The NIOSH Fire Fighter Fatality Investigation Reports


Firefighting is one of the most dangerous occupations because of the high rate of injuries and deaths related to the occupation. Firefighters are exposed to many hazards and risks including building collapses, extreme weather, heat, smoke, chemicals and stress. Considering these hazards, it is no surprise that staff in this occupation suffer many injuries and deaths than any other occupation in the United States.  The purpose of this paper is to conduct a research on an NIOSH Fire Fighter Fatality Investigation report that has affected how the fire service conducts its business. Therefore, this paper will conduct research on NIOSH Report F2018-06.

 NIOSH Report #F2018-06

This NIOSH investigation was carried out on two male career fire fighters, ages 50 and 29, who died in line of duty following a structure collapse. The two died while working to put off hot spots following a structure fire in a 140-year old mill building (Center for Disease Control and Prevention, 2019).

On March 21, 2018, New York Fire Department and Rescue Services battled a major fire in a 140-year old mill building under renovation to convert into apartments. The crews waged offensive interior attack and eventually defensively due to unsafe situation. While the main fire was put off, hot spots on the 3rd and 4th floors remained. The structure sustained several partial collapses. On March 22, 2018, the building owner, fire officials and the contracted engineer conducted visual inspection of the building for structural stability. The fire department personnel made a decision to access these upper floors by aerial ladder in order to put off the remaining hot spots (CDC, 2019). Three firefighters and a shift commander entered the floors with a hose line. No sooner had the crew started working than a collapse happened dropping them four floors down and got trapped, it took 29 minutes to free them from the debris. Two firefighters sustained fatal injuries (died in a hospital) while the other two sustained serious injuries. This incident illustrates that responder injuries and deaths can occur anytime and anywhere. It is important therefore to have an occupational safety and health program in all fire departments.

An investigation was completed which revealed that the building under construction lacked active sprinkler system and that the long-burning, deep-seated fire could not be reached by exterior master streams. In addition, the investigation showed that the building has previous partial collapse that contributed to the structure collapse. Furthermore, the firefighters made a mistake of entering the collapse zone after defensive fight thereby putting themselves in danger. Failure to indicate or mark collapse zones made the crew to act or behavior in manner that put their lives in danger. The investigation also pointed out inadequate risk v. gain analysis on the part of the Incident Commander (CDC, 2019).

The NIOSH investigation led to a number of recommendations. It recommended that fire departments should ensure firefighters receive training on collapse hazards of various structure construction types. Training all firefighters on structural collapse could help them understand dead loads as the largest amount of a building’s structural strength and subsequent weight and the lethal consequences of their failure. They should also train firefighters on the hazard of working within a collapse zone. The investigators also concluded that fire departments should make sure that the Incident Command conducts initial risk assessment and continuous assessment and communicate this information to the personnel at the scene. The strategy and tactics should match the conditions experienced as part of the continuous size-up.

The investigation made additional recommendation on the need for building owners, local governments and authorities to consider the use of sprinkler systems in residential apartments and commercial structures including during renovations (Angle, 2021). Municipalities, authorities and building owners should ensure sprinkler systems are installed in apartment complexes within their jurisdictions. Sprinkler systems can minimize firefighter fatalities because such systems can extinguish fires even before the arrival of the fire department. The incident Command should establish collapse zones and the same communicated to the screw at the scene for their own safety. In addition, the Incident Command should empower firefighters to stop or suspend unsafe practice, behaviors and actions that might put them in danger. The fire department should also ensure a separate Incident Safety Officer is appointed at each fire structure. Incidents such as these escalate in complexity and size that the IC becomes overwhelmed. Assigning an ISO to take responsibility for safety of the personnel and to assess the scene for hazards or unsafe conditions is necessary (Nation Fire Protection Association, 2007). On-scene health and safety of firefighters is best preserved by delegating responsibility to an ISO.  Personnel safety is influenced by clear and timely communication among the IC and ISO.

In addition, local authorities and municipalities should coordinate the gathering of building data and the information sharing between fire departments and building authorities. Local authorities having jurisdiction should create a checklist to make sure the preplan inspection of buildings garner the appropriate data on building characteristics, such as the type of construction, occupancy, material used, floor and roof design, fuel load, and distinguishing features. Once this information is captured, it is stored digitally and made available in case of an incident occurs.

The Command System was very much functioning. The Incident Commander (IC) did conduct size-up and risk assessment of the incident scene prior to starting interior firefighting. During the assessments general factors are considered, such as potential for civilians in the building, occupancy type involved, type of construction, age of structure, fire and smoke conditions. The IC, together with the contracted engineer and building owner also conducted visual inspection of the building and came to the decision that upper floors could be accessed by elevated aerial ladder. The IC did also request personal accountability report and order evacuation when the situation seemed unsafe (Angle, 2021). Personal accountability helps identify and track all personnel working at the incident scene in order to found who is missing, in danger or injured. The IC also called for additional; resources when the crew became entrapped following the collapse. However, the IC failed to establish a collapse zone following the initial risk assessment, a move that pout the fire fighters in danger. It is incumbent upon the IC to establish collapse zones and other zones to keep the screw safe.  The IC failed to continually evaluate the risk v. gain when deciding whether to engage in offensive or defensive fire suppression efforts. The Incident Command never appointed an Incident Safety officer (ISO) at the incident scene. NIOSH recommends the appointment of an ISO at each fire structure. In addition, the screw that entered the unsafe upper floors was not well equipped, especially with communication devices and the action to take if trapped.

The incident reminded local fire departments the importance of conducting pre-incident planning building inspections within their areas of jurisdiction to allow for the development of safe fire ground strategies. It also emphasized the importance of developing, implementing and enforcing standard operating procedures (SOP) for occupational safety and health program. Members serving in command roles released the need for written SOP in identifying incident management training standards (Center for Disease Control and Prevention, 2009). The SOP concerns safe fireground tactics that firefighter should use when operating in structures having truss construction. The incident served as a wakeup call to fire departments to ensure offensive and defensive attack is performed employing adequate fire streams and adequate water supply. The incident also highlighted the need to train firefighters on course of actions to take if they become trapped inside a collapsed building or structure.

No legal issues emerged from the incident. This does not mean that the incident had legal concerns. For example, the building owner was at fault given that the building had previous partial collapse. Similarly, the incident did not produce any legislation per se. the state of New York never passed any piece of legislation at the time to improve the safety of firefighters in response to this incident. Nonetheless, the two firefighters who lost their lines in the line of duty are the 12th and 13th firefighters to be killed in the history of the New York Fire Department (The Associated Press. (2018).


Angle, J. (2021). Occupational safety and health in the emergency services. Burlington, MA : Jones & Bartlett Learning

Center for Disease Control and Prevention. (2009). Nine Career Fire Fighters Die in Rapid Fire Progression at Commercial Furniture Showroom – South Carolina. Retrieved January 20, 2022 from

Center for Disease Control and Prevention. (2019). Structure Collapse at 140-Year Old Mill Building Kills 2 Career Fire Fighters and Injures 2 Others – Pennsylvania. Retrieved January 20, 2022

Nation Fire Protection Association. (2007). NFPA 1500: Standard on Fire Department Occupational Safety and Health Program. Quincy, MA: National Fire Protection Association

The Associated Press. (2018). A ‘tragic day in York’s history’: 2 firefighters dead, 2 injured in building collapse. The Morning Call. Retrieved January 20, 2022

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