Page i

40-Year-Old Firefighter Dies While Driving a Water Tender to a

Fire—Michigan

Executive Summary

A 40-year-old volunteer firefighter (Driver) was driving a fire department (FD) water tender to a fire 

along with a candidate firefighter (Candidate) when he became unconscious and subsequently died. 

The Driver told the Candidate that he was not feeling well and then collapsed over the steering wheel. 

The Candidate was able to stop the water tender, set the parking brake, and then move the Driver out of 

the vehicle and to the ground. The Candidate noted that the Driver was pulseless and called on the fire 

radio for assistance as he started chest compressions. A fire crew that was also enroute to the fire 

arrived within minutes to assist the Candidate with cardiopulmonary resuscitation (CPR). As the fire 

crews were performing CPR, an advanced life support (ALS) transport ambulance arrived and initiated 

ALS care as the Driver was loaded in the ambulance and transported to the nearest hospital. Continued 

resuscitation efforts enroute and in the emergency department (ED) were unsuccessful and he was 

pronounced dead. 

The medical examiner’s report listed the cause of death as atherosclerotic coronary artery disease. The 

medical examiner found severe atherosclerosis of the left anterior descending coronary artery and left 

circumflex coronary artery. Mild atherosclerosis of the aorta was also noted.

Key Recommendations 

The National Institute for Occupational Safety and Health (NIOSH) offers the following 

recommendations to reduce the risk of heart attacks and sudden cardiac arrest among firefighters at this 

and other fire departments across the country. 

• Key Recommendation #1: Implement comprehensive pre-placement and annual medical

evaluations consistent with National Fire Protection Association (NFPA) 1582 Standard on

Comprehensive Occupational Medical Program for Fire Departments, which should include a

baseline electrocardiogram (EKG) in all individuals prior to engagement in any strenuous

physical activity to rule out any underlying cardiac abnormalities [NFPA 2022].

• Key Recommendation #2: Consider a preplacement cardiac exercise stress test to determine the

capacity for physical exertion and decrease the risk for sudden cardiac death.

• Key Recommendation #3: Implement an annual fitness evaluation consistent with NFPA 1582

Standard on Comprehensive Occupational Medical Program for Fire Departments to ensure

personnel are physically fit to perform job expectations at emergencies [NFPA 2022].

F2021-06 • February 2023
Page i

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 provide a 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 Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
40-Year-Old Firefighter Dies While Driving a Water Tender to a 

Fire—Michigan

Page 1

F2021-06 • February 2023

Introduction

On November 18, 2020, fire department (FD) crews were dispatched to a reported camper on fire. The 

Driver was driving the water tender to the fire when he became unconscious and collapsed over the 

steering wheel. The Candidate riding in the front passenger seat on the water tender was able to safely 

bring the vehicle to a stop, remove the Driver, and start chest compressions. Personnel on an engine 

(Lieutenant [LT] and firefighter [FF]) also responding to the fire call, stopped, and assisted with basic 

life support (BLS). An ALS transport ambulance arrived and initiated advanced life support (ALS)

care. The Driver was transported to the nearest emergency room where he was pronounced dead.

In July 2021, a contractor (National Institute for Occupational Safety and Health [NIOSH] 

investigator) for the NIOSH Fire Fighter Fatality Investigation and Prevention Program (the NIOSH 

investigator) conducted a series of telephone and email interviews to investigate the incident.

During the investigation, the NIOSH investigator interviewed the Fire Chief and reviewed written 

statements provided by the:

• Candidate firefighter

• Firefighter

• Lieutenant

The NIOSH investigator reviewed the following documents:

• FD records

• Emergency medical services (EMS) (ambulance) report

• Emergency department (ED) records

• Autopsy report

Fire Department

At the time of the NIOSH investigation, the FD consisted of 22 volunteer firefighters and officers 

working out of a single fire station. The FD serves a population of approximately 4,000 in a 

geographic area of about 100 square miles and responds to approximately 100 fires and 

400 medical calls annually.
Page 2

40-Year-Old Firefighter Dies While Driving a Water Tender to a Fire—

Michigan

Report # F2021-06

Employment and Training

Applicants must be at least 18 years of age, have a clean driving record and no felonies. All firefighters 

can be certified to drive by the department after demonstrating proficiency. The Driver had been a 

member of the department for three years and was certified to drive and operate FD equipment.

Preplacement/Periodic/Return to Work Medical Evaluations

At the time of the interview, the FD did not require a pre-placement medical evaluation for applicants 

and/or annual medical evaluations for incumbents consistent with National Fire Protection Association 

(NFPA) 1582 Standard [NFPA 2022].

Wellness/Fitness Programs

At the time of the incident, the FD did not have a wellness/fitness program.

Investigation

On November 18, 2020, at approximately 2030 hours the FD was dispatched to a camper on fire. A 

chief brush truck, water tender, and fire engine responded to the camper fire. The water tender left the 

station first, and the brush truck followed. As they were responding to the reported fire, the Driver 

asked the Candidate if he was buckled in because a seatbelt alarm was sounding. After unbuckling and 

buckling the seatbelt again, the alarm turned off. The brush truck passed the slower water tender once 

they were outside of the city limits. The Candidate was seated in the front passenger seat of the water 

tender. The Driver asked the Candidate for the address of the fire, the Candidate found the address, and 

entered it into his phone to provide directions. The Candidate said everything seemed fine as they 

made a few turns to get to the fire, but then the Driver told the Candidate that he needed to pull over. 

The Candidate initially thought the Driver was having difficulty with his seatbelt, but then realized 

there was another problem when the water tender began to slow down and veer to the left, crossing the 

oncoming lane. The Candidate watched as the Driver slumped over the steering wheel and called out to 

him a couple of times with no response. The Candidate then reached over from the passenger seat and 

steered the moving vehicle off the road, put the water tender in neutral, and set the air brakes.

After stopping the water tender, the Candidate jumped out of the passenger seat and walked to the 

driver’s side, opened the door, and pushed the Driver back against the seat and away from the steering 

wheel. The Driver was unresponsive, and the Candidate got on the radio and called for dispatch. After 

three attempts with no response from dispatch, a LT responding to the camper fire in the fire engine 

got on the radio and asked the Candidate what he needed. The Candidate stated the Driver was down 

and unresponsive. The LT told the Candidate that they were only a couple blocks away and they would 

be there shortly to help. As the LT was talking with the Candidate, he told the FF with him in the 

engine to call dispatch on the fire channel for EMS assistance. The FF called dispatch and requested an 

ambulance as the LT continued to assure the Candidate that EMS was enroute. The Candidate was able 

to remove the Driver from the water tender, lay him on the pavement, and begin chest compressions.

As the engine approached the scene, the LT could see the lights from the water tender on the opposite 

side of the road and the Candidate doing chest compressions on the Driver. Once the engine stopped, 

the LT went to get medical equipment and the FF assisted with compressions. The FF noticed the 
Page 3 

40-Year-Old Firefighter Dies While Driving a Water Tender to a Fire—

Michigan

Report # F2021-06

Driver’s face was blue and he had agonal respirations. After doing compressions for a few minutes, the 

FF noticed that the Driver was beginning to breathe and discontinued compressions. The FF and 

Candidate removed the Driver’s boots, bunker pants, coat, and ripped open his T-shirt. The Driver’s 

skin was pale and sweaty, and although his breathing was beginning to become relatively normal, his 

face still appeared cyanotic. He had a slow and weak carotid pulse, and his left arm would move 

sporadically. The FF asked the Driver several questions, including if his chest, back, or head hurt. At 

each question, the Driver would respond with a faint, unintelligible verbal sound. The Driver attempted 

to roll onto his right side, and then there was no additional noticeable responses. 

The ambulance arrived at 2103 hours, and the Driver was placed on the cardiac monitor. The initial 

rhythm was idioventricular. The Driver was placed on the stretcher and cardiopulmonary resuscitation 

(CPR) was continued until the automated CPR machine was set up. After unsuccessful attempts at 

starting an intravenous (IV) line, an intraosseous (IO) line was placed in the Driver’s left tibia. A 

supraglottic airway device was placed in the Driver’s airway and he was suctioned due to profuse 

vomiting. Four doses of epinephrine were administered on scene at 2109 hours. While enroute to the 

hospital, another two doses of epinephrine were administered with one dose of 300 milligrams (mg) 

Amiodarone, and the automatic external defibrillation (AED) indicated a shock when the rhythm 

changed to pulseless electrical activity. The ambulance arrived at the ED at 2126 hours. Recusation 

efforts were unsuccessful, and he was pronounced dead. 

Medical Findings

The medical examiner’s report listed the cause of death as atherosclerotic coronary artery disease. The 

medical examiner found severe atherosclerosis of the left anterior descending coronary artery and left 

circumflex coronary artery. The left anterior descending coronary artery had 80 to 85 percent luminal 

atherosclerotic stenosis and the left circumflex coronary artery had 70 to 75 percent luminal 

atherosclerotic stenosis. Mild atherosclerosis of the aorta was also noted. 

Discussion 

Sudden Cardiac Events 

Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) refer to the sudden cessation of cardiac 

activity with hemodynamic collapse, usually due to sustained ventricular tachycardia/ventricular 

fibrillation. These events mostly occur in patients with structural heart disease (that may not have been 

previously diagnosed), particularly coronary heart disease (CHD). If corrective measures are not taken 

rapidly, this condition progresses to SCD. 

SCD accounts for 300,000–400,000 deaths annually in the United States. Most sudden deaths are 

cardiac, and most SCDs are related to arrhythmias secondary to structural heart disease or primary 

electrical abnormalities of the heart [Isbister and Semsarian 2019; Jazayeri and Emert 2019; Kuriachan 

et al. 2015; Podrid 2022]. SCA usually occurs in people with some form of underlying structural heart 

disease, and as much as 70 percent of SCAs have been attributed to CHD. The risk of experiencing 

SCA increases dramatically with age and with underlying cardiac disease. Men are two to three times 

more likely to experience SCA than women. SCD is the mechanism of death in over 60 percent of 

patients with known CHD. In addition, SCA is the initial clinical manifestation of CHD in 

approximately 15 percent. Even among the young, CHD is a relatively common cause of SCD. In one 
Page 4

40-Year-Old Firefighter Dies While Driving a Water Tender to a Fire—

Michigan

Report # F2021-06

study, CHD was the second most common condition (22%) underlying SCD among subjects aged 5 to 

34 years. In this study, the most common SCA-related conditions were sudden arrhythmic death 

syndrome (31%), coronary artery disease (22%), and hypertrophic cardiomyopathy (14%). There was a 

high overall prevalence of established cardiovascular risk factors (obesity, diabetes mellitus, 

hypertension, hyperlipidemia, smoking) with ≥ 1 risk factors in 58% of all SCA cases [Jayaraman et al.

2018].

Risk factors for SCA include dyslipidemia, hypertension, cigarette smoking, physical inactivity, 

obesity, diabetes mellitus, and a family history of premature CHD or myocardial infarction. There is 

also some evidence that acutely stressful situations increase the risk of SCA. Individuals of African 

American descent appear to have a higher rate of SCD, and poorer outcomes compared to those of 

Caucasian or Hispanic descent [Wong et al. 2019].

The approaches to preventing SCA and SCD are focused on identifying underlying risk factors and 

severe CHD that increases the risk of a fatal event. There are several risk factors that can be used to 

calculate a risk score for CHD, including the BMI, blood pressure, serum lipids and glucose. Based on 

age and risk factors, the American Cardiology Association/American Heart Association (ACC/AHA)

atherosclerotic cardiovascular disease (ASCVD) risk calculator can estimate the percent 10-year risk of 

heart attack or stroke [ACC/AHA 2021; Andrus and Lacaille 2013].

An exercise tolerance test can identify the presence of CHD that increases the risk of fatal and nonfatal cardiac events. An abnormal EKG that shows myocardial ischemia with exercise (loss of blood 

flow to the heart muscle) increases the risk of future CHD events, especially in those individuals with 

other risk factors for heart disease (high blood pressure, high lipid levels, elevated blood sugar or 

obesity) [Balady et al. 2004; Bruce et al. 1980; Mégnien and Simon 2009; Michaelides et al. 1990, 

1995, 2005; Sumanen et al. 2005; Van Campen et al. 1996].

Recommendations

Recommendation #1: Implement comprehensive pre-placement and annual medical evaluations 

consistent with NFPA 1582 Standard on Comprehensive Occupational Medical Program for Fire 

Departments, which should include a baseline EKG in all individuals prior to engagement in any 

strenuous physical activity to rule out any underlying cardiac abnormalities [NFPA 2022].

Discussion: NIOSH recommends that all new and incumbent personnel participate in annual medical 

evaluations to determine that personnel are healthy enough to participate in strenuous activity and to 

identify potential injuries or illnesses. Guidance regarding the content and frequency of the medical 

evaluations for firefighters can be found in Chapter 7 of NFPA 1582. At the time of the incident, the 

volunteer department did not have medical examination requirements for personnel. The Driver 

suffered from atherosclerotic cardiovascular disease, a condition where the arteries become narrowed 

and hardened due to buildup of plaque (fats) in the artery wall. When detected, atherosclerotic 

cardiovascular disease is treatable [NFPA 2022].

Recommendation #2: Implement a preplacement cardiac exercise stress test to determine the 

capacity for physical exertion and decrease the risk for sudden cardiac death.

Discussion: In an individual with CHD, an exercise stress test can detect ischemia (areas of the heart 

where the blood supply is not adequate) that increases the risk of fatal and non-fatal cardiac events. An 
Page 5 

40-Year-Old Firefighter Dies While Driving a Water Tender to a Fire—

Michigan

Report # F2021-06

exercise stress test should be considered for new firefighter job applicants (preplacement), especially 

for those individuals who have risk factors for heart disease ((high blood pressure, high lipid levels, 

elevated blood sugar or obesity). If the stress EKG indicates ischemia, the individual should be 

referred to a heart specialist for additional evaluation to determine if there may be an increased risk for 

SCA and SCD while performing firefighter job tasks. 

Recommendation #3: Implement an annual fitness evaluation consistent with NFPA 1582 Standard 

on Comprehensive Occupational Medical Program for Fire Departments to ensure personnel are 

physically fit to perform job expectations at emergencies [NFPA 2022].

Discussion: Although fire department personnel are exempt from commercial vehicle medical 

requirements when driving fire apparatus in Michigan, MIOSHA R408.17411(b) states, “Duties of 

employer - assure that prospective fire service personnel are physically fit and have the ability to 

perform assigned emergency operations” [MIOSHA 2022]. NIOSH recommends that fire departments 

phase in annual fitness evaluation program that is consistent with NFPA 1582-Chapter 8-Annual 

Occupational Fitness Evaluation of Members to ensure personnel can meet state and job requirements. 

NFPA 1582 [NFPA 2022]. 

NIOSH recognizes the challenges that volunteer departments face regarding funding and finding 

personnel. One consideration to meet the fitness evaluation standard, is to utilize recommendations for 

fitness assessments outlined in the annex section of NFPA 1583 - Standard on Health-related Fitness 

Programs for Fire Department Members. Although the annex is not a NFPA requirement, it does 

provide many benefits for fitness assessment [NFPA 2022]. 

References 

ACC/AHA [2021]. Atherosclerotic cardiovascular disease (ASCVD) risk estimator. Washington, D.C.: 

American College of Cardiology/American Heart Association. 

Andrus B, Lacaille D [2014]. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. J 

Am Coll Cardiol 63(25 Pt A):2886. 

Balady GJ, Larson MG, Vasan RS, Leip EP, O'Donnell CJ, Levy D [2004]. Usefulness of exercise 

testing in the prediction of coronary disease risk among asymptomatic persons as a function of the 

Framingham risk score. Circulation 110(14):1920–1925. 

Bruce RA, DeRouen TA, Hossack KF, Blake B, Hofer V [1980]. Value of maximal exercise tests in 

risk assessment of primary coronary heart disease events in healthy men: five years' experience of the 

Seattle heart watch study. Am J Cardiol 46(3):371–378. 

Isbister J, Semsarian C [2019]. Sudden cardiac death: an update. Intern Med J 49(7):826–833. 

Jayaraman R, Reinier K, Nair S, Aro AL, Uy-Evanado A, Rusinaru C, Stecker EC, Gunson K, Jui J, 

Chugh SS [2019]. Risk factors of sudden cardiac death in the young: multiple-year community-wide 

assessment. Circulation 137(15):1561–1570. 

Jazayeri MA, Emert MP [2019]. Sudden cardiac death: who is at risk? Med Clin North Am 

103(5):913–930. 
Page 6 

40-Year-Old Firefighter Dies While Driving a Water Tender to a Fire—

Michigan

Report # F2021-06

Kuriachan VP, Sumner GL, Mitchell LB [2015]. Sudden cardiac death. Curr Probl Cardiol 40(4):133–

200. 

Mégnien JL, Simon A [2009]. Exercise tolerance test for predicting coronary heart disease in 

asymptomatic individuals: a review. Atherosclerosis 205(2):579–583. 

Michaelides AP, Triposkiadis FK, Boudoulas H, Spanos AM, Papadopoulos PD, Kourouklis KV, 

Toutouzas PK [1990]. New coronary artery disease index based on exercise-induced QRS changes. Am 

Heart J 120(2):292–302. 

Michaelides A, Ryan JM, Bacon JP, Pozderac R, Toutouzas P, Boudoulas H [1995]. Exercise-induced 

QRS changes (Athens QRS score) in patients with coronary artery disease: a marker of myocardial 

ischemia. J Cardiol 26(5):263–272. 

Michaelides AP, Aigyprladou MN, Andrikopoulos GK, Richter DJ, Kartalis A, Tapanlis E, Fourlas CA, 

Stefanadis CI [2005]. The prognostic value of a QRS score during exercise testing. Clin Cardiol 

28(8):375–380. 

MIOSHA [2022]. Part 74: firefighting. Section R. 408.17411. Duties of employer. Lansing, MI: Labor 

and Economic Opportunity, Michigan Occupational Safety and Health Administration. 

NFPA [2022]. NFPA 1582. Standard on comprehensive occupational medical program for fire 

departments. Quincy, MA: National Fire Protection Association. 

NFPA [2022]. NFPA 1583. Standard on health-related fitness programs for fire department members. 

Quincy, MA: National Fire Protection Association. 

Podrid PJ [2022]. Overview of sudden cardiac arrest and sudden cardiac death. In: UpToDate. Alphen 

aan den Rijn, Netherlands: Wolters Kluwer. 

Sumanen M, Jussila M, Mattila K [2005]. Exercise treadmill test may predict clinical outcome among 

working-aged patients suspected of coronary heart disease in general practice. Scand J Prim Health 

Care 23(1):47–51. 

van Campen CM, Visser FC, Visser CA [1996]. The QRS score: a promising new exercise score for 

detecting coronary artery disease based on exercise-induced changes of Q-, R- and S-waves: a

relationship with myocardial ischaemia. Eur Heart J 17(5):699–708. 

Wong CX, Brown A, Lau DH, Chugh SS, Albert CM, Kalman JM, Sanders P [2019]. Epidemiology of 

sudden cardiac death: global and regional perspectives. Heart Lung Circ 28(1):6–14. 

Investigator Information

This incident was investigated by the NIOSH Fire Fighter Fatality Investigation and Prevention 

Program, Cardiac/Medical Team, in Cincinnati, Ohio. TJ Welch is a Firefighter Safety Specialist and 

worked in volunteer, industrial and municipal fire departments and co-authored the report. Mr. Welch 

is a State Certified Fire Officer, founding member of the California Incident Command Certification 

System, and chaired the CICCS committee on Physical Fitness Standards. Dr. Robert Harrison MD, 

MPH (California Department of Public Health) provided medical consultation, and Laura Styles, MPH 

(Public Health Institute) also contributed to this report. 
Page 7

40-Year-Old Firefighter Dies While Driving a Water Tender to a Fire—

Michigan

Report # F2021-06

Disclaimer

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to Web sites 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 Web sites.