Firefighter Injury Project Investigation Report

FIP Investigation #4

Two Firefighters Injured In A Fire With Reported Missing Persons

Division of Safety Research, National Institute for Occupational Safety and Health

Firefighter Injury Project (FIP), New Jersey Department of Health (NJDOH)

Two Firefighters Injured in A Fire With Reported Missing Persons, Firefighter Injury Investigation #4


On March 1, 1997, a municipal fire department responded to a 911 call to a house fire. As the firefighters were on route to the scene, they heard police reports on their radios that people were jumping out of windows. Upon arrival, they found injured people lying on the pavement and a man hanging out of an attic window screaming, engulfed by smoke, his clothes burned, ready to jump 30 feet to the pavement. Eighteen residents of the building were sent to area hospitals. Residents reported the possibility of more people trapped in the building that was engulfed in smoke and flames. Firefighters aggressively fought the fire and searched for missing persons for approximately an hour before they were allowed a rest period. At approximately 8:30 a.m., they were relieved by the next shift of firefighters. After being relieved, the firefighters were medically evaluated at the scene by emergency medical services (EMS) personnel. Two firefighters had symptoms associated with smoke inhalation. Each had inhaled smoke for short periods while they searched for missing people in the house. They were taken to an emergency room for evaluation and treatment for smoke inhalation.

New Jersey Department of Health (NJDOH) Firefighter Injury Project (FIP) investigators concluded that in order to prevent similar incidents in the future, the following guidelines should be followed:

  • Firefighters should be given supervised rest periods with appropriate frequency.
  • Adequate staffing should be maintained.

  • Firefighters should immediately exit hazardous atmospheres when their self contained breathing apparatus (SCBA) low air alarm sounds.


On March 10, 1997, the Firefighter Injury Project (FIP) staff learned about the firefighters' injuries from a newspaper article. On April 3, 1997, the fire department chief was called to ask if the department and injured firefighters would participate in a study of firefighter injuries.

On April 10, 1997, FIP investigators interviewed the injured firefighters, incident commander, training officer, and safety officer. Fire Incident Reports, department standard operating procedures (SOPs), respiratory protection program, and training materials were reviewed. The exterior of the incident site was photographed. and a video was viewed of the initial response to the scene by ambulances and fire departments, which was taken by an arriving emergency medical worker from his ambulance. Emergency room medical records were also reviewed during the investigation.

The employer was a paid municipal fire department established in 1863 that served a city of residential and industrialized areas of about three square miles, one square mile of which was parkland. The city's population was about 58,000 in 1996. Department personnel stated that approximately 3,200 calls were answered each year.

The department's 101 firefighters were divided among two fire stations. The command structure included one department chief and four deputy chiefs. Personnel assigned to fire suppression duties worked 24 hours on and then had 72 hours off. Each shift had a deputy chief assigned to the fire suppression unit. The six department firefighting vehicles were maximumly staffed with four firefighters (one officer and three firefighters), a total of 24 firefighters for a shift. However, the average number of staff on a shift was 18 due to vacations, sick, or other leave. Fire department vehicles had to be staffed with at least three firefighters in order to be put in service, which was the norm. The average years of experience for all the firefighters in the department was about 11 years. Forty percent of the staff had less than four years experience. A staff of about 150 firefighters in the late 1970's had been downsized to approximately 100 by 1996.

The department had an extensive training program administered by a full time department training officer. Firefighters were provided with about two hours of drill training on each weekday shift for a total of approximately 120 hours of training per year. Training for new recruits was provided by the department. They received 268 hours of classroom training and practical exercises that included a New Jersey Department of Community Affairs - approved Firefighter 1 course. Some of the topics covered by the course included SCBA use, and firefighting strategies and tactics. A full time safety officer routinely performed spot checks to determine the firefighters compliance with department SOPs and policies. If a violation was observed, a written notice would be issued advising the firefighter of the proper procedures to be followed.


On March 1, 1997, at 7:17 a.m., a 911 call came in reporting a fire several blocks away from the fire house where the firefighters were working the final hour of a 24 hour shift. In responding to this alarm, firefighters followed standard operating procedures (SOPs) requiring that all turn out gear (firefighting protective clothing) be put on before their fire engine and ladder trucks leave the firehouse. SCBA units were stored on the fire vehicles in jump seats and were put on their backs and secured on the way to the scene. The SCBA air tanks had a 30 minute use rating, although extreme physical exertion could decrease the actual time of usage. Firefighters were prepared to "go on air" in the event it was needed.

On route to the scene, firefighters observed a thick black column of smoke and heard police radio reports of people jumping out of windows. The incident commander ordered a second alarm. Within minutes of the 911 call, four fire engines and two ladder trucks arrived at the scene of a three-story wood frame house engulfed in smoke and flames. Each vehicle was staffed with a three man crew (a company commander and two other firefighters). Upon arrival they found a man trapped on the third floor and injured people lying on the pavement. The trapped man was hanging out of an attic window screaming, engulfed by smoke, his clothes burned, ready to jump 30 feet down to the pavement. Firefighters immediately rescued the trapped man by assisting him down a ladder. The injured people had jumped out of second story windows or escaped through the front door, some carrying children. Panicked victims advised the firefighters that more people might still be in the building. The exact number of residents was not confirmed but there were at least 18 people living in the building who required medical treatment. The incident commander requested additional ambulances through the fire department dispatcher. Two advanced life support and five basic life support ambulances responded to the scene. Mutual aid was also requested from fire departments in two neighboring cities. One mutual aid engine responded to the scene as requested.

The initial interior attack against the fire came from Firefighter #1, of Engine 1, who pulled a 1 3/4 inch hoseline from the engine to the front door. He went on air just before his attempt to enter the house with the hoseline. Heavy fire conditions at the burned down front door prevented him from making entry. Firefighters from Engine 4 brought a second charged 1 3/4 inch attack hoseline to the front door. Using both hoselines, progress was made in suppressing the fire on the first floor. The firefighters were able to enter the building and each went on air prior to making entry. Firefighters from Truck 1 conducted a primary search. Engine 1 firefighters stayed on the first floor and Engine 4 firefighters proceeded to the second floor, each using hoselines to suppress the fire. Engine 2, personnel, including Firefighter #2, were assigned to protect the building next to the burning house by using fire hoses. Engine 3 personnel were assigned to fight the fire with hoselines directed to the second floor from the adjacent alley. Truck 2 firefighters were ordered to search the second and third floors, and the mutual aid engine firefighters conducted a primary search in the basement. As the firefighters searched, they ventilated the building.

Approximately 25 minutes after the first alarm, the fire was brought under control. The firefighters began to conduct overhaul activities. During overhaul, they extinguished small pockets of fire, searched for victims, and performed salvage operations. All available firefighters were engaged in crucial tasks. Personnel were not available to provide relief until the next shift of firefighters, Tour 2, went on duty and arrived at the scene at 8:10 a.m.. Gradually, Tour 1 was relieved after working continuously in the hot, smoking atmosphere for about an hour. On scene EMS personnel conducted medical evaluations of the firefighters. Tour 1 was taken off duty from the fire scene by 9:00 a.m., except for two firefighters who been transported to a local emergency room by ambulance at approximately 8:30 a.m. Tour 2 conducted overhaul and a secondary search which also proved negative. At 10:35 a.m., Engine 4 was commanded to assist in the cause and origin investigation. The other fire companies returned to their respective stations.


Firefighter #1, a 38-year-old male with twelve years experience, was the acting company commander for Engine 1. He had lead the fire suppression efforts during the initial entry into the house. After working in the house for 15 to 20 minutes, his air was running low. He exited the house to have his air tank replaced, and then proceeded to the attic to assist in the search for an alleged missing 72-year-old man. During this intense search and rescue mission, he ran out of air but continued to work. After five to 10 minutes of being exposed to the hot and smoky atmosphere, without any respiratory protection, he exited the building to get a third air tank. Later when he was medically evaluated by the EMS personnel, he was coughing and complained of a headache and dizziness.

Firefighter #2, a 32-year-old male with seven years of experience, was a crew member on Engine#2. He had connected hoseline from Engine 2 to a hydrant, assisted Firefighter #1 in suppressing the fire, searched for victims, ventilated the roof with an ax from inside, and performed overhaul tasks. He said he used two or three air tanks. At one point, his SCBA mask was knocked off in the hot, smoky atmosphere. When he was medically evaluated by the EMS workers, he was wheezing.

Firefighter #1 and Firefighter #2 were given oxygen by EMS personnel, but remained symptomatic. EMS took them to a local emergency room where they were examined for smoke inhalation. They were given oxygen and had their arterial blood gases tested. After 3 hours, they were both released. Firefighter #1 reported being extremely tired for 3 days, but was medically released to return to active duty for his next shift, three days after this incident. Firefighter #2 was medically released from duty for a week.

Recommendations and Discussion

Recommendation #1:

Firefighters should be given supervised rest periods with appropriate frequency.

Discussion: Tour 1 firefighters worked continuously for approximately one hour without any rest periods. The United States Fire Administration (USFA) and the National Fire Protection Association (NFPA), Fire Department Occupational Safety and Health Program (NFPA 1500) recommend that firefighters be given supervised rest periods referred to as rehabilitation. The USFA and NFPA recognize that when emergency responders become fatigued, their ability to operate safely is impaired. There is increased risk for illness or injury, and this may jeopardize the safety of others on the incident scene. The provisions for a rehabilitation period should include: fluid and food replenishment; medical evaluation, treatment and monitoring; mental rest; and relief from extreme conditions. Supervisors should maintain an awareness of the condition of their subordinates and ensure that adequate steps are taken to provide for each member's safety and health. Firefighters should also advise their supervisors when they become fatigued to a point that could affect their performance. USFA recommends that the firefighters should be given a rehabilitation after two 30-minute rated SCBA air tanks have been used, or after 45 minutes, whichever comes first

Recommendation #2:

Adequate staffing should be maintained.

Discussion: There was not adequate staffing to allow the firefighters the opportunity to rest. According to those interviewed, the efforts of all the on-scene firefighters were essential since there was the possibility that lives could be saved. At this incident, each engine and ladder vehicle had a crew of three firefighters. Firefighter #1 and Firefighter #2 stated that they were exhausted and unsure whether their symptoms were due to smoke inhalation or exhaustion. Both felt that under staffing was a major contributor to the health effects they experienced. Firefighter #2 and other interviewed firefighters from this department stated the turn out gear they must wear is heavy, cumbersome, and hot. Also, Firefighter #2 felt the weight of the SCBA apparatus and equipment such as hoselines, axes, etc., partially contributed to his exhaustion. NFPA 1500 recommends that a minimum acceptable fire company staffing level be four members for each engine and each ladder company when responding to any type of fire. Five member crews are recommended for search and rescue and fire suppression tasks.

Firefighter #1 reported he would have entered the burning building by himself if it were not for the heavy fire conditions that prevented him from making entry. This practice was common to the department due to a lack of staffing. NFPA 1500 recommends that firefighters operating in hazardous areas should work in teams of two or more (a buddy system) to provide assistance to each other in case of emergency. NFPA also recommends that, in the early stages of an incident, on-scene firefighters should be assigned to assist in rescue of fire suppression members, if necessary. The New Jersey Public Employees Occupational Safety and Health, Standards for Firefighters, N.J.A.C. 12:100-10.10(e), requires that at least two firefighters work together when wearing SCBA, and they must maintain visual or voice communications with each other at all times.

Recommendation #3:

Firefighters should immediately exit hazardous atmospheres when their self contained breathing apparatus (SCBA) low air alarm goes off.

Discussion: Firefighter #1 continued to search for a reportedly missing person after his SCBA tank ran out of air. The decision to work without the use of a SCBA should be made by the officer in charge based on the conditions as outlined in the fire department's SOP for Mandatory Protective Gear and the department's written Respiratory Protection Program.


  • Emergency Incident Rehabilitation, Federal Emergency Management Agency, United States Fire Administration, July 1992.


  • Emergency Incident Rehabilitation, Federal Emergency Management Agency, United States Fire Administration, July 1992.

  • National Fire Protection Association. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, National Fire Protection Administration, Quincy, MA.

  • Guidelines for the Emergency Management of Firefighters: Occupational Health Service, New Jersey Department of Health, December 1992.
Last Reviewed: 8/18/2016