NIOSH Fire Fighter Fatality Investigation and Prevention Program

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F2019-18 MA 

Career Lieutenant Dies and Four 

Firefighters Injured at a 3-Story 

Multi-Family Residential 

Occupancy–Massachusetts
NIOSH Fire Fighter Fatality Investigation and Prevention Program 2

Summary

• A 39-year-old career lieutenant 

died, and four other firefighters 

were injured while fighting a 

multi-family residential structure 

fire. 

• At 01:00:06, Fire Alarm 

dispatched Car 4, Engine 15, 

Engine 2, Engine 13, Engine 12, 

Ladder 5 Ladder 3, Rescue 1, and 

Ladder 4 (rapid intervention 

team (RIT)) for a fire with 

occupants on the 2nd floor and a 

baby on the 3rd floor. 

• At 01:02:27, Engine 15 arrived on 

scene and reported a Type V 

structure with heavy fire showing 

on the 2nd floor of Side Bravo.

Photo courtesy of the fire department.

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NIOSH Fire Fighter Fatality Investigation and Prevention Program 3

Summary

• At 01:03:37, Car 4 arrived and had assumed Command. 

Engine 2 arrived and was assigned to stretching a supply line 

from a hydrant to Engine 15. 

• Command reported smoke showing from the roof and 3rd

floor Side Bravo and requested a 2nd alarm. 

• At 01:14:41 Rescue 1-Team 2 encountered heavy fire on the 3rd

floor hallway Side Alpha and Engine 2 knocked down fire in 

the front stairwell on their way to assist Rescue 1. 

• At approximately 01:19:16, Engine 13 made it to the doorway of 

the room of the fire origin which was the bedroom midway 

on the 2nd floor on the Side Bravo.

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2nd Floor Plan. Note: The origin of the fire started in the large bedroom.
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Summary

• The lieutenant stated they were on Division 3 with fire all around 

them, exit blocked, and they did not have a personnel 

accountability report (PAR). 

• At 01:23:56, Ladder 5 re-entered the structure and went to the 3rd

floor. At 01:27:36, the lieutenant from Ladder 5 called a Mayday. 

• Command acknowledged the Mayday and sent in a rapid 

intervention team (Ladder 4) to the 3rd floor. 

• Command advised the lieutenant there was a ladder (Ladder 3 

platform) on 2nd floor Side Bravo. 

• At 01:28:37, the lieutenant stated they were trapped, it was very 

hot, and they needed a hose line. 

• The lieutenant and chauffeur of Ladder 5 had temporarily taken 

shelter in a shed on the porch at the Bravo/Charlie corner. 

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NIOSH Fire Fighter Fatality Investigation and Prevention Program 6

Summary

• At approximately 01:32, the lieutenant 

of Ladder 5 grabbed the chauffeur of 

Ladder 5 and pushed him out of a 

window on the 3rd floor of Side Charlie.

• He fell approximately 15 feet, hitting 

an awning over the basement mandoor, then rolled off and fell about 

another 10 feet to the ground. 

• At 01:34:03, Car 400 notified Command 

that a civilian stated a firefighter was 

lying in the backyard (Side Charlie). 

• At 01:34:21, Engine 5 located the Ladder 

5 chauffeur on the ground and 

requested EMS.

• Over next 23 minutes, Ladder 4 (RIT), 

Ladder 1, Rescue 1-Team 2, Engine 12, 

Engine 4 and Car 2 encountered heavy 

fire while trying to get to the 3rd floor 

and locate the lieutenant. 

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3

rd floor porch window Ladder 5 firefighter went out of and 

initially landed on awning over basement door.

(NIOSH Photo)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 7

Summary

• Crews struggled to access the 3rd floor 

due to limited space in the enclosed 

stairwell that had high heat, zero 

visibility due to smoke, and the added 

obstruction of a hose line that had 

burned through and was gushing 

water. 

• At 02:07:20, Rescue 2 (Rescue 1-Team 2 

and Ladder 4) reached the 3rd floor of 

the Side Delta/Charlie stairs, but debris 

blocked the entrance to the porch. 

• A member of Rescue 2 breached the 

wall to the porch. 

• Several minutes later, after crawling 

across the porch, Rescue 2 made it to 

the porch shed door where the 

lieutenant had returned to take shelter. 

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Side Delta stairwell second floor where first entry hose line burst.

(NIOSH photo)
NIOSH Fire Fighter Fatality Investigation and Prevention Program 8

Summary

• Rescue 2 could hear the 

lieutenant’s personal alert 

safety system sounding. 

• Rescue 2 breached the shed 

door and found the lieutenant. 

• Rescue 2 accompanied by 

Ladder 1 located and grabbed 

the lieutenant. 

• Crews from Ladder 4, Ladder 1, 

and Engine 4 moved the 

lieutenant down the Side 

Delta/Charlie stairs. 

• The lieutenant was brought 

out the Side Delta/Charlie rear 

door where an EMS crew was 

waiting at approximately 02:13. 

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Third floor porch shed breached by Rescue 2 where Ladder 5 

Lieutenant took shelter. (NIOSH Photo)
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Summary

• The lieutenant was transported by EMS to the local trauma center where he was 

pronounced deceased. 

• Command advised Fire Alarm that the fire at Box 15-14 was declared under control at 04:05 

and was marked out at 06:31.

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Side Bravo and Side Charlie of the structure. 

(NIOSH Photo)

Side Delta of the structure. 

(NIOSH Photo)
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Contributing Factors

• Building construction and 

contents enhanced fire 

spread

• Wind driven fire

• Lack of scene size-up and 

risk assessment

• Lack of incident 

management and 

command safety

• Lack of a defined incident 

action plan

• Lack of crew integrity

• Poor survivability profile

• Inadequate company 

level staffing

• Lack of professional 

development 

opportunities 

• Lack of required sprinkler 

system

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NIOSH Fire Fighter Fatality Investigation and Prevention Program 11

Recommendations

• Incident commanders should ensure a detailed size-up and 

define a strategy and incident action plan (IAP) based on 

the scene size-up and risk assessment. Incident 

commanders should continually reevaluate the strategy 

and adjust the IAP based on continuous size-up, risk 

assessment, risk management, and the completion of 

tactical objectives. 

• Fire departments should use risk management principles, 

including occupant survivability profiling, at all structure 

fires. 

• Fire departments should develop and implement standard 

operating procedures/standard operating guidelines 

(SOP/SOG), training programs, and tactics for wind-driven 

fires.

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NIOSH Fire Fighter Fatality Investigation and Prevention Program 12

Recommendations

• Fire departments should ensure that all companies are 

operating based upon the assignment given by the incident 

commander, eliminating freelancing and ensuring tactical 

priorities are met. 

• The early establishment of divisions/groups provides an 

effective incident management organizational framework 

that the IAP can build on and expand. This enhances the 

accountability of resources operating in the hazard zone.

• Fire departments need to ensure that critical incident 

benchmarks are communicated to the incident 

commander throughout the incident.

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NIOSH Fire Fighter Fatality Investigation and Prevention Program 13

Recommendations

• Fire departments should ensure that once Command is 

established at an incident, the incident commander 

maintains control of situation status, resource status, 

fireground communications, and ensures the completion of 

the tactical objectives.

• Fire departments should incorporate the principles of 

command safety into the incident management system 

during the initial assumption of command. This ensures that 

strategic-level safety responsibilities are incorporated into 

the command functions throughout the incident.

• Fire departments should ensure adequate staffing for 

deployment to urban incidents involving high hazard 

occupancies and a concentrated population.

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CONTACT US

Fire Fighter Fatality Investigation and Prevention Program

Surveillance and Field Investigations Branch Division of 

Safety Research NIOSH 1000 Frederick Lane, MS 1808 

Morgantown, West Virginia 26505-2888

FFFIPP Webpage

Download the full report

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