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Captain Died After Crew was Trapped During a Search for a Civilian 

in a 3

rd Floor Apartment Fire – Maine 

Executive Summary 

On March 1, 2019, a 32-year-old 

male captain was killed by rapidfire progression while fighting a 

fire in a three-story apartment 

building. Also, four firefighters

was injured. At 1105 hours, the 

town fire department was 

dispatched with automatic aid 

resources for a report of smoke in 

a 6-unit apartment building with 

one civilian occupant trapped. A 

civilian occupant was the 9-1-1 

caller and trapped on the 3rd floor

in an apartment bathroom. Engine 

2, which consisted of a captain, 2 

firefighters, and driver/operator, 

arrived on-scene at 1108 hours

and reported heavy smoke 

showing from the rear of the 

structure. The captain from Engine 2

immediately assumed Command and 

requested a 2nd Alarm. The captain 

advised the regional communication 

center (RCC) that Engine 2 (the captain and FF1) were going to make entry into Side Alpha with a 13⁄4-inch 

hoseline to perform a primary search for a reported trapped civilian occupant. The captain of Engine 2 told 

the other firefighter (FF2) from Engine 2 to get a ground ladder to the 3rd floor to rescue the trapped civilian 

occupant. Meanwhile, the driver of Engine 2 was in the process of connecting Engine 2 to a hydrant. The 

captain and FF1 entered the interior stairwell through the front door on Side Alpha at 1109 hours and 

proceeded to the 2nd floor. A police officer identified as PD113 and FF2 placed the ground ladder to the 3rd

floor bathroom window on Side Bravo where the trapped civilian was located. The trapped civilian occupant 

climbed out the window and onto the ground ladder. The police officer (PD113) notified RCC that the 

The Side Charlie 3rd floor porch where the captain and 

firefighter 1 were removed.

(NIOSH Photo)

F2019-02 • May 1, 2023

Revised November 16, 2023
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Report # F2019-02

Captain Died After Crew was Trapped During a Search for a Civilian in a 

3

rd Floor Apartment Fire – Maine 

civilian occupant was out of the building at 1109 hours. This message was delayed getting to the captain of 

Engine 2 because the information was transmitted on a police channel by PD113. Engine 2 was operating on 

the 3rd floor when the message was transmitted on the fire channel. A decision was made to leave the 

hoseline on the 2nd floor and search the 3rd floor. The captain and FF1 from Engine 2 were unable to make 

entry into a 3rd floor apartment due to the fire. The captain made the decision to back out of the structure. 

The crew’s exit was blocked by heavy fire traveling up the central stairway. They were forced to search for 

another exit. The crew made their way towards the back of the structure in the center hallway and into the 

fire apartment. The captain reportedly threw himself on top of FF1 as conditions deteriorated. Between 1112 

- 1113 hours, the captain called a Mayday, which was not acknowledged by any resources on the fireground

or by RCC. At 1114 hours, Engine 4 from a mutual aid company arrived on-scene. The lieutenant

recognized that the captain and FF1 from Engine 2 were missing and called Command and initiated a

Mayday. As additional companies arrived on-scene, a rapid intervention group was assigned to locate the

Engine 2 crew. Also, crews began attacking the fire on Side Charlie while the rapid intervention group was

trying to access the 3rd floor. FF1 was able to make his way out onto the porch on Side Charlie and called

for help to the crews on the ground at 1116 hours. A ground ladder was placed to the 3rd floor on Side

Charlie. FF1 climbed down the ladder and was out of the building at 1122 hours. The rapid intervention

group located the captain in a room adjoining the Side Charlie porch. They moved him to the Side Charlie

porch. The captain was lowered down a ground ladder and moved to a stretcher. He was out of the building

at 1132 hours. EMS crews began resuscitation efforts and transported the captain to a trauma hospital in

New Hampshire at 1152 hours. The captain was pronounced deceased at a trauma hospital in New

Hampshire at 1201 hours.

Contributing Factors

• Incomplete size-up and risk assessment

• Lack of incident management

• Lack of personnel accountability

• Inadequate fireground communications

• Rapid fire spread in the interior center stairwell

• Lack of situational awareness

• Lack of fire sprinkler system in a multi-family residential occupancy.

Key Recommendations

• Fire departments should ensure a detailed scene size-up and risk assessment is conducted during

initial fireground operations and throughout the incident

• Fire departments should ensure that once command is assumed, command is maintained until

command is transferred, the incident is stabilized, or the incident is terminated

• Fire departments should ensure firefighters communicate critical incident benchmarks to incident

commanders throughout the incident
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Report # F2019-02

• Fire departments should ensure that firefighters are trained in procedures for conducting search

and rescue, especially above a fire

• Fire departments should ensure hoselines are deployed, staffed, and appropriately utilized to protect

crews operating in the hazard zone

• Fire departments should ensure that firefighters are trained in situational awareness

• Fire departments should utilize a functional personnel accountability system

• Fire departments should integrate current fire behavior research findings developed by the National

Institute of Standards and Technology (NIST),Underwriters Laboratories (UL) Fire Safety Research

Institute (FSRI), and the International Society of Fire Service Instructors (IFSFI) to develop and

revise operational procedures on fireground tactics and provide training in fire dynamics in

structures for all members.

Additionally, governing agencies (state, regional, and local) should consider adopting and enforcing 

regulations for interventions to reduce or eliminate the spread of fire in multi-family structures, including 

automatic sprinkler systems and self-closing doors.

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine 

deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these 

incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations 

are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any 

other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to 

develop a description of the conditions and circumstances leading to the deaths in order to providea context for the agency’s recommendations. The NIOSH 

summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and 

recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

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).
Page 1

F2019-02 • March 1, 2023

Revised November 16, 2023

Captain Died After Crew was Trapped During a Search for a 

Civilian in a 3rd Floor Apartment Fire – Maine 

Introduction

On March 1, 2019, a 32-year-old captain was killed during a rapid-fire event in a three-story apartment 

building. On March 4, 2019, the U.S. Fire Administration notified the National Institute for 

Occupational Safety and Health (NIOSH) of this incident. From March 18-23, 2019, two safety and 

occupational health specialists, a general engineer from the NIOSH Fire Fighter Fatality Investigation 

and Prevention Program, and an environmental health Commissioned Corps officer traveled to Maine 

to investigate this incident. The NIOSH investigators met with and interviewed representatives of the 

fire departments involved with the response; the Maine Office of the State Fire Marshal, Investigation 

Division; the Maine Department of Labor, Bureau of Labor and Standards, Workplace Safety and Health 

Division; law enforcement; and representatives from the Maine Office of the State Medical Examiner.

Investigators also met with representatives from the regional communications center that dispatches for 

the involved fire & rescue department as well as other fire departments in the region. 

Fire Department

This combination fire & rescue department operates out of one fire station with 4 career members, 3 

per diem members, and 20 on-call members. This department serves a population of approximately 

8,500 within an area of 34 square miles. In 2019, the fire & rescue department responded to 904 

alarms. The fire & rescue department is responsible for providing both emergency and non-emergency 

services to the town where they are located and the surrounding communities as requested. The fire & 

rescue department provides fire suppression, non-transport emergency medical services, vehicle 

extrication, fire prevention/education, issuing burning permits, and a number of other services to the 

community. 

All career department members work a 24-on-48 off-24-on 96-off shift. The fire & rescue department 

currently operates 2 engines, 1 quint, 1 tanker, 1 medium duty rescue squad, 1 forestry (brush) truck, 1 

boat, and 1 command vehicle. All fire & rescue department apparatus are maintained by local qualified 

vendors. Annual testing of fire apparatus and equipment is conducted by qualified vendors. 

The fire & rescue department has written policies and procedures, which are available to all 

department members within their stations. These policies and procedures have been implemented and 

are enforced. 
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rd Floor Apartment Fire – Maine 

Training and Experience

Fire service training in Maine is provided by the Maine Fire Service Institute (MFSI). The MFSI is a 

division within Southern Maine Community College. They had a full-time staff of 10 and an additional 

100 instructors throughout the state of Maine at the time of the incident. MFSI produces a variety of 

programs in regions around the state of Maine to meet the demands of the local fire departments. 

Complementing the program delivery, MFSI also serves as the certification entity for all firefighter 

programs. MFSI accomplishes this by fostering partnerships and collaborating with local departments, 

regional programs, the Fire Science Programs of Southern Maine Community College and Eastern 

Maine Community College, and other state agencies, such as the Maine Office of the State Fire 

Marshal and the Maine Bureau of Labor and Standards, Bureau of Labor and Standards, Workplace 

Safety and Health Division. 

MFSI offers National Fire Protection Association (NFPA) training including NFPA 1001, Standard for 

Fire Fighter Professional Qualifications, Fire Fighter I which is approximately 150 hours and Fire 

Fighter II which is approximately 150 hours. MFSI also offers a 75-hour course which is the minimum 

requirement mandated for any firefighter that performs interior structural firefighting by the Maine 

Bureau of Labor and Standards, Workplace Safety and Health Division. 

MFSI also offers the following Pro Board accredited certification training: 

• NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire

Fighter II

• NFPA 1021, Standard for Fire Officer Professional Qualifications, Fire Officer I and Fire

Officer II

• NFPA 1041, Instructor I and Instructor II, Standard for Fire and Emergency Services

Instructor Professional Qualifications

• NFPA 1035, Standard on Fire and Life Safety Educator, Public Information Officer, Youth

Firesetter Intervention Specialist and Youth Firesetter Program Manager Professional

Qualifications, Fire Life Safety Educator I.

Note: The Pro Board is a non-profit corporation that was incorporated in 1990 as the “National 

Board on Fire Service Professional Qualifications.” The organization is commonly known as the Pro 

Board.

Fire inspector certifications are through the NFPA. 

Maine Bureau of Labor and Standards

The Maine Department of Labor, Bureau of Labor and Standards mandates that all firefighters be 

certified to meet the Interior Structural Firefighter - Minimum Training Requirements. This 75-hour 

course consists of 18 topics.

The curriculum is based on training requirements from the Maine Department of Labor, Bureau of 

Labor and Standards and NFPA 1001, Standard for Fire Fighter Professional Qualifications.

Based upon Maine state statutes, the following apply to each fire department in the state:
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rd Floor Apartment Fire – Maine

Report # F2019-02

• Maine MRSA (Maine Revised Statutes Annotated) Title 26 §2102. Firefighter Training and

Education

• Maine MRSA Title 26 §2103. Standards for Equipment and Clothing

• Maine MRSA Title 26 §2104. Required Provision and Use of Protective Equipment

The captain, driver/operator, and firefighter 1 (FF1) from Engine 2 completed all necessary 

departmental and state training to be certified as interior firefighters. Firefighter 2 was in progress of 

completing training but was not cleared as an interior firefighter at the time of this incident. 

Timeline

The following timeline is a summary of events that occurred on March 1, 2019. Not all incident events 

are included in this timeline. The times are approximate and were obtained by studying the dispatch 

records from the RCC, audio recordings, witness statements, and other available information. 

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Regional Communication Center 

(RCC) received 9-1-1 call from 

subject who stated he was trapped on 

the right side of a building that was on 

fire.

1058 

Hours

RCC received a call from a New 

Hampshire dispatch center regarding a 

structure fire. An occupant was the 

trapped occupant was on the top floor

of an apartment building.

1059 

Hours 

9-1-1 caller (trapped occupant)

advised RCC, that he was located in a

bathroom on the top floor. He stated

he had seen smoke.

Mutual aid fire departments

dispatched.

A town police officer 107 (PD 107) 

advised.

1100 

Hours 
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rd Floor Apartment Fire – Maine

Report # F2019-02

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

1102 

Hours

PD 107 arrived on-scene and advised 

smoke showing from the rooftop and 

someone was hanging out of a 3rd floor 

window.

1103 

Hours 

PD 113 arrived on-scene and advised 

no access to the 3rd floor due to the 

smoke.

RCC dispatched an automatic aid 

response in for a multi-family 

residential structure fire with an 

entrapment. The response included 

the town’s fire department Engine 2, 

automatic aid Engine 4, automatic aid 

Ladder 1, and an automatic aid chief 

Car 1, and an EMS unit.

11:05:44 

Hours 

Engine 2 responded. 11:05:49 

Hours 

Engine 4 (automatic aid) responded to 

the multi-family residential structure 

fire.

1106 

Hours 

Automatic aid chief – Car 1 arrived 

on-scene.

1107 

Hours 

Per PD 113, building almost fully 

involved.

RCC dispatched medic 5 (contracted 

EMS unit) to the multi-family 

residential structure fire.

11:08:34 

Hours

Medic 5 on-scene. 11:08:38

Hours
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Report # F2019-02

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Town fire department Engine 2 onscene.

The captain of Engine 2 advised RCC 

there was heavy smoke showing from 

the rear of the structure. The captain 

assumed Command and requested a 

2

nd Alarm.

1108 

Hours

The Engine 2 captain advised Engine 2 

was stretching a hoseline via the interior 

stairwell to the 3rd floor to attempt to 

rescue the civilian.

The captain of Engine 2 ordered FF2 to 

take ground ladder and place it to the 3rd

floor to rescue the occupant.

FF2 and PD 113 placed a ground ladder 

to the 3rd floor bathroom window. The 

trapped civilian occupant came out of 

the building and onto the ground 

ladder.

1109 

Hours 

Per PD 113, the trapped civilian occupant 

was out of the building.

FF1 from Engine 2 pulled a 13⁄4-inch 

hoseline to the front door and then to the 

2

nd floor. FF1 met the captain of Engine 2 

on the 2nd floor.

Note: At some unknown time, Car 1 

assumed Command of the incident. There 

is no record in the dispatch log of when 

this occurred.

1111 -

1112

Hours

The captain and FF1 from Engine 2 went 

into a 3rd floor apartment. 

Command radioed that the trapped civilian 

occupant was out of the building. 

The captain and FF1 moved back to the 

stairwell of the building.
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Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

1113 

Hours

The captain of Engine 2 called a Mayday 

that was not acknowledged by Command 

or RCC. 

The captain and FF1 from Engine 2 are on 

the 3rd floor landing. The fire is coming 

up the stairwell and is also in the 3rd floor 

apartment they were trying to enter.

RCC dispatched Ladder 1 (automatic 

aid fire department) to the multifamily residential structure fire. 

Ladder 1 was enroute at 11:13:36 

hours.

11:13:34 

Hours 

Engine 4 on-scene. The officer of 

Engine 4 assumed Command.

The officer of Engine 4 advised RCC 

he could not locate the crew from 

Engine 2 and called a Mayday. Also, 

the officer requested emergency traffic 

only.

1114 

Hours 

Engine 4 tried to locate the crew of 

Engine 2. The officer of Engine 4 

called a Mayday when he found 

Engine 2’s hoseline on the 2nd floor 

was burned but intact.

1116 

Hours

Crews operating on Side Charlie 

located a firefighter (FF1) on the 3rd

floor porch. The firefighter (FF1) 

called for help. 

A request was made to Command for a 

ground ladder to Side Charlie.

1117 

Hours

Car 1 requested the rapid intervention 

group entered the interior stairwell and 

tried to get to the 3rd floor to locate the 

crew from Engine 2.

Rapid intervention group placed 

ground ladders to the 3rd floor porch. 
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Report # F2019-02

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Command requested an EMS unit 

respond to the scene. 

1118 

Hours

The rapid intervention group on the 3rd

floor worked to remove FF1 and locate 

the captain of Engine 2.

1122 

Hours

Firefighter 1 was brought down the 

ground ladder from the 3rd floor.

Car 2 from automatic aid on-scene.

Car 2 advised RCC that Car 2 was in 

Command.

1129 

Hours

Command requested an additional 

alarm for this incident. 

1130 

hours

1132 

Hours

The rapid intervention group has the 

captain of Engine 2 out of the building.

Command conducted a personnel 

accountability report (PAR). 

Command transitioned to a defensive 

strategy.

Command advised RCC the PAR was 

completed. All members accounted for 

at this time.

1136 

Hours

PAR completed.

The captain and firefighter (FF1) on 

Engine 2 were transported by EMS to 

trauma hospital in New Hampshire. 

1152 

Hours

Engine 2's captain declared deceased 

at the trauma hospital 

1201 

Hours

1218 

Hours

Command conducted another PAR. All 

members accounted for at this time.
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rd Floor Apartment Fire – Maine

Report # F2019-02

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Command advised RCC that the fire 

was knocked down at this time.

1222 

Hours

Command advised RCC the fire was 

out.

1249 

Hours

Command was terminated. 1742 

Hours

Personal Protective Equipment

At the time of the incident, the captain of Engine 2 was wearing a station/work uniform and structural 

firefighting ensemble which included turnout pants, turnout coat, boots, structural firefighting 

protective hood, and helmet. The captain was wearing a self-contained breathing apparatus (SCBA). 

The structural firefighting ensemble was evaluated by NIOSH investigators and determined not to be a 

factor in this incident. No further evaluations were conducted. 

Weather Conditions

At 1056 hours, the skies were partly cloudy, the temperature was 28 degrees Fahrenheit (F), the 

humidity was 37%, the winds were calm, and there had been no precipitation in the past 24 hours 

[Weather Underground 2019]. 

Investigation

On March 1, 2019, a 32-year-old captain was killed by rapid-fire progression while fighting a fire in a 

three-story apartment building. Four firefighters were also injured during this incident. 

At 1058 hours, an adult male called 9-1-1 stating the apartment building he lived in was on fire. He 

stated he was on the right side of the building on the 3rd floor. At 1105 hours, an engine (Engine 2) 

staffed with a captain, driver, and two firefighters (PAR 4) from the town’s fire & rescue department 

were dispatched for a multi-family residential structure fire with an occupant trapped. The initial alarm 

also included an engine company, ladder company, and chief officer from automatic companies. Note:

Due to the location of the town, mutual aid fire departments responded from Maine and New 

Hampshire. As Engine 2 was approaching the scene, the captain requested a 2nd Alarm be struck due to 

heavy smoke showing. At 1107 hours, a mutual aid chief officer (Car 1) arrived on-scene. 

At 1108 hours, Engine 2 arrived on scene. The captain assumed Command and was informed by a 

police officer (PD 113) on-scene that there was still a civilian occupant trapped inside. The captain 

and another firefighter (FF1) were going to make entry into Side Alpha with a 13⁄4-inch hoseline to 
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perform a primary search for a reported trapped civilian (See Photo 1). The captain of Engine 2 told 

the other firefighter (FF2) to get a ground ladder to the 3rd floor to rescue the trapped civilian 

occupant, who was hanging out the window. Meanwhile, the driver of Engine 2 was in the process of 

connecting Engine 2 to a hydrant. The captain and FF1 entered the stairwell through the front door 

with a 13⁄4-inch hoseline on Side Alpha at 1109 hours. FF2 and a town police officer (PD 113) placed 

the ground ladder to the 3rd floor bathroom window on Side Bravo where the trapped 

Photo 1: Initial arrival conditions. Showing Side Alpha and Side Delta. The victim 

was at window on 3rd floor on Side Bravo. The time was approximately 1108 hours.

(Photo courtesy of the town police department)
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civilian occupant was located. The civilian occupant was able to climb down the ladder to the ground 

(See Photo 2). The police officer notified the regional communication center (RRC) that the civilian 

occupant was out of the building at 1109 hours. This message was delayed in being transmitted to the 

captain of Engine 2 because the police officer transmitted his message on the police channel to RCC.

Engine 2 was inside performing a search of a 3rd floor apartment on Side Bravo. When Engine 4 

arrived on-scene, the officer assumed Command at 1114 hours. At an unknown time, Car 1 from a 

mutual aid department assumed Command of this incident. There are no times in the dispatch log to 

indicate when this occurred.

FF1 met the captain at the landing on the 2

nd floor with the charged 13⁄4-inch hoseline. The captain 

was donning his SCBA facepiece. A decision was made to leave the hoseline at the bottom of the 

stairs and enter the 3

rd floor apartment for a right-hand, primary search. When the Engine 2 captain 

and FF1 reached the doorway to the apartment, they found heavy fire and a compromised exit. The 

Photo 2: The orange arrow identifies the window where the civilian was located upon 

arrival of the fire department. The civilian was removed from the 3rd floor window 

via the ground ladder. 

(Photo provided by the Maine Office of the State Fire Marshal)
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captain and FF1 turned once more to try and enter the apartment and search for a new exit. The 

captain radioed a Mayday that was not acknowledged by Command or RCC.

The 2nd due mutual aid companies arrived and observed visible fire on Side Charlie. At approximately 

1114 hours, a lieutenant from a mutual aid fire department (Engine 4) saw a 13⁄4-inch hoseline 

stretched from Engine 2 into the front door on Side Alpha. Engine 4 stretched another 13⁄4-inch 

hoseline to the front door and into the stairwell. The lieutenant found Engine 2’s hoseline on the 2nd

floor, which was burned but still intact. The Engine 4 lieutenant who assumed Command called a 

Mayday. 

The captain and FF1 from Engine 2 were still on the 3rd floor and had made it into to the

apartment (Side Charlie). The Engine 2 crew could go no further due to the fire in the apartment. 

Also, there was fire coming up the stairwell. With conditions rapidly deteriorating, the captain 

grabbed FF1 and laid on top of him. FF1 stated they stayed there for some time until FF1 heard

water knocking the fire down around them. The time was approximately 1115 hours (See Photo 3).
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FF1 stated the room began to cool and visibility started to improve. He recognized an area of the room 

that was starting to show daylight through a wall. FF1 attempted to move the captain out of the 

apartment but got no response. The captain was unconscious. FF1 did not have the strength to move 

the captain and moved to the wall to get help. He went out on the porch and frantically waved his

hands. Due to the water from a portable monitor in operation, FF1 was not visible from the ground. 

FF1 re-entered the building and attempted to move the captain. FF1 had tucked his portable radio into 

his turnout coat. Unable to move the captain, FF1 went out on the porch and called Command on his 

portable radio. FF1 advised Command of his location and that the captain was unconscious. The time 

was approximately 1116 hours.

Firefighters with the rapid intervention group climbed a ground ladder to meet FF1 on the 3rd floor

porch. FF1 directed them to the captain. Then FF1 climbed down the ground ladder. Once FF1 was on 

the ground, he was walked to an EMS unit for medical treatment. The time was approximately 1122 

hours.

Photo 3. Exterior fire attack on Side Charlie while Engine 2 was on the 3rd floor. The 

time is approximately 1114 hours.

(Photo courtesy of town police department)
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There was still visible fire inside of the structure on the 1st and 2nd floors while the firefighters were 

trying to rescue the Engine 2 captain on the 3rd floor. The captain was found in a sunroom adjoining 

the Side Charlie porch, on air but not breathing. The rapid intervention group moved the captain to the 

porch. He was then lowered down the ladder to firefighters on the ground (See Photo 4). Per 

Command, RCC was advised that the captain of Engine 2 was out of the building at 1132 hours. 

Once on the ground, CPR and advanced life support were started on the captain. Command initiated a 

personnel accountability report (PAR). At 1136 hours, Command advised the RCC that all firefighters 

were out of the building and all members accounted for at this time. Command also advised 

fireground operations were operating in a defensive strategy. At 1142 hours, Command advised the 

RCC to clear the Mayday.

The captain was transported to a trauma hospital in New Hampshire at 1152 hours. The captain was 

declared deceased at 1201 hours.

At 1218 hours, Command advised the RCC that another PAR had been conducted. All firefighters 

were accounted for at this time. At 1222 hours, Command advised the dispatcher that the fire was 

knocked down. At 1249 hours, Command advised the dispatcher the fire was out. Command was 

terminated at 1742 hours. 
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• Incomplete size-up and risk assessment

• Lack of incident management

• Inadequate fireground communications

Photo 4. Ground ladders extended to a 3rd floor porch where the captain and 

firefighter 1 were removed from the structure. 

 (Photo provided by the Maine Office of the State Fire Marshal) 

Fire Cause 

According to investigators with the Maine Office of State Fire Marshal, assisted by the Bureau of 

Alcohol, Tobacco, Firearms and Explosives (ATF), along with detectives from the town police 

department, determined the origin of the fire was on the 3

rd floor exterior rear porch. The cause is 

“most probably disposal of smoking materials into an unapproved receptacle.”

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: 
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• Lack of personnel accountability

• Rapid fire spread in the interior center stairwell

• Lack of situational awareness

• Lack of fire sprinkler system in a multi-family residential occupancy.

Cause of Death

According to the New Hampshire Office of the Chief Medical Examiner, the cause of death was 

probable hyperthermia and/or hypoxia and the manner of death was accidental.

Recommendations

Recommendation #1: Fire departments should ensure a detailed scene size-up and risk assessment 

is conducted during initial fireground operations and throughout the incident. 

Discussion: The strategy and incident action plan (IAP) (tactics) of an incident are dictated by the 

size-up, initial risk assessment, and situation report made by the first arriving officer. The priority is to 

get fire department resources to Side Charlie as quickly as possible. However, unless an obvious life 

safety issue exists (e.g., visible victims requiring immediate assistance), interior firefighting operations 

should not commence until a report from Side Charlie is received. If physical barriers make the 360-

degree size-up impractical for the first arriving officer, the delegation of the size-up of Side Bravo, 

Side Charlie, and Side Delta may go to another engine company or other resource on the 1

st Alarm. 

Even if a 360-degree size-up is conducted, the assignment of resources should go to Side Charlie. 

Resources could include any unit—engine, truck, medic unit, or chief— preferably an engine company 

with a hoseline [Fire and Rescue Departments of Northern Virginia (FRDNV) 2013]. Until the 360-

degree assessment is completed, incident commanders should be cautious in committing fire crews, 

constantly monitor changing conditions, and be prepared to immediately adjust crew commitments or 

withdraw crews all together. 

The tasks that need to occur at any fire, regardless of the occupancy, are an initial on-scene report upon 

arrival, scene size-up, initial risk assessment, water supply, deployment of handlines and back-up 

handlines, search and rescue, ventilation, establishment of a rapid intervention crew (RIC), ground and 

aerial ladder placement, fire attack and extinguishment, and salvage and overhaul. 

At any incident, life safety is always the first priority, followed by incident stabilization (second 

priority) and then property conservation (third priority). The task of ensuring for the safety of 

firefighters is a continuous process throughout the incident. A sound risk management plan ensures 

that the risks are evaluated and matched with appropriate actions and conditions. The following risk 

management principles should be used during fireground operations: 

• Activities that present a significant risk to the safety of members shall be limited to situations

where there is a potential to save endangered lives

• Activities that are routinely employed to protect property shall be recognized as inherent risks

to the safety of members, and actions shall be taken to reduce or avoid these risks.

• No risk to the safety of members shall be acceptable when there is no possibility to save lives

or property
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• In situations where the risk to fire department members is excessive, activities shall be limited

to defensive operations [NFPA 2018].

Fireground operations are very dynamic and fast-paced. An incident commander needs to determine a 

strategy and then develop an IAP. Incident commanders need to follow the decision-making model that 

includes identifying incident critical factors (through a situational evaluation or size-up), considering 

the standard risk management plan, declaring the strategy (offensive or defensive), and then setting 

tactical objectives. This model will lead to the development of an IAP, which serves as the tactical 

road map to effectively manage the incident. An IAP defines where and when resources are assigned 

throughout the incident, along with tasks and objectives [NFPA 2014].

To ensure a standard outcome for each incident, incident commanders should match the standard 

conditions to standard actions. This is the core of the incident command system and the basis for all 

operations. Incident commanders should identify the incident’s current critical factors before taking 

any action. At each incident, incident commanders should start with a standard placement-oriented 

operational plan that develops a strong, dependable beginning for command and control of the incident 

[Brunacini 2002; FRDNV 2013]. 

Often the initial incident commander is a company officer who arrives on-scene prior to a chief officer. 

The company officer should provide a detailed size-up, which is communicated to all responding 

resources, including the dispatch center/fire alarm office. The company officer assumes command and 

makes decisions regarding the strategy and the IAP. Events can occur very quickly before a detailed 

tactical worksheet or written IAP is developed. When the company officer does not have the ability or 

time to record the IAP on paper, a verbal IAP is appropriate when transferring command [Brunacini 

2002]. 

Once an officer assumes command, the overall strategy is communicated. Command should make 

specific assignments to arriving companies along with tactical objectives, such as search, rescue, fire 

attack, ventilation, utility control, and exposure protection. The responding chief officer should 

monitor radio communications and document tactical objectives on a tactical worksheet if possible. 

When the chief officer arrives on scene, an update from the initial incident commander should occur 

(face to face or by radio). The chief officer will then assume command at a stationary location. By 

following this process, the initial and subsequent incident commanders will have a stronger position to 

manage an incident should an emergency event occur [NFPA 2014].

NFPA 1561 defines an IAP as a verbal plan, tactical worksheet, written plan, or combinations thereof 

that reflects the overall incident strategy, tactics, risk management, and member safety that are 

developed by an incident commander. NFPA 1561, Standard on Emergency Services Incident 

Management System and Command Safety [NFPA 2020] requires the following regarding an IAP: 

• 5.3.12.1. The incident commander shall be responsible for developing and/or approving an

incident action plan.

• 5.3.12.2. This IAP shall be communicated to all staged and assigned members at an incident.

• 5.3.20. The incident commander shall be responsible for reviewing, evaluating, and revising the

IAP and overall strategy of the incident (See Diagram 1).
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Recommendation #2: Fire departments should ensure that once command is assumed, command is 

maintained until command is transferred, the incident is stabilized, or the incident is terminated.

Discussion: The first resource or member to arrive to the scene will assume command of the incident 

by transmitting a standard initial radio report. The confirmation of command occurs when the dispatch 

center or fire alarm office repeats the initial radio report back to all responding units, confirming that 

the initial arriving resource is in command of the incident. Assuming command requires the firstarriving resource or member (the incident commander) to size up the incident, determine the incident’s 

strategy and formulate an incident action plan (IAP). All of this is executed and shared with all 

incident participants when the incident commander (IC) transmits the initial radio report [Brunacini 

and Brunacini 2004].

Diagram 1: Guide for developing an IAP at Type V and Type IV incidents, 

which communicated verbally.

(Diagram courtesy of FireFighterCloseCalls.com.)
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When the incident begins with an in-place IC, all later-arriving units will be assigned based on the IC’s 

IAP. This puts all the incident players on the same page. Everyone knows what the problem is and 

what action is being taken to solve it. Effective and coordinated action is the result of beginning (and 

ongoing) incident operations with an in-place and in-charge IC. Once command has been established, 

all routine communication between the dispatch center and the incident will be directed through 

command. The initial incident commander shall remain in command until command is transferred or 

the incident is stabilized and command is terminated. A formal IC must be in place, performing the 

functions of command, whenever a hazard zone exists [Brunacini and Brunacini 2004].

Many times, the strength of the local incident management is the fast-attacking IC, who directly 

supervises the use of quick force at the beginning of the event. That action is reinforced and upgraded 

by response chiefs who come in behind the initial fast attacking IC to quickly establish a stationary, 

exterior command post that supports and expands on the fast-attacking IC’s initial actions. The fastattacking command position provides the front-end command structure for that capability.

The entire response team coming in behind a fast attacking IC need to realize that the initial IC is in an 

attack position, not a command position. We trade off this position disadvantage because many times 

this initial front end fire attack is enough to stabilize the incident. When the front-end control efforts 

doesn’t stabilize the situation, the fast-attacking IC is not in the best position to continue command; 

they are in the worst position [Brunacini and Brunacini 2004]. 

The fast attacking command position should end in one of three ways: 

• Situation is quickly stabilized

• Command is transferred from the fast attacking company officer IC (#1) to a subsequent

arriving command officer (IC #2)

• If the situation is not stabilized and there is a delay in the arrival of a command officer, the fast

attacking company officer IC needs to move to an exterior (stationary) command position and

operate in the Command position. When this happens, the company officer has the following

crew options:

o Move up one of your crew members to company officer. Minimum 2-member company in

a hazard zone

o Assign your crew member(s) to another company in the hazard zone. This needs to be

acknowledged by both the original and the receiving officer and by their inclusion in the

accountability system

o Have the crew exit with the IC and perform IC support roles

o No crew will remain in a hazard zone without radio communications [Brunacini and

Brunacini 2004].

The fast attacking company officer IC will also directly supervise and assist their crew members with 

the tasks required to bring the incident’s problems under control. 

In most cases, this initial attack wave eliminates the incident hazards. For incidents that are not quickly 

controlled, are escalating, or are significant in scope and size upon our arrival, the strategic and tactical 

operational levels need to be upgraded with chief officers as required [Brunacini AV 2002].
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Recommendation #3: Fire departments should ensure firefighters communicate critical incident 

benchmarks to incident commanders throughout the incident. 

Discussion: Fireground benchmarks are essential for a successful and safe outcome. To ensure that the 

proper benchmarks are communicated at fireground incidents, fire departments should develop and 

maintain an SOP/SOG that specifies a consistent process for communicating critical benchmarks. This 

would include effective hands-on classroom and practical training programs with annual live fire 

training, a defined department deployment model, an effective incident management system, adequate 

radio equipment (mobile and portable radios), and adequate radio channels (dispatch, tactical, and 

command) [NIOSH 2013a, NIOSH 2013b, NIOSH 2014]. Effective incident communications provide 

the connection between the strategic, tactical, and task levels of management. This connection allows 

the team to commit resources and coordinate actions. To be effective, ICs need to coordinate the 

ongoing communication between and within the three operational levels (i.e., strategic, tactical, task) 

despite each level having its own special set of needs, capabilities, and challenges. These differences 

create logistical challenges for the entire team. They require a strong, well-practiced, procedures-based 

communications plan and positive function-based relationships among the participants [Brunacini and 

Brunacini 2004].

Radio communications allow the tactical and task levels to connect with the IC working on the 

strategic level. The overall outcome of the incident can be traced back to the quality of the radio 

communications among the participants. Since the IC is located at the command post (outside the 

hazard zone), interior conditions need to be communicated by interior crews as soon as possible to the 

IC. This allows the IC to modify their strategy, if needed. Subsequent updates, as well as when 

benchmarks are completed (e.g., “primary search complete is all clear” and “the fire has been knocked 

down”), are especially important to the IC. A fire department’s communications SOP/SOG should 

include communications necessary to gather and analyze information to plan, issue orders, and manage 

operations. For example: 

• additional resources required

• status of searches

• is there water on the fire

• assignment completed

• unable to complete an assignment or task

• special information

• ensure all companies and resources are operating on the designated radio channel

• emergency traffic or Mayday [FIRESCOPE 2017].

Critical incident factors and their possible consequences offer the basis for a standard incident 

management approach. A standard information approach is the launching pad for effective incident 

decision making and successful operational performance. ICs should use the critical factors, in their 

order of importance, to make tactical assignments for the IAP. The IC should develop a standard 

information system and use effective techniques to keep informed at the incident. ICs should not 

assume the action-oriented responder engaged in operational activities will stop what they are doing to 

notify the IC with a continuous supply of top-grade, objective information. It is the IC’s responsibility 

to do whatever is required to stay effectively informed [NIOSH 1999]. Radio discipline is essential for 
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all members operating at an incident scene. Members should be trained on and use the thought process 

of "is my transmission necessary." Radio transmissions should be reserved for relevant messages such 

as benchmarks, personnel accountability reports, safety issues or concerns, needed resources, changing 

conditions, and emergency traffic and Mayday. Non-relevant transmissions can distract the IC and add 

little, if anything, to the IAP.

The following are considerations of critical incident benchmarks that should be completed during 

fireground operations: 

• First-due company officer should assume command

• A complete size-up and risk assessment should be completed by the first-due company officer

• The first due companies should advise command if they did not lay a supply line

• Once operations were initiated on Side Charlie, the company officer should provide a

description of company locations and entry locations

• When companies change locations, the division supervisor should provide a complete

description of the tactical operations, including a description of the basement and its

dimensions

• When command assigns a division supervisor, this should be communicated to the companies

assigned to this division to ensure personnel accountability within the division

• Once the 1st Alarm companies are on-scene, a company or companies should be assigned as the

rapid intervention crew (RIC)

• Companies or units assigned to RIC should operate, or be located, together

• Once officers communicate critical information about smoke or fire in a structure, Command

should revise the IAP and communicate any tactical changes

• Company officers should conduct radio checks to ensure all company members are on the

correct radio channel. Radios should not be on the “scan” function

• The fire agency should evaluate and simplify the selection of radio frequencies to reduce the

possibility of mistakes upon dispatch

• Command should be advised when a company assigned water supply and is having trouble

establishing the water supply [Brunacini and Brunacini 2004].

Recommendation #4: Fire departments should ensure firefighters are trained in procedures for 

conducing search and rescue, especially above a fire.

Discussion: The firefighter-oriented search can be done with a two-, three- or four-person team. With a 

two-person search, the oriented firefighter, carrying a thermal imager, if possible, stays in touch with 

the search wall. The searcher then moves about the room while staying oriented with the lead 

firefighter. Orientation can be accomplished by touch with the use of a strap, rope, or tool; by sight 

through the use of the thermal imager or the naked eye if conditions allow it; or by voice through 

verbal communication throughout the search [IFSTA 2018].

Search priority is based on fire behavior. Since heat, smoke and flame extend upward and outward, the 

immediate fire area and fire floor are the primary search areas. Next is the one floor directly above the 

fire spread, then the rest of the floors above, beginning with the top floor and descending. Finally, all 
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floors below the fire are searched as primary searches end and secondary searches begin [IFSTA 

2018].

There are two main objectives in conducting a structural search: searching for life and assessing fire 

conditions. A primary search is a fast, efficient, and controlled method of finding occupants before or 

during fire extinguishment. To sustain maximum safety, firefighters search on their hands and knees 

or in a squat position. This establishes orientation in the direction of travel and if struck by debris, 

ensures the correct bearing will be maintained. Lower temperatures at floor level give firefighters an 

advantage should fire conditions change [IFSTA 2018].

An occasional pause while holding a breath gives firefighters a chance to hear conditions. Firefighters 

can hear a victim moaning, the creaking or crackling of structures or the fire itself, or an information 

update via radio traffic. Such a pause allows for better orientation to the entire fireground as well as the 

immediate search area.

Recommendation #5: Fire departments should ensure hoselines are deployed, staffed, and 

appropriately utilized to protect crews operating in the hazard zone.

Discussion: The primary purpose of the initial attack hoseline is for fire suppression, but it also 

protects the interior fire suppression crews if they become overrun with fire, need to cool down the 

area, and need to protect a firefighter’s egress point(s). A hoseline should be of sufficient length to 

advance the crew in their search for the fire and/or occupants [FDNY 2014]. 

In most cases, the first line is stretched via the interior stairs to the location of the fire. The purpose of 

this line is to protect the primary means of egress for occupants evacuating the building and to confine 

and extinguish the fire. An exception to stretching the first line up the interior stairs may be made 

when flame is issuing from windows opening onto the fire escape and endangering people trying to 

come down the fire escape. In this case, the first line may be operated from the street to protect people 

on the fire escape. A second line should be promptly stretched to the interior of the building. If the 

entrance door to the building is self-closing and equipped with a locking device, the first member 

entering the building should use a chock, rug, or other means of preventing the door from locking and 

thereby delaying other members trying to enter the building [FDNY 2014].

When an initial attack hoseline is deployed to an area and being operated and/or covering a search, a 

backup hoseline should be the next line pulled. Ideally a back-up hoseline should be at least the same 

size and preferably larger if the stretch length and maneuverability will allow. The back-up line is the 

primary protection for the crew operating the initial hoseline and can cover a retreat in case of a fire 

event overrunning or can assist in the search. Additionally, if the initial hoseline stretches short of the 

intended area, this needs to be communicated to command. This allows for the back-up hoseline of 

proper length to be stretched. 
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Recommendation #6: Fire departments should ensure that firefighters are trained in situational 

awareness. 

Discussion: All firefighters operating at an incident should be trained to maintain situational awareness 

and conduct a continuous risk assessment throughout the incident, reporting unsafe or changing 

conditions to the IC. The fireground dangers and hazards can and do change as the incident becomes 

larger and the event duration increases. The structural conditions of the fire building(s) can change 

significantly and endanger areas of the fireground that were not present earlier in the event. 

The IFSTA Essentials of Fire Fighting defines situational awareness as an awareness of the immediate 

surroundings. On the fireground, every firefighter should be trained to be constantly alert for changing 

and unsafe conditions. Even though a safety officer may have been designated for the incident, all 

personnel are obligated to remain alert to their immediate surroundings. This applies not only to the 

conditions found within a burning structure, but also to the exterior fireground as well [IFSTA 2018].

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

When situational awareness is not maintained, firefighters can develop tunnel vision and become so 

focused on firefighting or other operational assignments that they may fail to sense changes in their 

environment. 

The International Association of Fire Chiefs, Safety, Health, and Survival Section developed the 

"Rules of Engagement for Structural Fire Fighting." These rules assist the firefighter, the IC, and the

command team officers in risk assessment that enables making "Go or No-Go" decisions. The 

fireground creates a significant risk to firefighters and it is the responsibility of the IC and command 

organization officers to minimize firefighter exposure to unsafe conditions and stop unsafe practices

[IAFC 2012].

The rules of engagement can assist the IC, company officers, and firefighters in assessing their 

situational awareness. One principle applied in the rules of engagement is that firefighters and the 

company officers are the members most at 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. When it is not safe to proceed, the rules of engagement guide decision making while 

still maintaining command unity and discipline.

Rules of Engagement for Firefighter Survival:

• Size-up your tactical area of operation. (Pause for a moment, look over the area of operation,

evaluate individual risk exposure, and determine a safe approach to completing your tactical

objectives.)

• Determine the occupant survival profile. (Consider occupant survival as part of your individual

risk assessment and action plan.)

• Do not risk your life for lives or property that cannot be saved. (Do not risk your life when fire

conditions prevent occupant survival and when significant or total destruction of the building is

inevitable.)

• Extend limited risk to protect savable property. (When trying to save a building, limit risk

exposure to a reasonable, cautious, and conservative level.)
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• Extend vigilant and measured risk to protect and rescue savable lives. (During high-risk

primary search-and-rescue operations where lives can be saved, manage search-and-rescue

operations in a calculated, controlled, and safe manner while remaining alert to changing

conditions.)

• Go in together, stay together, and come out together, when two or more firefighters operate as a

team.

• Maintain continuous awareness of your air supply, situation, location, and fire conditions.

• Constantly monitor fireground communications for critical radio reports.

• Report unsafe conditions or practices that can harm you. Stop, evaluate, decide. (Officers

should prevent exposure to unsafe conditions or practices by allowing any member to raise an

alert about a safety concern without penalty and by mandating supervisors address safety

questions to ensure safe operations.)

• Abandon your position and retreat before deteriorating conditions can harm you. (Be aware and

exit early to a safe area when you are exposed to deteriorating conditions, unacceptable risk,

and a life-threatening situation.)

• Declare a Mayday as soon as you think you are in danger. (Officers should ensure firefighters

are comfortable with declaring a Mayday as soon as they think they are in trouble.) [IAFC

2012].

The Incident Commander’s Rules of Engagement For Firefighter Safety:

• Rapidly conduct or obtain a 360-degree situational size-up of the incident. (As part of the risk

assessment plan and action development plan, determine the safest approach to tactical

operations before firefighters are placed at substantial risk.)

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

survival of a rescue event before committing to a high-risk search and rescue.)

• Conduct an initial risk assessment and implement a safe action plan. (Before firefighters are

placed in high-risk positions on the fireground, develop a safe action plan by conducting a sizeup, assessing the survival profile, and completing a risk assessment.)

• Consider a defensive strategy when you do not have the resources to safely support and protect

firefighters. (Do not commit 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. (Do not commit firefighters to high-risk firefighting operations that may

harm them when fire conditions prevent occupant survival or when significant or total

destruction of the building is inevitable.)

• Extend limited risk to protect savable property. (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. (During high-risk searchand-rescue operations where lives can be saved, manage search-and-rescue and supporting

firefighting operations in a highly calculated, controlled, and cautious manner while remaining

alert to changing conditions.)
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• Maintain frequent two-way communications and keep interior crews informed of changing

conditions. (Request frequent progress reports and continually inform all interior crews of

changing fire conditions observed from the exterior that may affect crew safety.)

• Obtain frequent progress reports and revise the action plan. (Obtain frequent progress reports 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, their location, and status. (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 be aware of who is presently in or out of the

building.)

• Seriously consider a defensive strategy, if after completion of the primary search, little or no

progress toward fire control has been achieved.

• Always have a RIC in place at all working fires.

• Always have firefighter rehab services in place at all working fires. (Ensure all firefighters who

endured strenuous physical activities at a working fire are rehabilitated and medically evaluated

for continued duty and before being released from the scene.) [IAFC 2012].

In this incident, the captain was notified of a trapped civilian prior to arrival. After assuming 

command, the captain and firefighter 1 engaged in interior search and rescue efforts in a heroic effort 

to rescue the trapped victim.

Recommendation #7: Fire departments should use a functional personnel accountability system, 

requiring a designated accountability officer or resource status officer.

Discussion: Personnel accountability on a fireground means identifying and tracking all personnel 

working at the incident. A fire department should develop its own system and standardize it for all 

incidents. 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 [NIOSH 2011]. Some personal alert safety system 

(PASS) devices incorporated into SCBA can communicate automatically with a command /control 

module at the incident command post, establishing an automatic accountability system. NFPA 1500 

(Chapter 8, Section 8.5) and NFPA 1561 (Chapter 4, Section 4.5) contain guidelines for the 

development of an accountability system for fireground and other emergency operations [NFPA 2018, 

NFPA 2014]. 

The accountability process should start at the first arriving piece of apparatus. This is especially 

important when the initial incident commander assumes command and operates in the mobile 

command capacity. Accountability is assigned to the chauffeur or engineer of that piece. As the 

incident escalates, additional staffing and resources will be needed, adding to the burden of tracking 

personnel accountability. At this point a tactical worksheet should be established with an assigned 

accountability officer or chief's aide. In large incidents, this can also be used at the division level, with 

resources being assigned and tracked at the division level.
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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 IC [NFPA 2014]. The use of a personnel accountability system is recommended by 

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness 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

• training all members

• strict enforcement during emergency incidents.

The control of the personnel accountability system should be assigned to a member of the incident 

command team responsible for maintaining the location and status of all assigned resources and 

personnel at an incident. This is a separate role from the duties of the IC. The IC 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 position 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].

There are many different methods and paper or electronic tools for accounting of resources. Some 

examples are as follows:

• command boards

• tactical worksheets

• apparatus riding lists

• electronic bar-coding systems

• accountability tags or keys (e.g., PASSPORT System) [NFPA 2014].

Different methods and tools for resource tracking and accountability can be used in conjunction with 

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

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

incident [NFPA 2014].

As the incident escalates, additional staffing and resources may be needed, adding to the burden of 

tracking personnel. With an effective accountability system in place, the IC can readily identify the 

location and time of all firefighters on the fireground. A properly initiated and enforced personnel 

accountability system that is consistently integrated into fireground command and control enhances 

firefighter safety and survival by helping to ensure a more timely and successful identification. 

In this incident, personnel accountability was not established until after the Mayday was called. 

Arriving crews who initiated RIT knew there were firefighters inside of the structure but had no 

immediate way of determining who was lost, missing, or trapped.

Recommendation #8: Fire departments should use resources from the National Institute of 

Standards and Technology (NIST), Underwriters Laboratories (UL) Fire Safety Research Institute 

(FSRI), and the International Society of Fire Service Instructors (ISFSI) to develop and revise 
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operational procedures on fireground tactics and provide training in fire dynamics in structures for 

all members.

Discussion: The above organizations have conducted a series of live-burn experiments designed to 

replicate conditions in modern homes and residential structures and to validate previous testing done in 

laboratory settings. The results of these experiments enable firefighters to better predict and react to the 

effects of fire in these occupancies. The fire research experiments were conducted in cooperation with 

the Fire Department of New York; Chicago Fire Department; Spartanburg, South Carolina, Fire and 

Rescue; and other agencies. The live-burn tests were aimed at quantifying emerging theories about 

how fires are different today, largely due to new building construction and the composition of home 

furnishings and products. In the past, these products were mainly composed of natural materials, such 

as wood and cotton, but now contain large quantities of petroleum-based products and synthetic 

materials that burn faster and hotter and generate large volumes of fuel-rich smoke. Where a fire in a 

room once took approximately 20 minutes to “flashover”—igniting all the contents—this can happen 

with today’s furnishings in as little as 4 to 5 minutes [Kerber 2012].

Modern living spaces tend to be more open, less compartmentalized, and better insulated than homes 

built years ago. As a result, interior residential fires can generate oxygen-depleted, fuel-rich 

environments within minutes. This fire condition of hot, fuel-rich smoke (also known as a ventilationlimited fire) is highly reactive to the introduction of oxygen. Opening a door or venting a window 

introduces massive quantities of oxygen to this environment, which promotes explosive and rapid 

transition to flashover. These same conditions can occur in commercial structures as seen in the fire at 

the Charleston, South Carolina, Sofa Super Store [NIOSH 2009].

The NIST and FSRI experiments evaluated individual and combinations of methods for strategically 

ventilating and isolating fires to prevent or delay flashover. In contrast, kicking a door open or 

breaking a window without knowledge of conditions inside could create a portal for air that can 

literally fan the flames by introducing oxygen into an oxygen-limited fire environment. 

A flow path is composed of at least one inlet opening, one exhaust opening, and the connecting volume 

between the openings. The direction of the flow is determined by difference in pressure. Heat and 

smoke in a high-pressure area will flow through openings toward areas of lower pressure. Based on 

building design and the available ventilation openings (doors, windows, etc.), several flow paths can 

exist within a structure. Any operation conducted in the exhaust portion of the flow path will place 

members at significant risk because of the increased flow of fire, heat, and smoke toward their 

position. Operations conducted in the flow path, between where the fire is and where the fire will 

travel, place firefighters at significant risk because of the increased flow of fire, heat, and smoke 

toward their positions. This risk is true for natural-ventilation cases with or without wind. In cases with 

the potential for wind to affect the heat release rate and the movement of the fire, it is important to 

keep the wind at your back and attack the fire from the upwind side [UL FSRI 2013]. Another 

important safety procedure to remember, practice, and utilize in the event of becoming trapped or in 

distress in the hazard zone is door control and isolation. This allows a firefighter or firefighters to have 

protection until a rescue can occur.
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Fire suppression operations conducted from the interior of the structure need to be coordinated with 

ventilation operations. Previous research and examinations of line-of-duty deaths have shown that 

ventilation events occurring with firefighters in the structure prior to suppression have led to tragic 

results [NIOSH 2009, 2012, 2013a, 2013b]. One method of reducing this risk would be the application 

of exterior water. Water should directed into the structure from the exterior to cool the fire gases and 

reduce the heat-release rate of the fire prior to firefighters entering the building. 

UL has shown that effective suppression operations, either from the interior or exterior, did not 

increase the potential burn injuries to the occupants. However, the delay of suppression operations 

provides the potential for longer occupant exposures to IDLH conditions and increased potential for 

further injury or death [Zevotek et al. 2019]. 

Based upon the NIST, FSRI, and ISFSI research cited above, the following fireground operations 

should be considered for implementation.

• Size-Up

Size-up must occur at every fire. Consideration must be given to the resources available and

situational conditions, such as weather, fire location, size of the fire and building, and the

construction features. Ensure a 360-degree size-up is conducted whenever possible. A tactical

plan for each fire must be developed, communicated, and implemented.

• Ventilation

Fire departments should manage and control the openings to the structure to limit fire growth

and spread and to control the flow path of inlet air and fire gases during tactical operations. All

ventilation must be coordinated with suppression activities. Uncontrolled ventilation allows

additional oxygen into the structure, which may result in a rapid increase in the fire

development and increased risk to firefighters due to increased heat-release rates.

• Firefighting Operations

Given the fuel-rich environment in which the fire service operates, water should be applied to

the fire as soon as possible. In many cases, water application through an exterior opening into a

fire compartment may be the best first action, prior to committing fire-fighting resources to the

interior. Fire departments should cool the interior spaces of a fire building with water from the

safest location possible, prior to committing personnel into spaces with, or adjacent to, fully

developed or smoldering (ventilation-limited) fire conditions.

• Rapid Intervention

Fire department rapid intervention procedures should be updated to provide water on the fire as

soon as possible. During firefighter Mayday incidents, ventilation openings should be

controlled [ISFSI 2013].

Fire departments should consider a change in fireground tactics based upon the research conducted by 

NIST, FSRI, and ISFSI [Madrzykowski 2013; Madrzykowski and Weinschenk 2018]. Much of this 

research has been directed toward developing a better understanding of the characteristics of modern 
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fire behavior and providing the fire service with the knowledge needed to modify essential fire-fighting 

tactics. 

Recommendation #9: Governing agencies (state, regional, and local) should consider adopting and 

enforcing regulations for interventions to reduce or eliminate the spread of fire in multi-family 

structures, including automatic sprinkler systems and self-closing doors.

Discussion: This recommendation focuses on fire prevention and minimizing the impact of a fire if one 

does occur. The National Fire Protection Association (NFPA) Fire Protection Handbook states: 

“Throughout history there have been building regulations for preventing fire and restricting its spread. 

Over the years these regulations have evolved into the codes and standards developed by committees 

concerned with fire protection. The requirements contained in building codes are generally based upon 

the known properties of materials, the hazards presented by various occupancies, and the lessons 

learned from previous experiences, such as fire and natural disasters” [NFPA 2008]. Although 

municipalities have adopted specific codes and standards for the design and construction of buildings, 

structures erected prior to the enactment of these building codes may not be compliant. Such new and 

improved codes can improve the safety of existing structures [NFPA 2008]. Sprinkler systems are one 

example of a safety feature that can be retrofitted into older structures. Sprinkler systems can reduce 

firefighter and civilian fatalities since such systems can contain and may even extinguish fires prior to 

the arrival of the fire department.

The International Code Council's International Residential Code and the NFPA 101, Life Safety Code

requires sprinkler protection in all new one- and two-family dwellings and in most other properties 

[NFPA 2021]. Fire development beyond the incipient stage is one of the greatest hazards to 

firefighters. This exposure and risk to firefighters can be dramatically reduced when fires are 

controlled or extinguished by automatic sprinkler systems [Ahrens 2021]. The presence of automatic 

fire sprinklers also reduces the exposure risk to firefighters in rescue situations by allowing the safe 

egress of building occupants before the fire department arrives on scene. Finally, by controlling fire 

development, the exposure to hazards such as building collapse and overhaul operations are greatly 

reduced, if not eliminated. NFPA statistics show that most fires in sprinklered buildings are controlled 

prior to fire department arrival by the activation of one or two sprinkler heads.

Another important factor is requiring self-closing apartment exit doors to ensure that a fire does not 

spread due to an open apartment door. Closed doors can reduce the flow path of a fire, prevent fire 

spread, and protect other building occupants from smoke and fire. Self-closing doors are an effective 

method for slowing down the spread of a fire by providing sometimes critical, life-saving time for fire 

and rescue personnel to do their job and allow individuals to escape the fire or be rescued. It is 

imperative that where such doors are in place or required that they are unobstructed and that the selfclosing mechanisms are always fully operational. Such self-closing mechanisms should be included as 

a routine inspection item to ensure proper operation of the mechanism. In situations where the 

mechanism is not functioning due to resident action, management should treat this as a violation of the

lease and take appropriate action on a case-by-case basis. The importance of the proper functioning of 

self-closing doors should be addressed during regular, on-going resident education programs on fire 

safety. 
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Finally, emergency egress doors in residential properties should never be locked from the inside 

preventing emergency egress. There are some exceptions in certain types of facilities, but where this is 

necessary there are specific procedures that must be followed in accordance with local/state 

requirements [USDHUD 1999]. 

References

Ahrens M [2021]. US experience with sprinklers. October 2021. Quincy, MA. National Fire Protection 

Association. 

Brunacini AV [2002]. Fire command. Quincy, MA: National Fire Protection Association. 

Brunacini AV, Brunacini N [2004] Command safety. Phoenix, AZ: Across the Street Publications. 

FDNY [2013]. Training Bulletin, Search 1: New York, NY: Fire Department of New York. October 

17, 2013. 

FDNY [2014]. Firefighting Procedures Volume 1, Book 1, New York, NY: Fire Department of New 

York. April 15, 2014. 

FRDNV [2013]. Engine company operations. Fire and Rescue Departments of Northern Virginia, 

firefighting and emergency operations manual. 2nd ed. Fairfax County, VA: Fire and Rescue 

Departments of Northern Virginia. 

FIRESCOPE [2017]. Field Operations Guide (FOG), ICS 420-1. Riverside, CA: FIRESCOPE. Date 

accessed: December 17, 2020. 

IAFC [2012]. Rules of Engagement for Structural Firefighting. Fairfax, VA: International Association 

of Fire Chiefs. Date accessed: May 8, 2021. 

IFSTA [2018]. Essentials of Fire Fighting, 7th ed. Stillwater, OK: Fire Protection Publications, 

International Fire Service Training Association. 

ISFSI [2013]. ISFSI Position statement—Fire dynamic research in tactical operations. Stillwater, OK: 

International Society of Fire Service Instructors. Date accessed: October 31, 2022. 

Kerber S. [2012]. Analysis of changing residential fire dynamics and its implications on firefighter 

operational timeframes. Fire Technology, 48:865-891, October 2012. 

Kerber S, Madrzykowski D, Dalton J, Backstrom B [2012]. Improving fire safety by understanding the 

fire performance of engineered floor systems and providing the fire service with information with 

tactical decision making. Northbrook, IL: Underwriters Laboratories. Date accessed: October 31, 2022. 
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Madrzykowski D [2013]. Fire dynamics: The science of firefighting. International Fire Service Journal 

of Leadership and Management 7:7-15. Date accessed: October 31, 2022. 

Madrzykowski D and Weinschenk C [2018]. Understanding and fighting basement fires. 

Columbia, MD: Underwriters Laboratories, Fire Fighter Safety Research Institute. Date accessed: 

October 31, 2022.

NFPA [2008]. Fire protection handbook. 20th ed. Quincy, MA: National Fire Protection Association.

NFPA [2014]. NFPA 1561, Standard on emergency services incident management system and 

command safety. 2014 ed. Quincy, MA: National Fire Protection Association.

NFPA [2018]. NFPA 1500, Standard on fire department occupational safety, health, and wellness 

program. 2018 ed. Quincy, MA: National Fire Protection Association.

NFPA [2021]. NFPA 101, Life safety code. 2021 ed. Quincy, MA: National Fire Protection 

Association.

NIOSH [1999]. NIOSH Alert – Request for Assistance in Preventing Injuries and Deaths of Fire

Fighters due to Structural Collapse. Cincinnati, OH: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 99-146.

NIOSH [2009]. Nine career fire fighters die in rapid fire progression at commercial

furniture showroom – South Carolina. 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 F2007-18. 

NIOSH [2011]. Two career fire fighters die and 19 injured in roof collapse during rubbish fire at an 

abandoned commercial structure—Illinois. 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 F2010-38. 

NIOSH [2013a]. Career captain sustains injuries at a 21⁄2 story apartment fire then dies at hospital—

Illinois. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Institute for Occupational Safety and Health, F2012-28. Date 

accessed: October 31, 2022.

NIOSH [2013b]. Career fire fighter dies during fire-fighting operations at a multi-family residential 

structure fire—Massachusetts. Morgantown, WV: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, 

F2011-31. Date accessed: October 31, 2022.
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NIOSH [2014]. Two career fire fighters die in a rapid fire progression while searching for tenants—

Ohio. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, F2014-02. Date accessed: 

October 31, 2022.

UL FSRI [2013]. Governors Island Experiments. Columbia, MD: Underwriters Laboratories, Fire 

Safety Research Institute. Date Accessed: May 8, 2021.

USDHUD [1999]. NOTICE PIH 99-11 (HA) Subject: Fire Safety. Washington, DC: U.S. Department 

of Housing and Urban Development, Office of Public and Indian Housing.

Weather Underground [2019]. Weather History. Atlanta, GA. The Weather Underground. Date 

Accessed: November 18, 2019.

Zevotek, R, Stakes K, and Willi J [2019]. Impact of Fire Attack Utilizing Interior & Exterior Streams 

on Firefighter Safety & Occupant Survival: Air Entrainment, Underwriter’s Laboratory, Fire Safety 

Research Institute, Columbia, MD. 

Investigator Information

This incident was investigated by Karis Kline, Safety and Occupational Health Specialist, Stephen T. 

Miles, Safety and Occupational Health Specialist, Matt Bowyer, General Engineer, with the Fire 

Fighter Fatality Investigation and Prevention Program, and Melanie Fowler, an environmental health 

Commissioned Corps officer (US Public Health Service), Surveillance and Field Investigations 

Branch, Division of Safety Research, NIOSH located in Morgantown, WV. The report was finalized 

by Murrey Loflin, Safety and Occupational Health Specialist with the Fire Fighter Fatality 

Investigation and Prevention Program. An expert technical review was provided by Jake Hoffman with 

the Toledo, OH Fire Department. A technical review was also provided by the National Fire Protection 

Association, Public Fire Protection Division. 

Additional Information

National Institute for Standards and Technology (NIST) and Underwriters Laboratories (UL)

Over the past decade, NIST and UL’s Firefighter Safety Research Institute has worked with fire 

departments and fire service organizations to conducted research on fire behavior, fire safety issues, 

and fireground operations. Since 2019, UL’s website has made available 25 training videos on these, 

and other topics. 

International Association of Firefighters (IAFF) Fire Ground Survival Program 

The IAFF Fire Ground Survival Training program provides training for Mayday prevention and 

Mayday operations for firefighters, company officers, and chief officers. Firefighters must be trained to 

perform potentially life-saving actions if they become lost, disoriented, injured, low on air, or trapped. 

Funded by the IAFF and assisted by a grant from the U.S. Department of Homeland Security through 

the Assistance to Firefighters (FIRE Act) grant program, this comprehensive fireground survival 

training program applies the lessons learned from firefighter fatality investigations conducted by the 
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National Institute for Occupational Safety and Health (NIOSH). It was developed by a committee of 

subject matter experts from the IAFF, the International Association of Fire Chiefs (IAFC), and 

NIOSH. 

IAFC Rules of Engagement for Firefighter Survival. The International Association of Fire Chiefs 

(IAFC) is committed to reducing firefighter fatalities and injuries. As part of that effort the nearly 

1,000 member Safety, Health, and Survival Section of the IAFC has developed “Rules of Engagement 

for Structural Firefighting” to provide guidance to individual firefighters, fire officers, and incident 

commanders, regarding risk and safety issues when operating on the fireground. The intent is to 

provide a set of “model procedures” for structural firefighting to be made available by the IAFC to fire 

departments as a guide for their own standard operating procedure/standard operating guideline 

development. 

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

(2014 edition) 

The primary focus of the revision to NFPA 1561 in the 2014 edition is to develop requirements 

directly aimed at reducing and eliminating fireground injuries and fireground deaths of fire department 

members. The most apparent change to this edition is the inclusion of “Command Safety” in the 

document title and the creation of a new chapter, “Command Safety.” This chapter is intended to 

provide a foundation on how to incorporate the incident management system at all emergency 

incidents, especially Type V and Type IV incidents. 

The chapter on Command Safety clearly defines the requirements for the incident commander to meet, 

including establishing a fixed command post, personnel accountability, the use of staff aides, rapid 

intervention crews, and the appointment of a safety officer and assistant safety officer(s)(as needed), 

plus the expectations and authority of the safety officer. Annexes cover Functional Assignments for 

High-Rise Building Incidents, Development of Subordinate Officers or Implementing a More Efficient 

Management System, Incident Management for the Fire Service on Type V or Type IV Incidents, and 

Structural Fire-Fighting—Risk Assessment and Operational Expectation. 

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

(2014 edition) can be purchased from the National Fire Protection Association at http://www.nfpa.org.

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. Mention of any company or product does not constitute endorsement by NIOSH or 

CDC.