Read NISOH Report NIOSH investigators have listed communications issues, inadequate planning and operational snafus as factors in a 2008 blaze that claimed the lives of two North Carolina firefighters. Victor Isler, 40, and Justin Monroe, 19, members of the Salisbury Fire Department, were overcome by a raging fire in a millwork building. A captain, who also was part of the interior firefighting team, as well as several others were hurt. NIOSH investigators reported: "The captain attempted to radio for assistance as the conditions deteriorated but fire fighters (sic) on the outside did not initially hear his Mayday. Once it was realized that the crew was in trouble, multiple rescue attempts were made into the burning warehouse in an effort to reach the trapped crew as conditions deteriorated further. Three members of a rapid intervention team (RIT) were hurt rescuing the injured captain." Among the contributing factors in the deadly outcome by officials who probed the incident included: Intermittent radio communication problems (unintelligible transmissions in and out of the fire structure) led to RIT teams being activated multiple times prior to the actual Mayday event and the potential misunderstanding of operational fireground communications at various points in the incident. Inadequate size-up and incomplete pre-plan information may have contributed to a misunderstanding in the location of the doorways connecting the warehouse to the office area. The deep-seated fire burning within the floor of the office area that was able to spread to the rest of the production and warehouse facilities. The concealed space between the basement ceiling and office floor contained solid wood floor joists representing a large concealed fuel load. The procedures used in which operational modes were repeatedly changed from offensive to defensive. Lack of crew integrity at a critical moment in the event. Weather conditions and the location of the command post contributed to poor visibility of the fire scene from the command and impacted accessibility of the command post by command and general staff. NIOSH investigators went on to suggest a number of recommendations. They include: Ensure that detailed pre-incident plan information is collected and available when needed, especially in high risk structures limit interior offensive operations in well-involved structures that are not equipped with sprinkler systems and where there are no known civilians in need of rescue develop, implement, and enforce clear procedures for operational modes. Changes in modes must be coordinated between the Incident Command, the command staff and fire fighters ensure that Rapid Intervention Crews (RIC) / Rapid Intervention Teams (RIT) have at least one charged hose line in place before entering hazardous environments for rescue operations ensure that the incident commander establishes the incident command post in an area that provides a good visual view of the fire building and enhances overall fireground communication ensure that crew integrity is maintained during fire suppression operations encourage local building code authorities to adopt code requirements for automatic protection (sprinkler) systems in buildings with heavy fire loads.