Communication Faulted in NIOSH N.J. LODD Report

A federal investigation into the Line of Duty Death (LODD) of a New Jersey career firefighter suggests that the loss of direct communication between an apparatus driver and the firefighter spotting him while backing was a primary factor leading to the tragic death when the engine backed over the veteran brother.

The National Institute for Occupational Safety and Health (NIOSH) released a report this week investigating the causes of the backing accident that resulted in the death of the 57-year-old career firefighter in a New Jersey community on Jan. 2, 2009.

NIOSH, which is a division of the federal Centers for Disease Control and Prevention, does not identify the victim, the driver of the apparatus, or the fire department (customary practice for the agency) but media at the time of the incident reported the fallen firefighter as Gary Stephens, who had served 28 years with the Elizabeth (N.J.) Fire Department.

The driver has not publically been mentioned other than to say he was an 18-year member of the department with training and certification in emergency vehicle operations. The driver was not cited in the accident.

The report states that the department, while not identifying it, is comprised of 269 uniformed firefighters with seven stations and a population of about 124,000 in a geographic area of 12 square miles.

"Key contributing factors identified in this investigation include loss of direct communications between driver and spotter, driver distractions, possible loss of footing by the victim, and possible failure of the automatic reverse braking system," the written NIOSH report states.

The 1996 apparatus involved in the accident was equipped with an after-market system that engaged the rear brakes if a rubber air chamber compressed after contact with an object. A compression of as little as 0.05 psi would make the system activate and stop the vehicle. Investigators could not determine if the system was working at the time of the incident. However, during testing after the incident, the system failed and there was damage to the rear bumper and rubber sensor that could not be attributed to the fatal incident, according to the report.

The report indicates the accident occurred during an early morning working structure fire call. The involved engine was assigned to establish a water source at a nearby hydrant to supply an elevated master stream. Initially, the engine was dispatched to do a forward lay of supply hose from the hydrant, but the orders were changed to a reverse lay enroute, according to the report. The incident commander decided to have the engine pump from the hydrant to the aerial, rather than just lay the hose which would have happened in the forward lay.

The assignment required the crew to lay hose from a hydrant 300 feet from the scene, beneath a multi-lane highway overpass that was at least partly obstructed by a police cruiser and a tow truck, according to the report.

The victim, clad in full turnout gear, with helmet and SCBA, got out of the cab to guide the driver around the cruiser and the tow truck, and walked backward, keeping an eye on the driver through the officer's side (right) mirror. The speed was estimated at about 5 mph according to the report.

While backing, the driver noticed the tow truck drive past him toward the scene and he focused his attention on that momentarily when he felt the truck run over something. A police officer yelled to the driver to stop the engine because something or someone had just been run over. The victim, according to the report was found underneath the 32,360-pound engine just in front of the officer's side rear wheels. He was transported to a local hospital where he was pronounced dead.

According to the county medical examiner's autopsy report, the victim died from blunt force trauma to the head, torso, and upper extremities.

The entire backing incident was eight minutes from the time the engine was on the scene until the victim was rescued from under the truck to his transport to the local hospital, the report said.

To help minimize the risk of similar occurrence in the department, and in others, NIOSH investigators recommended the following:

  • Ensure that standard operating procedures (SOPs) are developed, implemented, and enforced on safe backing of fire apparatus (e.g., visual and audio communication, use and position of spotter(s)) and include adequate training and testing methods (e.g. written and practical tests) to ensure fire fighter comprehension.
  • Consider evaluating current safety equipment used on fire apparatus to assist drivers during backing operations and consider supplementary safety equipment (e.g., additional mirrors, automatic sensing devices, and/or video cameras) for further assistance.
  • Implement proper procedures for inspection, use, and maintenance of safety equipment used to assist in the backing of fire apparatus to ensure the equipment functions properly when needed.

In further elaboration on the three points, the report says that even though there are lots of technologies available to aid drivers in backing, there is no substitute for visible spotters.

"Drivers need to make sure they maintain visual contact with the spotter(s) and stop backing immediately when visual contact is lost," the report said. "Backing should only be resumed when visual contact is reestablished and the designated spotter gives appropriate directions to continue."

The report said the department should consider additional backing aids, like additional mirrors, backing cameras, automatic brake systems and backing sensors. And, if the department has these, they should be inspected at the recommended intervals and repaired as necessary.

 "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," the report states.