A Summary of a NIOSH fire fighter fatality investigation has been released on the incident: http://www.cdc.gov/niosh/face200410.html
A summary of the investigation states: A 40-year-old male career fire fighter (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 fire fighters from another department, when one of these fire fighters lost the seal on his self contained breathing apparatus (SCBA) face piece. The fire fighter immediately abandoned the nozzle position and retreated out of the closest door. The backup fire fighter also retreated out of the building when his partner left. In the black smoke and zero visibility, the fire fighters 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 fire fighter (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 on scene.
The report makes eleven recommendations which, had they been in place, might have saved the life of the victim. The first two outline the major problems that existed during the incident.
Recommendation #1: Conduct pre-incident planning and inspections to facilitate development of a safe fire ground strategy1-4
In this case, the metal building, roof and ceiling, and lightweight wood roof truss construction created a dangerous fire environment conducive to early structural collapse. Concealed spaces above suspended ceilings allow flame spread to go undetected.
Recommendation #2: 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.
While SOGs should be written specific to each department, there is also a need to have regional planning. The complexities of a large scale incident are already difficult without the added confusion about differences in coordinating critical operations.
