Firefighter Injury Project Investigation Report

FIP Investigation #5

Three Firefighters Injured In A Multi-Residential House Fire

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

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

Three Firefighters Injured In A Multi-Residential House Fire, Firefighter Injury Investigation #5


On On March 25, 1997, a municipal fire department responded to a general alarm for a fire at a three story house where approximately 20 people resided in nine or ten illegally subdivided apartments. Upon arrival, fire was observed coming out of the second floor rear windows. Occupants reported that there may have been several people trapped in the building, including a mother and child. Firefighters worked aggressively, each using at least two self contained breathing apparatus (SCBA) air tanks for more than 30 minutes. Two firefighters became trapped by the fire; one was evaluated for smoke inhalation. Two other firefighters were evaluated and treated for smoke inhalation after breathing in smoke and dust while breaking through a ceiling looking for hidden hot spots.

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 to ensure that supervised rest periods can be provided.
  • SCBA should be used during overhaul operations involving demolition of materials.


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 and April 23, 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 emergency room medical records were 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 maximally 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 25, 1997 at 7:53 p.m., the fire department responded to a 911 report of a fire. The fire occurred in a three story wood frame house divided into small apartments located in a residential neighborhood. The weather conditions were warm and drizzle was coming down. In responding to the fire alarm, firefighters followed standard operating procedures (SOPs) requiring that all protective clothing be put on before their fire apparatus (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.

Engine 3, Engine 4 and Ladder Truck 1 initially responded to the scene within two minutes of the alarm. Upon arrival, fire was observed blowing out of the second floor rear windows as police officers assisted occupants out of the burning building. Occupants reported that there may have been several people trapped in the building, including a mother and a child on the second floor.

At 7:57 p.m., the on-scene fire department incident commander ordered a second alarm which brought Engine 1, Engine 2, and Truck 2 to the scene shortly after 8:00. Each vehicle was staffed by three man crews consisting of an officer and two firefighters. A deputy chief acted as incident commander until the chief of the department arrived.

Two members of ladder truck 1 immediately initiated a primary search for victims on the second floor while the engine companies established hoselines. Two emergency medical service (EMS) units were on hand: one volunteer basic life support unit and one advanced life support unit.

Injured Firefighter #1

Firefighter #1, a 33-year-old male with eight years experience, and his company commander forcibly entered the front door to search for the missing occupants. When they opened the door to the second floor apartment in which the fire had originated and where the missing child was reported to be, they encountered extreme fire, smoke, and heat conditions that prevented them from entering the apartment. After encountering these conditions, they connected their SCBA air supply lines to their facepieces and activated the air flow. They closed the apartment door and continued searching other apartments for missing persons. Before they finished the second floor search, they received a radio transmission advising them that a missing grandfather may have been in the third floor attic apartment. On their way up the stairway to the third floor, they saw flames shooting toward them from the smoky second floor. Fearing a flash over (a sudden spread of flame over an area), they made a forced entry into the locked attic apartment at the top of the stairs and closed the door behind them. Realizing they were trapped, they radioed in a "may day" for help and sought another exit to escape from the intensely hot, smoky apartment. Both of their SCBA low-air alarms went off which added further stress to the firefighters.

At approximately 8:15 a.m., the incident commander was informed by the driver of Ladder Truck 1 that his two crew members radioed that they were trapped on the third floor of the burning building. The incident commander ordered Ladder Truck 2 and Engine 1 companies to initiate rescue operations, and requested mutual aid from a neighboring city fire department. A mutual aid engine responded to the scene and was assigned to assist in rescue of fire suppression members, if necessary, and was placed on standby.

When the trapped firefighters could not find another exit, they opened the door where they had entered, hoping that conditions had improved. Firefighters from Engine 1 and Engine 4 had aggressively attacked the fire on the second floor using two 1 3/4" hoselines. This improved the conditions in the interior stairway allowing the trapped firefighters to escape down the stairway. When the firefighters reached the smoky second floor landing, Firefighter #1 removed his mask because he was having trouble seeing out of his fogged-up SCBA mask lense. Both firefighters continued down the stairs to exit the building. They had been in the building for approximately twenty minutes. Once outside, the officer and Firefighter #1 had their SCBA air tanks replaced. Without any rest period, they immediately returned to continue the search with the Ladder Truck 2 crew.

By approximately 8:20 p.m., the major portion of the fire was under control and they were able to search the apartment in which the fire originated. The apartment ceiling had collapsed and the firefighters had to crawl through the hot, smoky layers of debris to look for the missing child. Firefighter #1's low air alarm went off again and he exited the building before running out of air. He was given a third SCBA air tank and immediately reentered the building only to realize that he was dizzy and his legs were shaky. He left the building feeling nauseated, weak, and was having difficulty breathing. He had been in the building for approximately 35 minutes. EMS personnel immediately gave him oxygen and transported him to a local hospital emergency room where he was examined for smoke inhalation. His arterial blood gases were tested and oxygen was administered for approximately two hours before he was released. On doctor's advice, he was relieved of duty for the rest of the day.

Firefighter #1 reported that he believed his symptoms were the result of exhaustion. The elements contributing to his state of exhaustion, he felt, were his extreme heat exposure, sudden extreme physical exertion after going from relaxing at the fire house to the high stress activities at the fire scene, the stress of being trapped by the fire, and feeling the overwhelming urgency to find the missing occupants, especially the child.

InjuredFirefighter #2 and #3

Immediately upon arrival at 7:55 p.m., Firefighter #2, a 26-year-old male with three years of experience, and his company commander from Engine 3 established a 2 ½ inch hoseline and took turns spraying water on the adjacent house in an effort to keep the fire from spreading. Approximately ten minutes later, Engine 2 firefighters stretched a second 2 ½ inch hoseline to assist in the effort. Although this house did not catch on fire, the heat from the burning building was so intense that it melted the vinyl siding, and the occupants were ordered to vacate the house.

Firefighter #3, a 33-year-old male with five years experience from Engine 2, came on scene at approximately 8:05 p.m. in response to the second alarm and was ordered to ventilate the third floor. After approximately 20 minutes, his SCBA tank ran out of air. He said he decided to stay and continued to work for five minutes without the SCBA air before exiting the building to have the air tank replaced.

At approximately 8:20, the fire was declared under control. All fire crews were ordered to assist in the search for victims and to conduct overhaul activities on the second and third floors. Overhaul involved extinguishing small pockets of fire and performing salvage operations. The two-year old child was found dead at approximately 8:30 p.m. in the apartment where the fire had originated. Reports of a missing mother and grandfather had proven to be unfounded. Search efforts were ended.

Firefighters #2 and #3 were then ordered to overhaul a room in the apartment where the child was found. By that time, the rooms were fairly well ventilated. Firefighter #2 reported that he heard an officer say it was okay to discontinue SCBA use, so he took off his SCBA. He said he was glad to do this because the SCBA unit was heavy, hard to see out of and physically restrictive. Firefighter #3 still kept his mask on but disconnected the air hoseline. Firefighters #2 and #3 opened the ceiling above them looking for pockets of fire. When the ceiling was opened, a cloud of smoke and dust burst out and was inhaled by the firefighters. They both began uncontrollable coughing and were ordered to go outside where they began vomiting. When Firefighter #2 vomited blood, EMS personnel transported the two firefighters to a local hospital emergency room (ER) where they were evaluated and treated for smoke inhalation and given arterial blood gas tests. The two injured firefighters believed that the dust that was in the smoke was responsible for their symptoms. The two fire fighters were placed off duty for about a week on doctor's advice. Firefighter #2 continue to expectorate a black substance for several days. When he returned to duty, he still did not feel completely recuperated. Firefighter #3 coughed up a black substance for several days, had chest pain for approximately 1 ½ weeks, and had a sore throat that affected his voice for several weeks. At the time of the interview, almost four weeks after the incident, he reported he was feeling fine.

By 10:00 p.m., four of the fire department apparatus returned to their respective fire stations. One engine and one ladder company remained on-scene until 2:27 a.m. to ensure that rekindling would not occur and to assist in investigations conducted by the medical examiner and by county fire officials. The displaced occupants were given temporary refuge in one of the fire stations by a Red Cross Disaster Team. A critical incident debriefing was later held for the firefighters to assist them in psychologically dealing with this fatal fire.

Recommendations and Discussion

Recommendation #1:

Firefighters should be given supervised rest periods with appropriate frequency.

Discussion: There were no supervised rest periods during this fire.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 to ensure that supervised rest periods can be provided.

Discussion: At this incident, each engine and ladder truck had a crew consisting of three firefighters .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.

Recommendation #3:

SCBA should be used during overhaul operations involving demolition of materials.

Discussion: Firefighters #2 and #3 were not using their SCBA when they broke through a ceiling which released smoke and unknown particles into the air. Consequently, they both suffered health effects caused by inhalation of these substances. When performing salvage operations that require demolition, it is not uncommon for building materials to release airborne particles. These hazards are addressed in the New Jersey Public Employees Occupational Safety and Health, Standards for Firefighters, N.J.A.C. 12:100-10.10(c) which requires that SCBA be worn at all times while engaged in interior structural firefighting, during emergency situations involving toxic substances, and during all phases of firefighting and overhaul. The department's SCBA SOP also required wearing SCBA during active overhaul unless otherwise directed by the Incident Commander.


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

  • Guidelines for the Emergency Management of Firefighters: Occupational Health Service, New Jersey Department of Health, December 1992.


  • Emergency Incident Rehabilitation, Federal Emergency Management Agency, United States Fire Administration, July 1992.
  • Guidelines for the Emergency Management of Firefighters: Occupational Health Service, New Jersey Department of Health, December 1992.
  • National Fire Protection Association. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, National Fire Protection Administration, Quincy, MA.
Last Reviewed: 8/18/2016