NIOSH has released the fatality investigation report into the Jan. 9, 2009 apparatus crash that killed Boston Lt. Kevin M. Kelley.
Three firefighters were injured and the 52-year-old lieutenant was killed when the ladder truck they were riding in failed to stop while traveling down a hill.
The crew of Ladder 26 had just cleared from a medical assist call prior to the incident. The driver turned left out of a parking lot and immediately had to stop and back up to allow the aerial ladder overhanging the cab enough clearance to pass a utility pole on the street.
After clearing the pole, the driver immediately negotiated a right downward curve and when he applied the brake pedal and had no response, according to the report.
The driver tried placing the ladder truck in neutral and applying the parking brake to slow the apparatus down, but there was still no response. He luckily navigated the ladder truck through a busy intersection, crashing through two parked cars and a brick wall, before coming to rest within a multi-story residential complex.
Kelley was was pronounced dead at the scene while the driver was extricated and transported to a local hospital where he was treated for serious traumatic injuries. Two other firefighters were also transported to the hospital with minor injuries.
Key contributing factors identified by NIOSH include apparatus braking system deficiencies, deficiencies in the apparatus maintenance program, insufficient training for fire apparatus operators and fleet maintenance personnel and failure to wear seat belts.
In order to minimize the risk of similar occurrences, NIOSH says fire departments should:
- Ensure that preventive maintenance programs are developed and implemented for fire apparatus according to manufacturer guidelines/specifications and national consensus standards.
- Ensure that preventive maintenance on fire apparatus is performed and/or overseen by qualified personnel who meet the certification requirements outlined in NFPA 1071 Standard for Emergency Vehicle Technician Professional Qualifications.
- Develop and utilize policies and procedures that monitor preventive maintenance and other automotive services performed by vendors.
- Work with local, state, and federal authorities having jurisdiction (AHJ) in adopting an air brake endorsement for noncommercial driver’s licenses that would require individuals operating air brake equipped fire apparatus to verify their knowledge and skill proficiency (e.g. air brake system, air pressure gauges and alarms, and pre-trip inspection) prior to operating the fire apparatus.
- Ensure that current driver training programs provide ample classroom instruction, behind the wheel driving, procedures for driver clearance, and annual refresher training.
- Develop and implement fire apparatus inspection procedures and check sheets for their fleet, provide a systematic approach for communicating and receiving inspection sheets from the field, and institute a system to file and track fleet records (e.g., inspection sheets, work orders, repairs, apparatus specifications, and maintenance).
- Ensure that policies and procedures are developed and enforced on the use of seat belts.
- Develop policies and procedures that assist with determining specifications for new apparatus and replacement cycles of existing fire apparatus.
Additionally, fire departments and fleet maintenance divisions should:
- Understand that the manual adjustment of automatic slack adjusters, a mechanical component of the air brake system that adjusts brakes as necessary when the vehicle is in operation, may contribute to unexpected brake failure.
Additionally, governing municipalities (federal, state, regional, and local) should:
- Consider enacting legislation to include operators and occupants of fire department vehicles in existing seat belt legislation and/or repeal existing laws that exempt drivers and occupants of fire service vehicles from mandatory seat belt use.