Revised Date: June 24, 2008 

Improper Set-up of Aerial Ladders with a Locking Waterway May Put Fire Fighters at Risk 

NIOSH recommends that all fire departments utilizing aerial ladder trucks with locking (pin-anchored, lever 

actuated, clamped) waterways immediately take the following actions to reduce the risk of fire fighters being 

struck by unsecured waterways or parts of the waterway: 

• Ensure that Standard Operating 

Procedures (SOPs) and/or Guidelines 

(SOGs) on setting up multi-position

waterways include steps to properly 

position the waterway and to inspect and 

verify that the locking mechanism 

(anchoring pin(s), lever, clamps, etc.) are 

properly installed and functioning as 

designed before pressurizing the 

waterway.

• Properly train and practice the correct 

method of securing waterways and 

verifying they are secured (per 

manufacturer’s recommendations).

NIOSH is currently investigating an April 8, 2008 

fire fighter line-of-duty-death that illustrates that 

adhering to manufacturer recommended set-up 

procedures for aerial ladder operations is 

paramount to ensuring fire fighter safety. Preliminary findings in this investigation suggest that some 

equipment designs do not provide secondary stops for the waterway on aerial adders. Thus, failure to 

properly secure the waterway in the proper position can lead to catastrophic waterway failure and 

possible serious or fatal injury to fire fighters working in the area. The pin-anchored waterway design 

involved in this particular investigation is not limited to a single model or apparatus manufacturer. During 

this investigation, NIOSH became aware of at least 10 similar incidents that occurred in Delaware, Michigan, 

New Jersey, Texas, Virginia, California, Minnesota, Missouri and Ontario without serious injury. Newer 

aerial ladder trucks may incorporate different types of anchoring mechanisms and/or a more fail-safe design 

but proper set up still needs to be verified before operation.

Photo 1 - A properly seated pin at the fly section for defensive water 

stream operations is highlighted in the red circle. The hole behind it 

(yellow arrow) shows the location where the pin would be inserted (from 

the top) to keep the monitor assembly back at the second ladder section 

for rescue mode. NOTE: Various methods are used throughout the fire 

apparatus industry to secure the waterway: this picture represents a pinanchored waterway design.

Circumstances of incident under investigation by NIOSH 

On April 8, 2008, a volunteer Deputy Fire Chief (the Incident Commander), was killed when struck by a 

motorized water monitor and 30 feet of aluminum pipe that was “launched” off an elevated aerial ladder at a 

fire at an industrial manufacturing plant in Pennsylvania. The truck was normally transported in the “rescue 

mode” with the monitor pinned to the second section of ladder so that the waterway would not be in the way 

if the ladder was set up for rescue operations. At the incident scene, when the waterway was pressurized, the 

monitor and its support bracket, along with the last 30-foot section of pipe were “launched” off the aerial 

ladder by the force of the water pressure in the pipe. The monitor flew approximately 75 feet and fell, 

striking the Incident Commander on the head, killing him instantly. After the incident, the anchor pin was 

found on the ground, in front of the truck’s cab. The waterway did not include any secondary mechanical 

stops to prevent the separation of the water monitor in the event the anchoring pin was not properly seated. 

The NIOSH Fire Fighter Fatality Investigation and Prevention Program is currently investigating this incident 

and a full report will be available at a later date. 
 

2 

NIOSH Safety Advisory: Improper Setup of Aerial Ladders (cont.) Revised Date: June 24, 2008

NIOSH would like to bring this information to the attention of all U.S. fire departments and fire fighters who 

operate or work around aerial ladder trucks with locking (pin-anchored, lever actuated, clamped) waterways 

so that future occurrences of waterway monitor “launches” or the unexpected movement of the waterway 

monitor can be prevented. If secondary mechanical stops are present, the unexpected impact of the waterway 

monitor against the mechanical stop could cause structural damage to the aerial ladder and jeopardize the 

safety of any fire fighter standing on the aerial ladder. While not a contributing factor in the fatal incident, 

NIOSH reminds fire departments to comply with relevant federal regulations and NFPA standards for fire 

apparatus inspections and certification. 

Photo 2 – Aerial ladder with monitor at tip Photo 3 – anchoring pin

Photo 4 – Monitor and pipe that “launched” Photo 5 - The receiver assembly where the pin is inserted 

 

The NIOSH Fire Fighter Fatality Investigation and Prevention Program is conducted by the National 

Institute for Occupational Safety and Health (NIOSH). The purpose of the program is to investigate fire 

fighter line-of-duty-deaths and formulate recommendations for preventing future deaths and injuries. The 

program does not seek to determine fault or place blame on fire departments or individual fire fighters but 

to learn from these tragic events and prevent future similar events. For more information, visit the 

program website at www.cdc.gov/niosh/fire or call 1-800-CDC-INFO.