Death in the Line of Duty

Editor’s note: The National Institute for Occupational Safety and Health (NIOSH) Firefighter Fatality Investigation and Prevention Program conducts investigations of firefighter line-of-duty deaths to formulate recommendations for preventing future deaths and injuries. The program does not seek to determine fault or place blame on fire departments or individual firefighters, but to learn from these tragic events and prevent future similar events. NIOSH is a unit of the U.S. Centers for Disease Control and Prevention (CDC).

Firehouse® Magazine is pleased to join with NIOSH in presenting this valuable information. It is important to note that while some incidents that will be described here occurred several years ago, the information presented is valuable today. The accounts that follow are summaries of NIOSH investigations. The complete reports are available on the program website.


Career Fire Chief Dies Searching for Fire in a Restaurant/Lounge (Case F2004-10)

On Feb. 18, 2004, a 40-year-old male career firefighter (the victim) was fatally injured in a commercial restaurant/lounge structure fire. The victim, providing mutual aid, had been searching for the seat of the fire with two volunteer firefighters from another department when one of these firefighters lost the seal on his self-contained breathing apparatus (SCBA) facepiece. The firefighter immediately abandoned the nozzle position and retreated out of the closest door. The backup firefighter also retreated out of the building when his partner left. In the black smoke and zero visibility, the firefighters were unaware that the victim was still inside the structure. Soon after, the incident commander (IC) ordered an emergency evacuation because of an imminent roof collapse, and an air horn signal was sounded. Personnel accounting indicated that a missing firefighter (the victim) was still inside the building when the roof partially collapsed. After several search attempts, the victim was found in a face-down position with his mask and a thermal imaging camera cable entangled in a chair. His facemask was dislodged and not over his mouth. He was pronounced dead at the scene.

The coroner listed the cause of death as smoke inhalation. An independent toxicology report listed the victim’s carbon monoxide level at 51% saturation. There was no notable trauma.


  • Fire departments should conduct pre-incident planning and inspections to facilitate development of a safe fireground strategy.

  • Fire departments should review, revise where appropriate, implement and enforce written standard operating guidelines (SOGs) that specifically address incident command (IC) duties, emergency evacuation procedures, personnel accountability, rapid intervention teams (RIT) and mutual aid operations on the fireground.

  • Fire departments should train on the SOGs, the incident command system and lost firefighter procedures with mutual aid departments to establish inter-agency knowledge of equipment, procedures and capabilities.

  • Fire departments should ensure that the IC maintains the role of directing fireground operations for the duration of the incident or until the command role is formally passed to another individual.

  • Fire departments should ensure that the IC conducts a risk-versus-gain analysis prior to committing firefighters to the interior and continually assesses risk versus gain throughout the operations.

  • Fire departments should consider appointing a separate, but systematically integrated incident safety officer.

  • Fire departments should ensure that all firefighters are equipped with radios that are capable of communicating with the IC.

  • Fire departments should ensure personnel accountability reports (PAR) are conducted in an efficient, organized manner and results are reported directly to the IC.

  • Fire departments should revise and enforce policies and guidelines regarding activation of personal alert safety system (PASS) devices.

  • Fire departments should ensure that firefighters train with thermal imaging cameras and they are aware of their proper use and limitations.

  • Fire departments should ensure that individual firefighters are trained and aware of the hazards of exposure to carbon monoxide and other toxic fire gases.


TENNESSEE Volunteer Firefighter Killed and Career Chief Injured During Residential Fire (Case F2002-12)

SUMMARY On March 1, 2002, a 21-year-old male volunteer firefighter (the victim) died after becoming separated, disoriented and lost as he, the chief and other firefighters were trying to escape from the interior of a fully involved house fire. Two firefighters eventually pulled the victim out of the house into the front yard, but he was unresponsive and not breathing. The victim received cardiopulmonary resuscitation and was transported to the local hospital, where he was pronounced dead on arrival.

CAUSE OF DEATH The medical examiner reported the cause of death as asphyxiation. The victim’s carboxyhemoglobin level was listed at 31.8%.


  • Fire departments should ensure that incident command (IC) conducts a complete size-up of the incident before initiating firefighting efforts and continually evaluates the risk versus gain during operations at an incident. Departments should also ensure that the first officer or firefighter inside evaluates interior conditions and reports them immediately to incident command.

  • Fire departments should ensure that adequate numbers of staff are available to operate safely and effectively.

  • Fire departments should ensure that a rapid intervention team (RIT) is established and in position immediately upon arrival.

  • Fire departments should use evacuation signals when command personnel decide that all firefighters should be evacuated from a burning building or other hazardous area.

  • Fire departments should ensure that a separate incident safety officer, independent from the incident commander, is appointed.

  • Fire departments should ensure that team continuity is maintained.

  • Fire departments should ensure that ventilation is closely coordinated with the fire attack.

  • Fire departments should instruct and train firefighters on initiating emergency traffic (Mayday-Mayday) when they become lost, disoriented or trapped.

  • Fire departments should ensure that backup lines are equal to or larger than the initial attack lines.

  • Fire departments should ensure that firefighters are equipped with a radio that does not bleed over, cause interference or lose communication under field conditions.


Volunteer Firefighter Dies During Wildland Fire Suppression(Case F2002-37)

On Aug. 1, 2002, a 48-year-old male volunteer firefighter (the victim) was severely burned while fighting a wildland fire. The victim was spraying water from the bed of a pickup truck that was equipped with a portable water tank and pump when he fell out of the truck bed into the fire. The victim ran about 200 yards trying to escape the fire, but during his escape attempt, he was severely burned. He died five days later from his burn injuries.

The coroner listed the victim’s cause of death as second- and third-degree burns over 70% of the body.


  • Fire departments should ensure that firefighters follow established procedures for combating ground cover fires.

  • Fire departments should develop and implement an incident command system.

  • Fire departments should develop, implement and enforce SOPs.

  • Fire departments should provide firefighters with wildland-appropriate personal protective equipment (PPE) that is NFPA 1977 compliant and appropriate wildland firefighter training.

  • Fire departments should use National Weather Service (NWS) Fire Weather (WX) Forecasters for all fire weather predictions and immediately share all information about significant fire weather and fire behavior events (e.g., long-range spotting, torching, spotting, gusts and fire whirls), with all personnel.

  • Fire departments should follow the 10 standard fire orders developed by the National Wildfire Coordinating Group.

  • Fire departments should ensure that the incident commander conveys strategic decisions to all suppression crews on the fireground and continuously evaluates fire conditions.


Volunteer Fire Police Captain Dies from Injury-Related Complications After Being Struck by a Motor Vehicle While Directing Traffic (Case F2003-16)

On Feb. 23, 2003, law enforcement and fire department units were dispatched to a motor vehicle incident (MVI) at a state highway/township road intersection. Emergency personnel (firefighters and fire police) were on the scene for approximately 30 minutes when a vehicle struck the victim while he was directing traffic in a heavy fog. On-scene personnel, trained as emergency medical technicians, came to the aid of the victim. He was then transported to the trauma center of a local hospital for further treatment. The victim was scheduled to be released from the hospital on March 1, 2003, but was not, due to complications. The victim remained in the hospital until April 19, 2003, when he died as a result of complications from his injuries.

The death certificate listed the immediate cause of death as severe pneumonia as a consequence of complications due to a pedestrian motor vehicle accident.