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Brick Gable End Collapses at a Residential Fire Killing a Fire Captain and Seriously Injuring Three Other Firefighters – Illinois						Print
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										FF ShieldDeath in the Line of Duty...A summary of a NIOSH fire fighter fatality investigation
F2019-03 Date Released: November 1, 2023

Executive Summary
On March 5, 2019, a brick gable end (rafter) collapsed during a residential structure fire, killing a 37-year-old career fire captain. Three other firefighters were seriously injured during the collapse. At 1615 hours, the county 9-1-1 received a telephone call from the homeowner stating their home was on fire. Engine 2311 (E2311) and Engine 2312 (E2312) were dispatched from county fire protection district (FPD) 23. The fire chief from the volunteer FPD 23 drove E2311 to the incident. While enroute the fire chief requested automatic aid from two independently operated county fire departments: county FPD 16 (volunteer) and fire department (FD) 22 (career).
At 1627 hours, E2311 arrived on scene. Flames and smoke were venting through the roof on Side Bravo, with a partial roof collapse. Both the occupants were out of the house upon arrival of the fire department, but multiple caged animals remained in the Side Alpha/Bravo corner of the home. The fire chief assumed Command as the incident commander (IC) and declared a defensive strategy, although this was not heard or received by dispatch or responding firefighters. Firefighters from FPD 23 pulled and began flowing water from a 13⁄4-inch handline from E2311 to the Alpha/Bravo corner (Photo above). E2312 laid a 5-inch supply line from the nearest hydrant to E2311. The captain from E2312 conducted an incomplete (2700) size-up in a counterclockwise direction (Side Alpha, Side Delta Side Charlie), but findings from this incomplete walk-around were not reported to the IC.
At 1632 hours, the IC requested dispatch to send county FPD 14 to the scene. At 1633 hours, firefighters from E2311 initiated an interior attack through the front door on Side Alpha, but excessive storage in the foyer limited advancement to only 5 to10 feet. They directed water into the Side Bravo first floor and Side Charlie ceiling and attic space.
County FPD 22 (E2211, fire chief via POV) arrived on-scene and were assigned to the Sides Bravo and Charlie with the fire chief from FPD 22 assigned as the Side Bravo/Charlie sector chief. After pulling a 21⁄2-inch hoseline and a 13⁄4-inch handline from E2311 and flowing water, E2211 radioed E2311 they had no water pressure. The IC, and the lieutenant operating E2311, began to investigate the cause of the low water pressure.
At 1647 hours Engine 1412 (E1412) from county FPD 14 arrived on-scene and initially staged on Side Alpha. After a partial walk-around, the captain of E1412 discussed the possibility of a below grade Side Bravo walk out basement fire with the IC and the Side Bravo/Charlie sector chief. They discussed accessing the basement by cutting open the lower-level garage door with a K-12 saw (a saw fire departments frequently use to cut openings into a variety of materials). At 1656 hours, E1412 was at the lower-level garage doors with a K-12 saw.
At about 1655 hours, the assistant chief from FPD 16 became concerned that the entire roof could collapse. He told FD 22’s assistant chief to “watch those guys’ working on Side Bravo. The assistant chief from FD 22 then became concerned about the stability of the Side Bravo bricked gable rafter which extended to the roof ridge. The roof supporting the gable had burned away. These concerns were voiced to the Side Bravo/Charlie sector chief who felt the brick wall supporting the gable looked stable with no bulging, bowing, cracking, or spooling. Therefore, no collapse zone was established. NIOSH received conflicting information about whether these collapse concerns were voiced to the IC.
At 1656 hours, the IC radioed that the basement was about to be opened. It took a few minutes for the five firefighters operating and assisting with the K-12 saw to open the lower-level garage door. At 1703 hours, the roof’s triangular brick gable rafter suddenly “tipped over” falling as a single sheet onto the driveway; a perimeter collapse. The gable fell approximately 21 feet before striking four firefighters from E1412 and E2212 working to open the garage door on Side Bravo. The fifth firefighter working on Side Bravo was not hit or injured.
A Mayday was called. On-scene firefighters rushed to assist as the IC radioed county 9-1-1 to send more ambulances to the scene. The captain from E1412 was unconscious and not breathing. He was brought out of the collapse zone where cardiopulmonary resuscitation (CPR) was initiated. At 1718 hours, the captain was transported to a local hospital with a police escort. At 1750 hours, the captain was pronounced deceased in the emergency department (ED) by the attending physician due to thoracic and cervicospinal trauma. On-scene paramedics stabilized the three remaining seriously injured firefighters who were subsequently transported to the ED. One was hospitalized, two were treated and released; these three firefighters survived.

Contributing Factors
*Lack of a collapse zone*
*Lack of situational awareness*
*Incomplete scene size-up*
*Incomplete risk assessment and incident action plan*
*Incomplete duties of command safety*
*Task saturation of the IC*
*Lack of an IC aide*
*Lack of an incident safety officer*
*Inadequate water supply*
*Inconsistent live fire training among volunteer firefighters*
*Lack of a personnel accountability system*Key Recommendations
*Fire departments should ensure the IC establish collapse zones including exclusion zones or no-entry zones at defensive fires as needed due to dangerous or hazardous conditions*
*Fire departments should ensure firefighters are trained in situational awareness, personal safety, and accountability*
*Fire departments should ensure the first arriving officer conducts a detailed scene size-up*
*During initial fire ground operations, fire departments should ensure the IC conducts a risk assessment, develops a risk management plan, and incorporates these into an incident action plan (IAP). The IAP needs to be clearly communicated to responding personnel and, for more extensive incidents, a tactical worksheet may be required*
*Fire departments should ensure their IC incorporates the principles of command safety into the incident management system*
*Fire departments should develop a process to prevent task saturation of ICs during complex or multi-alarm incidents*
*Fire departments should make available an IC aide during working structure fires*
*Fire departments should ensure that an incident safety officer, independent of the IC, is appointed at working structure fires*
*Fire departments should ensure that an adequate sustainable water supply is established and maintained. Firefighters should have periodic training on hydrant operations*
*Fire departments should ensure that all members engaged in emergency operations receiveannual training and evaluation on fireground operations including live fire training to improveproficiency during fireground operations*
*Fire departments should utilize a functional personnel accountability system, requiring acheck-in and check-out procedure with the designated accountability officer or IC.*Read the full report
Report Slides
							
					
							Last Reviewed:  November 17, 2023						Source: 	National Institute for Occupational Safety and Health
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