Possible degraded load transfer and load capacity of the existing wood floor joists 
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due to age, creep, the effects of loss of moisture content or cyclical exposure to environment 

elements.

• The small size of the row house structure, when impacted by unstable or compromising 

structural stressors may not have the resiliency or resistance to recover from those conditions or 

allow for load transfers and still maintain its structural stability and integrity. 

The alignment of seven separate conditions correlated in this row house occupancy to create a variance 

an irregularity that made this incident and fire operation unique that contributed to the collapse 

conditions and outcome;

• The Existing Hoarding, Heavy Contents and Clutter

• The presence of the legacy notch lines in the wood joists from building front inward created an 

existing condition that made each of the floor joists highly susceptible and prone to the effects 

of fire, heat and failure. 

• Inherent building support systems (Wood joist) degrade or affected material conditions & 

postulated diminished structural integrity 

• Floor joist framing at the stairwell and floor area above that creates a susceptible and prone 

interior condition (to fire) that is inherent in all row houses of this layout type, floor plan and 

configuration (Workingman’s Row House)

• The suggested impact of water introduced during fire suppression affecting hoarding and clutter 

conditions

• The location and extent of fire

• The transitional tactics from Offensive to Defensive to Offensive may not have considered 

structural integrity of critical internal building systems or components that may have been 

subject to varying degradation, damage or compromise and the compounded effects of imposed 

loads on the building from hoarding, heavy content and clutter. 

Generally, when operating companies are confronted with intense fire conditions within a building of 

Type III construction with similar vintage, occupancy use and tenant space configuration; and those 

fire conditions have either impinged or propagated within or along concealed spaces, voids or 

compartment for an extended period of time prior to arrival or during fireground operations, it is highly 

probable and predictable that the structural integrity of the various assembly, supports and structural 

floor joists and wall systems will be compromised and subject to varying degrees of degradation. 

Rapid or prolonged fire extension or exposure within a compartment of floor area of a row house or 

building of Type III construction will result in probable building component and assembly 

compromise, deterioration, failure and collapse.22,26,28,29,30

The probability for isolated and catastrophic building compromise and structural collapse could have 

been readily apparent to all operating personnel and fundamentally recognized as one of the foremost 
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operational considerations during the incident management, command and control and in the overall 

tactical assignment.29,30

The performance characteristics of wood and wood joists when exposed to fire are readily known. 

Thermal degradation of structural wood components and the effects of fire impingement on wood 

members and assemblies responding to heating; decompose or pyrolyzes into volatiles and char. As 

wood burns and chars the loss of wood cross-section (mass) of single or multiple structural wood 

members such as dimensioned wood floor joists continue in direct fire growth phases leading to the 

loss of redundancy capabilities a structural component, assembly or system, resulting in deflection, 

loss of load carrying capacity, compromise or collapse.11,31,32,37,38

• Operational safety considerations during initial or subsequent fire operations when confronted 

with compartment or concealed ceiling or floor space fire impingement, extension and 

structural stability are very fluid demanding command and tactical decision-points that can 

dramatically change in an instant transitioning from benchmarking tactical progress by 

operating companies to that of a highly demanding and rapidly escalating collapse, mayday, 

rapid intervention team deployment and rescue efforts.

• The complete loss of wood cross-section of wood floor joists due to flame impingement results 

in structural compromise of the component to perform as designed to carry and transfer loads 

or to carry attached loads present within this structure at the time of the fire. 

• Uneven deterioration or burn thru of wood floor joists, wall/floor connections, floor joist and 

joist bearing in masonry wall pockets and the possible loss of joist stability would lead to 

structural compromise. This would result in the collapse of the floor joists and the 

corresponding collapse of the floor diaphragm affecting stability and integrity of floor, wall and 

compartment integrity and sustainability. 

V. Graphics and Diagrams 
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Appendix 2 Diagram 3. Cross-Section of Row house 2240 North Colorado Street Graphic 

Courtesy of Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 3a. Typical Wood Floor Joist. Graphic Courtesy of Buildingsonfire.com | C.J. 

Naum
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Appendix 2 Diagram 4. Detail-B Masonry Party Wall and Floor Joist Section & Detail-A Gasline & Notch

Graphic Courtesy of Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 4a. Detail-B Detail-A Gas-line & Notch. Graphic Courtesy of 

Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 5. Row house Floor Joist Plan-Second Floor. 2240 North Colorado Street. 

Graphic Courtesy of Buildingsonfire.com | C.J. Naum
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Appendix 2 Diagram 5a. Detail-C Stairwell Opening Framing and Second Floor Joists. Graphic 

Courtesy of Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 6. Second Floor Collapse Areas. Photo: Analysis Diagram Courtesy of 

Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 7. Cross-Section of Second Floor Collapse Configuration 2240 North 

Colorado Street Graphic Courtesy of Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 8. Second Floor Joist Reconstruction and Collapse Area, looking inward 

from the Alpha Division. Photo Courtesy of Fire Department, Photo Analysis Diagram Courtesy of 

Buildingsonfire.com | C.J. Naum 
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Appendix 2 Diagram 9. First Floor Collapse Zone Reconstruction and Orientation, looking 

inward from the Alpha Division. Photo Courtesy of Fire Department. Analysis Diagram Courtesy of 

Buildingsonfire.com | C.J. Naum Post Collapse and after debris removal from both First and Second 

areas. 
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A. First Floor Front Living Room Area

A1. Primary Collapse Zone under the area of the Middle Second Floor bedroom above. This area had 

the predominate level of collapse severity and catastrophic level of building materials and debris 

pile from the V-Floor collapse profile. This collapse area consisted of both building materials, 

structural components and heavy content (Hording material) furnishing, etc. that created a 

significant matrix of materials, loads and mass. 

B. Masonry Brick Bearing Party Wall- Bravo (B) Division 

C. Second Floor Stair Landing 

D. Masonry Brick Bearing Party Wall- Delta (D) Division 

E. Single Run Straight Stairway from First Floor to Second Floor 

F. NA

G. Typical Wood Floor Joist; Location of Joist #11 spanning from Bravo (B) Division to Delta (D) 

Division Masonry Brick Bearing Party Walls; Approximate Span 16 feet 

H. Second Floor Joist Outline at the Bathroom wall area not involved in the subsequent floor collapse 

I. Second Floor Hallway leading to Rear Bedroom 

J. Second Floor Bathroom 

K. Approximate Centerline of the Row house floor-span & approx. CL of the Second Floor VCollapse Profile

L. Depiction of the directional movement of the second-floor assembly and floor diaphragm failing 

approx. mid-span resulting in a V- Collapse profile

M. Typical Masonry Wall Pockets for Floor Joist bearing (Refer to Diagram 5) 
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Appendix 2 Diagram 10. Second Floor Collapse of Floor Joists Details of Failures, looking 

inward from the Alpha Division. Photo Courtesy of Fire Department. Analysis Diagram Courtesy of 

Buildingsonfire.com | C.J. Naum 
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Appendix 2 Photo 5. Front First Floor Looking inward to Collapse Zone 1st Floor. Photo 

Courtesy of Fire Department. Hording, Heavy Content and Clutter from Second Floor Rooms into the 

V-Shaped Floor Collapse. Photo Courtesy of Fire Department.
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Appendix 2 Photo 6. Front First Floor Looking inward to Collapse Zone and Second Floor 

Debris Heavy Content. Photo Courtesy of Fire Department. Foreground: Compromised front 2nd

Floor Bedroom joists V-pattern. Background: Beyond the decorative wood “beam” is the 

catastrophic full V-pattern collapse of the Center 2nd Floor Bedroom 
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Appendix 2 Photo 7. Front First Floor Looking inward to Collapse Zone and Second Floor 

Debris Heavy Content. Photo Courtesy of Fire Department. 

Appendix 2 Photo 8. Second Floor Collapse of Floor Joists. Photo Courtesy of Fire Department.
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Appendix 2 Photo 9. Second Floor Collapse of Floor Joists. Photo Courtesy of Fire Department . 

Appendix 2 Photo 10. Second Floor Collapse of Floor Joists at Fireplace. Photo Courtesy of Fire 

Department.
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Appendix 2 Diagram 11. Reduction in Wood Floor Joist Component Breadth and Depth over 

time. Graphic Courtesy of Buildingsonfire.com | C.J. Naum. Adapted from AWC Technical Report 

#10 (2012) 

Appendix 2 Diagram 12. Charring Effect on Wood Floor Joist Component and Cross Section 

Graphic Courtesy of Buildingsonfire.com | C.J. Naum 
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Appendix 2 Photo 11. Fire Conditions Pre-Arrival of FD Time: 08:55:20. Photo: Courtesy of Fire 

Department (from resident video).
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Appendix 2 Photo 12. Fire Conditions upon FD Arrival. Photo: Courtesy of Fire Department
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Appendix 2 Photo 13. Initial FD Operations; Transitional Attack Time: 08:57:49. Photo: Courtesy 

of Fire Department (video taken by area resident across the street). 

 
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Appendix 2 Photo 14. Initial Fire Attack View from Police Body Cam Time: 09:05:16. Photo 

Courtesy of fire department obtained from Police Body camera 
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Appendix 2 Photo 15. Transitional Fire Attack from Offensive to Defensive Operations View 

from Police Body Cam Time: 09:07:57. Photo Courtesy of fire department obtained from Police 

Body camera

NOTE: 

• Incident Command orders all companies out of the occupancy

• Introduction of Water Stream via hoseline from street exterior into front second floor window 

• Note degree of smoke, density and colorization 
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Appendix 2 Photo 16. Transition back to Offensive Fire Operations and Initial Structural 

Collapse View from Police Body Cam Time: 09:33:28. Photo Courtesy of fire department obtained 

from Police Body camera. 

VI. Appendix Report References 

1. Philadelphia Fire Department, Health and Safety Department Provided Internal Information; Incident #18-0060250, 

Box 7743, 2240 North Colorado Street Fire

2. National Building Codes Recommended by the National Board of Fire Underwriters (1900-1915)

3. NFPA [2012] NFPA 220 Standard on Types of Building Construction, 2012 ed. Quincy, MA: National Fire Protection 

Association 

4. City of Philadelphia, Philadelphia Planning Commission, Rowhouse Manual (2008); 

https://www.phila.gov/CityPlanning/resources/Publications/RowhouseManual_Final.pdf

5. History of the Philadelphia Rowhouse http://philadelphiaencyclopedia.org/archive/row-houses/

6. Donna J. Rilling. Making Houses, Crafting Capitalism: Builders in Philadelphia, Philadelphia: University of 

Pennsylvania Press. 2001.

7. Naum, C.J. [2012] Building Anatomy: Types and Classifications Firehouse Magazine, July 2012
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8. Architecture and Building Construction, International Correspondence Schools, Scranton, PA [1899 & 1902] 

Carpentry Section 9-2 https://archive.org/details/textbookonarchit02inte

9. U.S. Department of Agriculture Forest Service American Woods—FS-239 Revised October 1970 

https://www.fpl.fs.fed.us/documnts/usda/amwood/239hemlo.pdf

10. USDA Forest Products Laboratory (FPL) (2010) Wood Handbook: Wood as an Engineered Material FPL-GTR-190 

11. NFPA Fire Protection Handbook, 13th edition (1969) National Fire Protection Association

12. Handbook of Building Construction Data, G. A. Hool (1929) 

13. Architectural Graphics Standard, 6th Edition [1970] American Institute of Architects 

14. HUD, Residential Structural Design prepared by the NAHB Research Center, Inc., for the U.S. Department of Housing 

and Urban Development, Washington, DC, 2000

15. U.S. Department of Housing and Urban Development Office of Policy Development and Research REVIEW OF 

STRUCTURAL MATERIALS AND METHODS FOR HOME BUILDING IN THE UNITED STATES: 1900 to 2000

16. Correspondence from NIOSH FFFIT, S. Miles to Philadelphia FD Dated May 9, 2018

17. Philadelphia Fire Department, Health and Safety Department Internal Incident Overview Presentation After Action 

Review Incident #18-0060250, Box 7743, 2240 North Colorado Street Fire, and/or correspondence from the PFD 

Health and Safety Dept. Staff. 

18. Naum, C.J. [2012] Predictability of Performance of Buildings on Fire, Firehouse Magazine, June 2012, pp. 87-89

19. Naum, C.J. [2013] Reading the Building and Predictable Performance Indicators of Buildings on Fire. Fire Department 

Instructors Conference Proceedings, Indiana, April 2013

20. Naum, C.J. [2013] Reading the Building: The Importance of the Size-Up Firehouse Magazine, April 2013, pp. 128-131

21. Naum, C.J. [2012] Occupancy Profiling and Buildings on Fire Risk Assessment Matrix, Buildingsonfire.com 

additional information can be accessed at http://buildingsonfire.com/buildings-on-fire-risk-assessment-matrix

22. Naum, C.J. [2014] Adaptive Fireground Management and Operations. National Professional Development 

Symposium, National Fire Academy, Maryland, June 2014

23. Naum, C.J. [2015] Building Construction for Today’s Fire Service 

Firehouse Magazine, January 2015, pp. 74-75 

24. Naum, C.J. [2015] Today’s Building: What Happens When They Burn 

Firehouse Magazine, February 2015, pp. 74-77 

25. Buildings on Fire Risk Assessment Matrix Courtesy of Buildingsonfire.com and the Command Institute, additional 

information can be accessed at http://buildingsonfire.com/buildings-on-fire-risk-assessment-matrix

26. National Institute of Occupational Safety and Health, Death in the Line of Duty: Career lieutenant and fire fighter 

killed and two fire fighters injured by wall collapse at a large commercial structure fire - Pennsylvania. F2012-13 

(2012)

27. National Institute of Occupational Safety and Health, Death in the Line of Duty: 4 Career fire fighters killed and 16 fire 

fighters injured at commercial structure fire –Texas. F2013-16 (2013) 

28. Naum, C.J. [2016] Operational Considerations at Buildings of Ordinary and Heavy Timber Construction. Fire 

Department Instructors Conference Proceedings, Indiana, April 2016

29. Naum, C.J. [2015] Establishing Collapse Zones at Building Fires, Firehouse Magazine, April 2015 

https://www.firehouse.com/operations-training/article/12054302/establishing-collapse-zones-at-building-fires

30. Naum, C.J. [2015] Buildings on Fire: Collapse Zones: Building Characteristics & Occupancy Risks, Firehouse 

Magazine, June 2015

31. American Wood Council (AWC) Technical Report N0.10 [2014] Calculating the Fire Resistance of Exposed Wood

32. American Society for Testing and Materials, ASTM E119 Fire Tests of Building Construction and Materials ASTM 

Fire Test Standards, ASTM, Philadelphia, PA, 

33. Madsen, B. “Moisture Content- Strength Relationships for Lumber Subject to Bending” University of British 

Columbia

34. Gerhards, C. C [1980] “Effect of Moisture Content and Temperature on the Mechanical Properties of Wood: An 

Analysis of Immediate Effects” 
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35. Nolan, S., [2002] “New Loads for Old Structures” The Journal of the Entertainment Services and Technology 

Association 

36. Cavalli, Cibecchini, Togni, Sousa, [2016] “A Review of the Mechanical Properties of Aged Wood and Salvaged 

Timber” https://www.researchgate.net/publications/299978150

37. Structural Integrity During Fire, Fire Protection Handbook 18th Edition, A.E. Cote

38. SFPE Handbook of Fire Protection Engineering, 2nd Edition (1995) 

39. Bland, K.E., “Behavior of Wood Exposed to Fire: A Review and Expert Judgment Procedure for Predicting Assembly 

Failure,” Master’s Thesis, Worcester Polytechnic Institute, Worcester, MA, May 1994.

40. Underwriters Laboratories “Report on Structural Stability of Engineered Lumber in Fire Conditions”., Project Number: 

07CA42520 Underwriters Laboratories Inc., Northbrook, IL. September 30, 2008

41. Klein, G., (2008) Naturalistic Decision Making 

http://www.ise.ncsu.edu/nsf_itr/794B/papers/Klein_2008_HF_NDM.pdf

42. Naum, C.J. [2009] Operational Safety Considerations at Ordinary & Heavy Timber Constructed Occupancies. 

http://www.firegroundleadership.com/2010/12/03/operational-safety-considerations-at-ordinary-and-heavy-timberconstructed-occupancies-training-download/

VII. Additional Information Provided by Chief Naum

Comments 

In many building and structures and various residential and commercial occupancies that have had a 

long-life cycle (decades or in excess of 100 years plus) the likelihood of renovations and alternations 

affecting predictable building performance and fireground operations should be anticipated and 

considered in any incident action plans, tactical plans and task assignments. 

Maintenance, age and damage and the desire for modernization usually results in renovations and 

alternations of many commercial and residential interiors. As was the case here, the ceiling system 

present at the time of the fire had multiple layers of materials added over time that consisted of original 

plaster and lath attached directly to the dimensioned lumber ceiling joists, wood tongue & grove panel 

boards, and gypsum wallboard. 

Building materials, finishes, construction systems and assemblies will react differently and at different 

intervals when exposed to elevated temperature gradients and will individually or collectively react to

fire, heat and physical load stresses, transfers and resiliencies leading to restraint, movement or loss of 

material integrity.

Each building material and component is affected differently (over time) based on their material 

characteristics and fire resistance or vulnerability. This includes such factors as; applied structural load 

intensity, member/component type, structural member dimensions and boundary type, incident heat 

flux from the fire on the structural member or assembly, type of wood construction and effects of 

temperature rise and impingement on the structural member or assembly and the relevant properties of 

the members. 
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Certainly, at the divisional and company supervisory level, task assignments must consider the 

implementation of area safety risk surveys and focused observations to identify subtle or obvious 

building anatomy, structural, architectural, engineering or aesthetic conditions or features that may 

have an impact on assignments, tasks or the simple presence in an area or establishment of exclusion 

zone restricting or limiting personnel access or operations. 

This must be a practiced and learned skill set, since the implementation of such assessments and 

observations must be done in rapid and timely succession when confronted with highly demanding and 

time limiting incidents with both escalating fire extension and severity and civilian life safety 

considerations. 

Anticipate Compromise and Collapse in Type III buildings with minimal to moderate fire in 0-15-

minute elapsed time spans; 

Expect Compromise and Collapse in Type III buildings with moderate to extending fire in 15-25-

minute elapsed time spans, Plan, Prepare and Execute with Critical Thinking and Conservative-Biased 

Risk Management, Tactical Discipline and Tactical Patience.12,18,19,20 

Appendix 2 Diagram 13. Compromise and Collapse Time & Benchmarks. Provided with 

Permission from the Command Institute, Center for Fireground Leadership. Fireground 

Operations Training Series on Type III & IV Buildings. Graphic Courtesy of C.J. Naum 
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Appendix 2 Diagram 14. Compromise and Collapse Time & Benchmarks. Provided with 

Permission from the Command Institute, Center for Fireground Leadership. Fireground 

Operations Training Series on Type III & IV Buildings. Graphic Courtesy of C.J. Naum

General Insights and Learnings 

• Intuitive, tactically-driven versus risk assessed operations where rapid deployment or 

operational complacency may lack in critical thinking when confronted with an active of post 
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fire in a mixed occupancy Type III building space - that may require alternate tactics and 

increased operational safety considerations.

• Rapid Tactical Decision-making leading to Tactical driven operations must include Risk-Based 

influences 

• Occupancy Risk Considerations versus Occupancy Type precursors 

• Understand building construction, fire dynamics and company capabilities

• Understand the effects of fire on structural stability and resiliency of Type III buildings of 

various vintage and architectural styles

• Lack of building knowledge, ineffective profiling and size-up assessment, inadequate 

situational awareness, diminished sensitivity to time, intervention and compromise-collapse 

susceptibility and negligible formulation of predictable building, occupancy, systems feature 

effects can lead to adverse fireground conditions, operations and command compression. 

• Understand a building’s anatomy, occupancy risks and the characteristic of the building’s 

internal compartments (occupied rooms and space use) they are integral to effective and 

efficient firefighting operations within buildings on fire and are essential for all phases of fire 

engagement and suppression.

• The probability for isolated and catastrophic building compromise and structural collapse in 

Type III buildings should be readily apparent and fundamentally recognized as one of the 

foremost operational considerations during the incident management, command and control 

and in the overall tactical assignment in structures fires in buildings of ordinary construction

• Anticipate Compromise and Collapse in Type III buildings with minimal to moderate fire in 

0-15-minute elapsed time spans; Expect Compromise and Collapse in Type III buildings with 

moderate to extending fire in 15-25-minute elapsed time spans, Plan, Prepare and Execute with 

Critical Thinking and Conservative-Biased Risk Management, Tactical Discipline and Tactical 

Patience 

• Conduct a Risk Assessment Profile and Size-up of the Building and Fire Conditions at all 

incidents

• Identify and manage Interior and Exterior Collapse Management Zones 

• Incident Commanders must be cognizant of the span of operational time and the effects of fire 

dynamics on critical building systems and assemblies and the relationship to building integrity, 

compromise and collapse

• Identify secondary collapse potential and don’t allow tunnel vision, distractions or command 

compression to disregard intervention or restriction before they occur; the results could be 

detrimental 

• Understand the concept of building volume, space, connectivity, fire load package, occupancy 

load risks, and fire dynamics; they drive tactical options and selection

• Understand building, system, assembly, component; structural integrity and collapse 

predictability, precursors and operational considerations; they lead to preparedness, vigilance 

and actions before bad things occur 

• Type III Buildings require prompt, aggressive and coordinated exploratory opening of ceiling 

spaces, transoms, concealed spaces (floors, ceiling, roofs, plenums, walls, shafts etc.) to 
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determine assumed or actual structural systems, assemblies and location, severity, magnitude 

and impacts of fire

• Progress reports and cursory status reporting by company may not identify critical structural 

integrity considerations, assessment profiling or risks 

• Building type, style, size, age, condition and any subsequent alterations, renovations and 

modifications may alter expected building conditions or features and performance under 

fireground operations. 

• With specific construction systems, features and vintage, various types and styles of Type III 

buildings and occupancies have defined predictable performance factors-that when recognized, 

assimilated and applied to adaptive tactical models for operations, a favorable balance of risk 

and incident demands may be correlated by command and company officers to achieve both 

operational excellence and mission requirements. 

• Learn to Read the Building and comprehend what you see, with required actions; don’t let the 

experience of past successes disguise and mask the distinctive characteristics of the building 

• Incident commanders and company officers should develop skill sets in Building Construction, 

Collapse indicators and Reading the Building profiling to support fireground observations and 

decision making. 

• Develop and implement Fireground risk assessment consideration for structural collapse and 

protocols for establishing and managing collapse zone and exclusion areas.

• Identify and implement alternate of adaptive tactical procedures or protocols for buildings in 

your jurisdiction that have inherent structural collapse characteristics and may be prone to 

collapse or comprise during fireground operations. 

• The recognition for and timely formation of effective collapse zones for both primary and 

secondary collapse must be a principal strategic fireground consideration when suspected or 

apparent collapse indicators are identified and assessed; Anticipate, Expect and implement 

controls proactively.

• All personnel should be trained to recognize subtle or readily apparent collapse indicators and 

be able to read the building and comprehend collapse considerations for primary and secondary 

collapse conditions for buildings in the jurisdiction.

• The design and implementation of a placarding system to identify high risk and high frequency 

collapse prone buildings to support timely size-up and IAP development for initial arriving 

companies. 

• The incident commander should establish and manage Collapse zone early in an incident to 

preclude time delays and reactionary measures that place personnel in risk prone settings. 

• In buildings of Type III Ordinary (URM or RM) or Type IV Heavy Timber construction 

including Mill and Semi-Mill construction, Incident command must be highly focused to the 

high probability of internal and external collapse, establish and control collapse zones in 

multiple divisions and possible exposure properties and expect collapse to occur.

• Catastrophic floor system-diaphragm and perimeter wall compromise or failure can occur 

without warning just as companies are commencing with initial interior operations within a 

building or space or during overhaul operations. Other historical incidents in which fires and 
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subsequent collapse of roofs, floors and wall systems that led to LODDs provide additional 

lessons learned.

• Commanders and Officers recognize and plan for the possibility of adverse latent problems and 

inherent risks even when projecting and expecting successful outcomes.

Reading the Building & Predictive Indicators 

Of the many variables and factors that influence the fireground during the conduct of fire suppression 

operations, there are three (3) integral factors that can have the greatest impact on operational integrity, 

effectiveness and firefighter safety: (1) The Building; (2) The Compartment, and (3) The 

Company.22,29,30

Lack of building knowledge, ineffective building and fire profiling and size-up assessment, inadequate 

situational awareness, diminished sensitivity to time, intervention and compromise-collapse 

susceptibility can lead to adverse fireground conditions, operations and command compression.23,24

• The ability to accurately identify key building attributes and features or conditions- concurrent 

with compartment fire conditions; process that data -comprehend, synthesize and prioritize key 

aspects and correlate that to a fluid risk profile model that must be acted upon tactically within 

a compressed timeframe with company level resources is mission critical during fireground 

operations. 

• Building features, Tenant space occupancy proximity, connectivity of these tenant spaces 

present influencing operational considerations that could affect incident operations in terms of 

access, size-up and assessment, smoke tunneling, compartment ventilation, single or multiple 

flow paths routes, physical compartment configurations and influence of size (SF) and volume 

(CF) for tenant space(s) and concealed spaces with impacts on ventilation-limited or fuellimited conditions, structural integrity and collapse considerations, tenability for personnel 

within the space and connectivity of individual tenant spaces and fire dynamics.

• The probability for isolated and catastrophic building compromise and structural collapse based 

on fireground conditions in a Type III building should have been readily apparent at a much 

earlier time frame to all operating personnel (command and company levels) and should have 

been fundamentally recognized as one of the foremost operational considerations during the 

initial course of incident management, command and control. 

• The presence and configuration of actual or presumed unprotected steel structural components 

is a predictive indicator for higher risk and higher probability of compromise or collapse when 

combined with actual or postulated fire dynamics and behavior in tenant spaces and room 

compartments. 

• The presence of various construction requires an understanding of the presumed or known 

structural support system, the size and volume of the compartment fire, the intensity and 

propagation of flame and heat, ventilation features (shafts, vertical chases and ventilation shuts, 

vents, louvers, soffits etc.) and the consideration of time element.
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• The need for augmented and adequate fire suppression capabilities in terms of sustained water 

delivery, stream penetration and reach and adequacy of flow rates based on open compartment 

fire conditions or presumed/actual concealed fire areas must be assessed, monitored and 

adjusted accordingly.

Reading the Building: Risk and Severity Considerations19,20

• Building Construction System and Type

• Building Age, Vintage and Condition 

• Building Use and Function 

• Likelihood of renovations and alternations affecting operations (building life span)

• Building Size and Volume: Tenant Spaces and individual Occupancy Compartments (Apts.) 

• Time of Alarm 

• Location and Progression of Fire and Fire Dynamics 

• Degree of tenant space compartmentation: connectivity of concealed spaces and compartments and 

high probability for unstopped concealed spaces, voids and plenum spaces and the effect on 

structural systems, assemblies (steel, wood and masonry)

• Inherent Structural Compromise and Collapse potential-internal due to unprotected construction 

systems, materials and structural assemblies (steel, wood and masonry)

• Structural Collapse characteristics of Steel I-beams, Steel (or cast-iron) Columns and Wood Joist 

Systems, Masonry Assemblies; structural integrity and collapse considerations

• Physical arrangement of tenant occupancies and the relationship of upper floors and apartments 

(compartments) and impacts from smoke tunneling, compartment ventilation, single or multiple 

flow paths routes, ventilation-limited or fuel-limited conditions, tenability and connectivity of 

spaces-fire dynamics

• Fire Loading and potential for significant Heat Release Rates/effects on fire suppression based on 

commercial-retail tenant occupancy and building use

• Identifiable and Measurable Safety parameters 

• Adequacy of Fire Flow Rates based on postulated fire growth and selected tactics and the ability to 

place into service adequate handlines with effective and sustainable delivery application rates

• Probability of Rapid Fire Travel and Extension growth 

• Effect of fire impingement (extent and duration) and exposure to structural systems, components or 

assemblies that affect both internal or external building integrity

• Uncertainty of Civilian Occupancy Load 

• Uncertainty of Civilian Occupancy Reaction Time and Responsiveness to Emergencies 

• Probability of Fire Department Life Hazard and Risk Threat 

• Resource Intensive Deployment Requirements 

• Identified Severity of Risk Level and Acceptability of Risk to Organization 

Based on potential severity and urgency factors given a fire of any great magnitude or other initiating 

event, this would require judicious and thoughtful pre-fire planning at the company or Battalion level 
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to not only identify postulated incident events and occurrences, but to also assess the potential 

demands for escalating incidents, resource needs and suggested incident management scenarios, 

situations and consequences. 

The probability for an escalating multiple alarm fire occurring in this building and occupancy creating 

limiting conditions of operations, high resource demands, operational severity, urgency and escalating 

incident growth issues were highly probable and could be expected based on fire location within a 

given tenant location, the occupancy use of that tenant space, the time of day of the incident and the 

operational readiness and availability of the fire department to respond, deploy and intervene. An 

understanding and application of inherent building system anatomy, presenting fire conditions upon 

arrival combined with increased situational awareness and application of predictable building 

performance considerations based on the building’s construction, may have provided additional 

considerations for an enhanced fire suppression operation.7,18
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Appendix 2 Sketch 1. NAUM Report.
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Appendix 2 Sketch 2. NAUM Report.
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Appendix 3

National Institute of Standards and Technology

Findings from the Materials and Structural Systems Division

Engineering Laboratory

Inorganic Materials Group (Mr. Paul Stutzman)

100 Bureau Drive, Gaithersburg, MD 20899-8615

Description provided by NIST:

I received two bricks, one (A) that had a light-colored mortar adhered to the top faces and a second (B) 

that had a dark material on the top face. 

The binder on A is a lime-based mortar with no evidence of portland cement as part of the binder from 

scanning electron microscopy with X-ray microanalysis and X-ray powder diffraction (XRD). A SEM 

image of mortar from A (Mortar_2_SE.jpg) shows the mottled, porous binder and that it is 

chemically calcium and magnesium with little silicon or aluminum. The XRD data shown in 

Mortar_A_Binder.png shows it is comprised primarily of calcite (the black stick figures in the peaks is 

a reference for calcite) and quartz. Generally portland cement hydration products would contain some 

portlandite (Ca(OH)2) which would have a peak at 18 degrees two-theta. Given this mortar is 

relatively old the portlandite may have carbonated to calcite however, SEM imaging does not show 

any of the textural characteristics of a portland cement mortar.

The darker material of B appears to be a soil based upon the clay minerals (chlorite and possibly 

kaolinite, illite/mica) in the binder (the glue binding the sand grains) based upon X-ray powder 

diffraction, but also contains minor black fragments and what appear to be slag or ash grains. The dark 

material on B is very friable relative to the mortar on specimen A and does not contain any portland 

cement. The XRD patterns of a clay fraction (size separation to remove the sand-size particles, 

file=B_Binder_clay_Fraction.png) shows peaks at the low angle region typical of common clays found 

in soils as mentioned earlier (the first three peaks from the left side are characteristic of these clays).
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Appendix 3 Diagram 1. Mortar A
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Appendix 3 Photo 1. NIST Report to NIOSH, Micro Photo, Brick A.
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Appendix 3 Diagram 2. Graft of mortar composition, NIST Report to NIOSH. B Binder clay 

fraction.
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Appendix 3 Photo 2 .NIST Report to NIOSH, Mortar 2 SE.
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Appendix 3 Photo 3. NIST Report to NIOSH, Mortar B SEM 1.
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Appendix 3 Photo 4. NIST Report to NIOSH, Mortar A SEM 1.
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Appendix 3 Diagram 3. Graft of mortar composition, NIST Report to NIOSH.