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A Summary of a NIOSH fire fighter fatality investigation September 27, 2000
Six Career Fire Fighters Killed in Cold-Storage and Warehouse

Building Fire - Massachusetts
SUMMARY
On December 3, 1999, six career fire fighters died became lost, and at 1847 hours, one of them sounded
after they became lost in a six-floor, maze-like, cold- an emergency message. A head count ordered by
storage and warehouse building while searching for Interior Command confirmed which fire fighters were
two homeless people and fire extension. It is missing.
presumed that the homeless people had accidentally
started the fire on the second floor sometime between Fire fighters who had responded on the first and third
1630 and 1745 hours and then left the building. An alarms were then ordered to conduct search-and-
off-duty police officer who was driving by called rescue operations for Victims 1 and 2 and the
Central Dispatch and reported that smoke was homeless people. During these efforts, four more
coming from the top of the building. When the first fire fighters became lost. Two fire fighters (Victims
alarm was struck at 1815 hours, the fire had been in 3 and 4) became disoriented and could not locate
progress for about 30 to 90 minutes. Beginning with their way out of the building. At 1910 hours, one of
the first alarm, a total of five alarms were struck over the fire fighters radioed Command that they needed
a span of 1 hour and 13 minutes, with the fifth called help finding their way out and that they were running
in at 1928 hours. Responding were 16 apparatus, out of air. Four minutes later he radioed again for
including 11 engines, 3 ladders, 1 rescue, and 1 aerial help. Two other fire fighters (Victims 5 and 6) did
scope, and a total of 73 fire fighters. Two incident not make initial contact with command nor anyone
commanders (IC#1 and IC#2) in two separate cars at the scene, and were not seen entering the building.
also responded. However, according to the Central Dispatch
transcripts, they may have joined Victims 3 and 4 on
Fire fighters from the apparatus responding on the the fifth floor. At 1924 hours, IC#2 called for a head
first alarm were ordered to search the building for count and determined that six fire fighters were now
homeless people and fire extension. During the missing. At 1949 hours, the crew from Engine 8 radioed
search efforts, two fire fighters (Victims 1 and 2) that they were on the fourth floor and that the structural
The Fire Fighter Fatality Investigation and Prevention

Program is conducted by the National Institute for
Occupational Safety and Health (NIOSH). The purpose of
the program is to determine factors that cause or contribute
to fire fighter deaths suffered in the line of duty.
Identification of causal and contributing factors enable
researchers and safety specialists to develop strategies for
preventing future similar incidents. To request additional
copies of this report (specify the case number shown in the
shield above), other fatality investigation reports, or further
information, visit the Program Website at:
Photograph by Roger B. Conant. http://www.cdc.gov/niosh/firehome.html
Cold Storage and Warehouse Building Shortly or call toll free 1-800-35-NIOSH
After First Alarm - 1825 Hours
Fatality Assessment and Control Evaluation
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Investigative Report #99F-47
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Six Career Fire Fighters Killed in Cold-Storage and Warehouse Building Fire -
Massachusetts
integrity of the building had been compromised. At ensure that Incident Command always
1952 hours, a member from the Fire Investigations Unit maintains close accountability for all
reported to the Chief that heavy fire had just vented personnel at the fire scene
through the roof on the C side. At 2000 hours, Interior
Command ordered all companies out of the building, use guide ropes/tag lines securely attached
and a series of short horn blasts were sounded to signal to permanent objects at entry portals and
the evacuation. Fire fighting operations changed from place high-intensity floodlights at entry
an offensive attack, including search and rescue, to a portals to assist lost or disoriented fire
defensive attack with the use of heavy-stream fighters in emergency escape
appliances. After the fire had been knocked down,
search-and-recovery operations commenced until recall ensure that a Rapid Intervention Team is
of the box alarm 8 days later on December 11, 1999, established and in position upon their
at 2227 hours, when all six fire fighters bodies had arrival at the fire scene
been recovered. NIOSH investigators concluded that,
to minimize the risk of similar occurrences, fire implement an overall health and safety
departments should program such as the one recommended in
NFPA 1500, Standard on Fire Department
ensure that inspections of vacant buildings Occupational Safety and Health Program
and pre-fire planning are conducted which
cover all potential hazards, structural building consider using a marking system when
materials (type and age), and renovations that conducting searches
may be encountered during a fire, so that the
Incident Commander will have the necessary identify dangerous vacant buildings by
structural information to make informed affixing warning placards to entrance
decisions and implement an appropriate plan doorways or other openings where fire
of attack fighters may enter
ensure that the incident command system is ensure that officers enforce and fire fighters
fully implemented at the fire scene follow the mandatory mask rule per
administrative guidelines established by the
ensure that a separate Incident Safety Officer, department
independent from the Incident Commander,
is appointed when activities, size of fire, or explore the use of thermal imaging cameras
need occurs, such as during multiple alarm to locate lost or downed fire fighters and
fires, or responds automatically to pre- civilians in fire environments
designated fires
In addition,
ensure that standard operating procedures manufacturers and research organizations
(SOPs) and equipment are adequate and should conduct research into refining existing
sufficient to support the volume of radio and developing new technology to track the
traffic at multiple-alarm fires movement of fire fighters on the fireground.
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INTRODUCTION The Fire Department involved in the incident serves a

On December 3, 1999, six male career fire fighters, population of 170,000 in a geographic area of 39.4
ages 34, 38, 38, 41, 42, and 51 (the victims) died square miles and is comprised of 479 uniformed
after becoming lost in a cold-storage and warehouse personnel and 12 fire stations. The Fire Department
building fire. On December 4, 1999, the liaison from requires 480 hours of training, which includes 80 hours
the fire department involved in this incident and the of hazardous materials training and a written test to
International Association of Fire Fighters (IAFF) become certified as Fire Fighter I and II. The training is
notified the National Institute for Occupational Safety designed to cover personal safety, forcible entry,
and Health (NIOSH) of the incident. On December ventilation, fire apparatus, ladders, self-contained
5, 1999, a Safety and Occupational Health Specialist, breathing apparatus, hose loads, streams, hazardous
the Senior Fire Fighter Investigator, and the Team materials, structure fire, pumps, repelling, search and
Leader from the NIOSH Fire Fighter Fatality rescue, terrorism, vehicle extraction, cardiopulmonary
Investigation and Prevention Program traveled to the resuscitation, first aid, aerial operations, water and ice
incident site to conduct an investigation. A second rescue, scuba diving, and electrical emergencies. The
investigation team consisting of the Team Leader and victims had 12 years, 5 months; 2 years, 1 month; 8
three Safety and Occupational Health Specialists years, 9 months; 16 years, 5 months; 20 years, 3 months;
conducted a second investigation during the week and 27 years of fire fighting experience respectively.
of January 3-7, 2000. During the week of April 17,
a third trip was completed by the Team Leader to Although 21 pieces of fire apparatus and over 73
finalize details of the prior two investigations, and an personnel were involved in this incident, only those
engineer and physical scientist from the NIOSH directly involved up to the time of the fatal incident are
Respirator Branch conducted a Self-Contained mentioned in this report. Table 2 provides a summary
Breathing Apparatus maintenance evaluation at the of the time line, apparatus, and personnel dispatched
request of the Fire Chief (see Attachment). The for each of the fire alarms for this fire.
incident was reviewed with the Chief, the Safety
Officer, the Division Chief, the Deputy Chief and fire WEATHER INFORMATION
fighters from the Fire Department involved. The Weather conditions during the major events of this
incident was also reviewed with a representative of incident (from 1600 to 2100 hours) were as follows:
the IAFF, a representative of the Professional Fire Wind was from the southwest at 7.5 mph and surface
Fighters of Massachusetts, the State Fire Marshal, visibility was unlimited. The sky, overcast with broken
the Coroner, the District Attorneys representative, clouds, was clear by 2100 hours. The temperature
and the State Police. The incident site was visited was 45 degrees Fahrenheit, and the relative humidity
on three separate occasions, photographs of the was 37 percent.
incident site were obtained, and the medical
examiners report was requested. Dispatch BUILDING INFORMATION
transcription records, standard operating procedures, The structure was a cold-storage and warehouse
building drawings, and the victims training records building that had been vacant since 1991. The
were also obtained from the Fire Department. original building was constructed in 1905, and 7 years
NIOSH investigators also completed a walk-through later (1912) another building was constructed on the
tour of a cold-storage warehouse similar to the one western (D) side. The building constructed in 1905
involved in the incident. was designated Building A, and the side constructed
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in 1912 was referred to as Building B. The entire Franklin and Arctic Streets for 236 Franklin Street.
building contained six floors above ground, for a total Engines 1, 6, 12, and 13 responded, along with
of 94,176 square feet, and a full basement (see Figure Ladders 1 and 5, Rescue 1, and Car 3, which
1). The exterior walls, constructed of brick, included the Incident Commander (IC#1) and his
measured 18 inches thick. The interior walls were Aide. Engine 1 was first to arrive on the scene at
covered with 6 to 18 inches of asphalt-impregnated 1816 hours and reported heavy smoke showing. At
cork (depending on the floor level), 4 inches of 1817 hours, Central Dispatch advised all companies
polystyrene and/or foam glass, and a thin layer of that the correct address was 266 Franklin Street
glassboard (see Photo 1). The flooring was wooden (cold-storage warehouse, see Photo 4). IC#1 arrived
except for the flooring in the basement and first and on the scene at 1819 hours and requested Central
second floors, which were concrete. The joists Dispatch to strike a second alarm for Box 1438
consisted of heavy timbers. Two stairwells were Franklin and Arctic Street for 266 Franklin Street
present; one was located on the B side and extended due to the size of the building. Second-alarm
from the basement to the flat roof, and the other was companies consisted of Engines 2 and 16, Aerial
located on the C side and extended to the third floor Scope 2, and Car 2, which later became Incident
only (see Figure 2). Two sets of freight elevators Commander Two (IC#2). As the second-alarm
were present, one on the B side and the other on the companies arrived on the scene, they were directed
C side, and both were adjacent to stairwells. Two by IC#1 to stage under a nearby interstate overpass.
loading dock areas existed; one was located on the At 1820 hours, IC#1 radioed Central Dispatch and
B side while the other was located on the C side requested any available building information, but no
(see Photo 2). Six windows were present on the information was ever found or received. Note: Due
second-floor level, three on the A side and three on to the lack of pre-fire planning and inspection,
the D side of Building B, but they had been covered and lack of building plans/drawings, confusion
with plywood. Window openings which were present existed among the fire fighters as to the
in the stairwell on the B side were also covered with configuration and number of floors contained
plywood. Although the building entrances and exits within the building. IC#1 then entered the building
had been secured by plywood since 1991, homeless through a doorway from the first floor ground level
people had gained access to the building and on the A side and proceeded up the stairs to the
established living quarters. second floor, where he conducted interior building
operations. Simultaneously, his Aide circled the
INVESTIGATION building to conduct a scene survey, and crews from
On December 3, 1999, at 1813 hours, an off-duty Engine 13 and Ladder 1 also entered the building.
police officer reported smoke coming from the top The Aide reported that he was on the C/D corner of
of a building at 236 Franklin Street. Note: It has the building and that he saw heavy fire burning in and
been determined that the fire was presumably up the elevator shafts.
started by two homeless people. The fire was
started sometime between 1630 and 1745 hours At 1822 hours, Engine 13 also reported fire in the
in building B on the second floor (see Figure 2 elevator shaft on the second and third floors on the
and Photo 3). Therefore, the fire had been in C/D corner. Ladder 1, in a freezer room on the
progress for about 30 to 90 minutes before the second floor, reported they had a room full of fire,
box alarm was struck. At 1815 hours Central and they requested a line be brought in (see Photo
Dispatch advised all companies strike and box 1438 5). IC#1 ordered a 2 ½-inch line from Engine 1 and
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a 2 ½-inch line from Engine 16 be laid to the elevator Victims 1 and 2 from Rescue 1, met at the stairwell
shaft on the second floor at the C/D corner. A 1 3/4- on the first floor. They all proceeded up the stairwell
inch line from Engine 1, a 2 ½-inch line from Engine and observed the other crew from Rescue 1 enter
12, and a 2 ½-inch line from Engine 6 had been laid the third floor. Engine 1s crew and the two victims
to the second and third floors through the stairwell from Rescue 1 continued to the roof via the stairwell.
on the B side (see Figure 3). All the lines were Once on the roof, they proceeded to the C/D corner
charged except the 2 ½-inch line from Engine 6, and where they joined a crew from Ladder 1. The victims
active fire fighting began. (The line from Engine 6 from Rescue 1 reported to Interior Command that
had been laid to the third floor in Building A, but they were on the roof and had heavy smoke and
since no fire was found there, the line was not embers showing. The crews cleaned out a skylight
charged.) At 1826 hours, IC#1 was advised that measuring 15 square feet which was located over
two homeless people might be in the building. Car 2 the elevator shaft, and Ladder 1 reported that the
(the second Incident Commander [IC#2] and his skylight was completely vented and that hot embers
Aide) arrived on the scene at 1831 hours. IC#2 were coming through. The three crews (Engine 1,
assumed command and was positioned on the Rescue 1, and Ladder 1) left the roof, returned to
outside of the A/B corner of the building. He the stairwell, and descended the stairs. Engine 1s
requested a status report from IC#1, who was now crew were in the lead down the stairs, and they
the Interior Commander conducting interior returned to the first floor. Ladder 1s crew descended
operations, and he was told that heavy fire was the stairs after the Engine 1 crew and entered the
burning on the second and third floors in Building B second floor from the stairwell on the B side. Victims
and that two homeless people might be in the building. 1 and 2 from Rescue 1 entered the sixth floor and
began a top-down, search-and-rescue sweep and
When Engine 1, Ladder 1, and Rescue 1 arrived on fire extension check. After conducting the search-
the scene on the first alarm, they all split up into crews. and-rescue sweep and fire extension check, they
Engine 1s crew was comprised of a Captain and exited the sixth floor and entered the fifth floor.
one fire fighter who entered the building looking for Simultaneously, the other crew from Rescue 1
fire extension while the other two fire fighters from (Lieutenant and one fire fighter) left the third floor
Engine 1 remained at the apparatus to set it up. and went to the fourth floor while Ladder 1s crew
Ladder 1s company split into two crews; one crew worked the second floor. The search-and-rescue
proceeded to the roof while the other crew checked crews were not using search ropes due to the light-
for fire extension. Rescue 1, which was comprised to-moderate smoke conditions. Heavy, black, acrid
of a Lieutenant and four fire fighters, including Victims smoke suddenly filled the second floor, causing all
1 and 2, split into two, two-man crews while the crews on the second floor to become disoriented
driver remained with the apparatus. IC#2 instructed and lose sight of one another. Ladder 1s crew
the crews from all three companies to search the conducted a right-hand search and eventually found
building for homeless people and fire extension. the doorway that opened into the stairwell. They
descended the stairwell until they found Interior
The crew from Engine 1 (Captain and fire fighter) Command who was now located between the
entered the building from the B-side loading dock second and third floors in the stairwell. Interior
and joined one of the crews from Rescue 1 who had Command relocated to the bottom of the second-
entered the building from the A-side first floor ground floor stairwell and ordered a head count. It was
level stairway. The two crews, which included determined that two fire fighters from Rescue 1 were
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missing. The Aide for Interior Command, without of the victims: We have an emergency, Command.
wearing a self-contained breathing apparatus We are two floors down from the roof. This is the
(SCBA), went to the fourth floor and stayed in the rescue company. Come now, two floors down from
stairwell yelling, to no avail, for the missing fire the roof. Guys, not the top floor, one floor down.
fighters. At 1834 hours, IC#2 radioed the Lieutenant A short time later, radio contact was made with the
from Rescue 1, requesting his location and inquiring victims to determine their status. One of the victims
whether the primary and secondary searches for any replied, We need air, we need air. Im sharing a
civilians were completed. The Lieutenant responded tank off me right now. We are lost. You got to send
that they had checked the third floor and were a rescue team up here for us. Second floor down
advancing up the stairwell to another floor. He from the roof, two floors down. We were on the
reported no fire but heavy smoke. The Lieutenant roof, and then we checked the next floor down.
and fire fighter from Rescue 1 proceeded to the fourth Now we are on the next one. Hurry. At 1853
floor and were checking a room when visibility hours, Engine 13 reported that conditions inside the
dropped to nearly zero. They were running low on building were deteriorating very quickly. IC#2
air so they left the room, descended the stairs, and requested a fourth alarm and that the Chief of the
returned to an apparatus to change air bottles. While Department be notified. At 1854 hours, IC#2
they were changing air bottles, the driver told them radioed Interior Command that a fourth alarm had
that two fire fighters from Rescue 1 were lost. The been struck and asked for verification of the floor
Lieutenant and fire fighter re-entered the building, the two fire fighters were trapped on. Interior
and believing they were going to the fourth floor, Command responded, They are on the second floor
instead went to the third floor because they thought from the top. Two floors down from the roof, and I
the building had only five floors. Using search ropes, have Ladder 2, Engine 3, and Ladder 1 all going
they searched the area on the third floor all the way looking for them. At 1855 and 1856 hours, Interior
back to a door opening through the firewall which Command made the following two requests:
separated the two buildings (see Figure 2 and Photo Rescue 1, activate your PASS system so we can
6), but did not encounter the victims. At 1841 hours, hear you. Activate your emergency alarm. Activate
Interior Command radioed Central Dispatch to make your PASS emergency alarm. At 1857 hours, one
the following broadcast: All companies working of the victims radioed back, They are activated.
inside the structure use extreme caution. There may
be holes in the floor, and the building may be When Engines 3 and 7 and Ladder 2 arrived on the
extremely unsafe. At 1842 hours IC#2 requested scene for the third alarm, the Engines were staged
a third alarm due to heavy fire conditions (see Photo on the A/D corner, and Ladder 2 was staged on the
7). Central Dispatch struck a third alarm and A side of the building. The companies were instructed
requested that Engines 3 and 7 and Ladder 2 to proceed to Command at the front (A/B) corner
respond. At 1847 and 1848 hours respectively, one of the building. Ladder 2s company consisted of a
of the victims from Rescue 1 made the following two Lieutenant and three fire fighters. The driver stayed
radio transmissions: Rescue to Command, I need at the truck while the Lieutenant and two fire fighters
help on the floor below the top floor of the building. proceeded to the command post. At the command
We are lost. Rescue to Command, we need help on post they received orders to conduct search-and-
the fourth floor. At 1849 hours, IC#2 had Central rescue operations on the fifth floor. They proceeded
Dispatch clear the radio channel for emergency traffic, to the dock doors on the B side and entered the
and another radio transmission was heard from one building. The Lieutenant and one fire fighter from
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Ladder 2 (Victims 3 and 4) were the first up the Engine 3s company consisted of a Lieutenant and
stairwell while the third fire fighter followed. At four fire fighters, including Victims 5 and 6. Before
the third-floor level the trailing fire fighter joined a leaving the Engine, the Lieutenant told the company
fire fighter from Engine 3 who had become that they were going to be used for search-and-rescue
separated from his crew. The two fire fighters operations and that they would be entering the
began knocking out the plywood covering the building. According to a pre-determined plan, the
window on the third floor. After knocking out the company split into two crews, one consisting of the
plywood, they went to the fourth floor and Lieutenant and two fire fighters, and the other
knocked out the plywood in that window. They consisting of the senior fire fighter and a junior fire
ascended the stairwell to the fifth floor where they fighter (Victims 5 and 6). When both crews exited
thought they would meet up with the Lieutenant the truck, one crew ran to the command post while
and fire fighter from Ladder 2, but about 10 minutes the second (Victims 5 and 6) finished putting on
had passed without seeing them, and they assumed their gear. When the Engine 3 crew arrived at
that the Lieutenant and fire fighter had entered the Command, two other crews were already there: three
room. The low-air alarm sounded on the SCBA members from Ladder 2 and three members from
worn by the fire fighter from Ladder 2, so he and Engine 7. Working in crews of three or four, they
the fire fighter from Engine 3 returned to the first were instructed to use ropes while looking for the
floor. While on the first floor, at 1906 hours, the four missing fire fighters. The Lieutenant from Engine
fire fighter from Ladder 2 radioed the Lieutenant 3 received instructions to take air bottles up the
from Ladder 2 and requested his location. The stairwell and to try to locate Victims 1 and 2 who
Lieutenant replied, We came up the stairwell. We were supposedly on the fourth floor. The Lieutenant
are on the fifth floor. He asked the Lieutenant, and two fire fighters each grabbed an air bottle and
What is your location on the fifth floor? and the proceeded up the B stairwell to what they thought
Lieutenant replied, Good question. He asked was the fourth floor. The third fire fighter became
the Lieutenant to repeat the message, and the separated from the crew while going up the stairwell.
Lieutenant replied, We are doing a sweep. I Once at the third floor, the Lieutenant and one fire
believe we are in the front part of the building. fighter entered the room and began their search.
At 1910 hours, the Lieutenant from Ladder 2 Visibility was about 1 ½ feet vertically off the floor
radioed Command: Chief, get a company up the and about 5 feet horizontally along the floor. While
stairwell to the fifth floor. We cant locate the they were searching two rooms which were thought
stairwell, or give us some sign as to which way to to be freezers about 35 square feet in size, visibility
go. We are running low on air and we want to get worsened, and they used a right-hand search to locate
out of here. At 1914 hours, the victims from the door into the stairwell. They went down the
Ladder 2 radioed again, requesting the following: stairwell and out onto the loading dock on the B side
Send someone up to the stairwell to the fifth floor where they changed air bottles. Once again they
and stand in the doorway and start yelling. We went up the B stairwell, this time to the fifth floor,
cant find the door. The crew from Engine 3 (no and without making contact with Victims 1 and 2,
victims) responded, We have the message and came back down to the loading dock. One of the
are going to the fifth floor. Although the crew Engine 3 fire fighters accompanied the Aide from
from Engine 3 located the doorway on the fifth IC#2 up the stairwell to the third and fourth floors.
floor at 1919 hours, they did not make contact They held their breath to stop the flow of air into the
with the victims from Ladder 2. face pieces of their SCBAs so that they could hear
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better and listened for PASS devices, but they never imaging unit was brought to the scene by a
heard anything. They returned to the loading dock, neighboring fire department and put into service at
and the fire fighter walked along the outside of the 1952 hours, but it stopped working at 1955 hours
buildings A side. He joined up with a fire fighter due to the intense heat. At 1952 hours, a member
from Ladder 2 (the setup man) and another fire fighter. from the Fire Investigations Unit reported to the Chief
The three fire fighters used a 1 3/4-inch line off an of the Department that heavy fire (flames of
Engine in the area to hit the fire through one of the approximately 30 to 40 feet) had just vented through
windows on the second floor of the A side. Note: the roof on the C side. At 2000 hours Interior
Two other fire fighters (Victims 5 and 6) did not Command ordered everyone out of the building, and
make initial contact with command nor anyone a series of short horn blasts were sounded to signal
at the scene, and were not seen entering the the evacuation. The operations changed from an
building. However, according to the Central offensive attack, including search and rescue, to a
Dispatch transcripts, they may have joined defensive attack with the use of heavy-stream
Victims 3 and 4 on the fifth floor. appliances (see Photo 8). After the fire had been
knocked down, search-and-recovery operations
At 1924 hours, IC#2 called for a head count of all the commenced until recall of the box alarm at 2227
fire fighters, and it was then determined that six fire hours on December 11, 1999.
fighters were missing. At 1929 hours, the Chief of the
Department called for a fifth alarm, and Engines 5 and CAUSE OF DEATH
10 responded. At 1928 and 1929 hours, the victims The causes of death as released by the Office of the
from Engine 3 and Ladder 2 were radioed, but no District Attorney are as follows: Victims 1 and 5
response was ever received from either crew. Note: died as a result of severe thermal injuries and
Between the hours of 1859 and 1932, Central exposure to heat and noxious gases. Victims 2, 3,
Dispatch made eight dispatches regarding problems 4, and 6 died of inhalation of smoke, soot, and hot
with radio emergency buttons (e.g., Engine 6, your gases.
emergency button is going off. Car 200, your
alarm button is going off. Car 200, disable your RECOMMENDATIONS AND DISCUSSION
portable. Engine 12, you have an open cam. Recommendation #1: Fire departments should
Engine 12, your emergency alarm keeps going off ensure that inspections of vacant buildings and
and will not allow transmission. Engine 1, radio pre-fire planning are conducted which cover all
portable 2 alarm keeps going into alarm, and we potential hazards, structural building materials
cant transmit.). At 1931 and 1936 hours, the victims (type and age), and renovations that may be
from Engine 3 and Ladder 2 were radioed a second encountered during a fire, so that the Incident
time, and again no response was received. At 1948 Commander will have the necessary structural
hours, Interior Command radioed the victims from information to make informed decisions and
Ladder 2 and Engine 3 a third time but never received implement an appropriate plan of attack.1
a response.
Discussion: Inspections of vacant buildings allow fire
At 1949 hours, the crew from Engine 8, who had fighters to become familiar with the interior of the
responded on the fourth alarm, radioed that they were buildings and any hazardous contents left behind.
on the fourth floor and that the structural integrity of During a fire when the building is filled with smoke,
the building had been compromised. A thermal knowledge of the layout of rooms, stairs, fire escapes,
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Massachusetts
windows, elevators, and hazards inside the building is concealed and undetermined; and (6)
structure will be important life-saving information. heat buildup inside the windowless building can
During a vacant building inspection, the structural be monumental. Buildings of this nature present
stability and hazards in hallways, stairways, and numerous and varied hazards as evidenced by the
fire escapes can be identified and evaluated, and above description, and it is paramount that fire
an informed plan of attack can be developed. In officers and fire fighters be aware of the hazards
this incident, the exterior walls were constructed present before they enter into a building of this
of brick materials 18 inches thick. The interior nature. Detailed pre-fire planning of large, vacant,
walls were covered with 6 to 18 inches of asphalt- commercial buildings can assist fire fighters in
impregnated cork (depending on the floor level), preparing for a possible fire in the building.
4 inches of polystyrene and/or foam glass, and a Multiple-company on-site training sessions,
thin layer of glassboard, all of which added greatly supervised by a battalion chief, should be held to
to the fire load and gave off toxic fumes when practice large-scale fire fighting operations at the
burned. Two stairwells existed, but only one locations of these identified high-hazard vacant
stairwell (B side) extended from the basement to occupancies. When a pre-fire plan is drawn up
the roof. The other stairwell on the C side extended for a large, vacant building, the following
only to the third floor, a condition which created information on fire fighting strategy should be
limited access throughout Building B. Two sets considered: (1) potential hazards inside, (2) water
of freight elevators were present, but both were supply, (3) defensive strategy, (4) exposure
inoperable, and they created a chimney effect for protection strategy, (5) mutual-aid considerations,
the fire to reach other areas of the building. The (6) collapse dangers, (7) apparatus positioning,
interior rooms were maze-like in construction and and (8) venting strategies. Additionally, fire
contained freezers of varying sizes. Only two departments should have the capability of
passageways per floor connected Building A to transmitting the pre-fire plans to the Incident
Building B. Six windows were present on the Commander on the fireground via a mobile data
second floor and one window was present on terminal (an onboard computer) in the event they
each floor of the stairwell on the B side, and the are not readily available as hard copy.
windows were securely covered with plywood.
Buildings with few openings are commonly known Recommendation #2: Fire Departments
as windowless buildings and may present the should ensure that the incident command
following fire fighting problems: (1) locating a fire system is fully implemented at the fire scene.2
is difficult because the exact number of floor levels
cannot be defined by counting windows from the Discussion: The Incident Command System (ICS)
outside at the command post; (2) horizontal or defines the roles and responsibilities to be assumed
cross venting of burning floors inside buildings by personnel and the operating procedures to be
by opening windows is limited or not possible; (3) used in the management and direction of
smoke buildup is rapid, and descends down from emergency incidents and other functions. The
the top floors to street level due to reduced Incident Commander (IC) is the individual with
ventilation; (4) access to upper floor windows by overall responsibility to implement and oversee the
aerial ladder master streams or for aerial ladders system. The functions of the IC include, but are
for rescue or search is limited or not possible; (5) not limited to (a) assumption, confirmation, and
flame and smoke spread throughout the entire position of command, (b) situation evaluation,
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Massachusetts
(c) initiating, maintaining, and controlling c. Initiate, maintain, and control communications.
communications, (d) deployment, (e) strategy/ It is the ICs responsibility to initiate, maintain, and
incident action planning, and (f) organization. control effective incident communications. This
communications function is critical to safe and
a. Assumption, confirmation, and position of effective incident operations because it is the means
command. After the IC arrives on the fireground by which the IC and all the other incident participants
and assumes command, a stationary command post stay connected. Being able to effectively
on the exterior of the fire building should be communicate becomes the major tool the IC uses to
established. Command positioning becomes a critical exchange information and to create effective action.
factor in the overall effectiveness of the incident. The IC should use the stationary command post
National experience reflects that a strategic level of advantage to maintain continuous and clear
command can only be produced if the IC is in a communications.
stationary command post position. The command
post should be situated in a conspicuous location d. Deployment. The deployment function requires
which affords the IC a good view of the fire building the IC to provide and manage a steady, adequate,
and surrounding area. Ideally, it would offer a view and timely stream of appropriate resources.
of two sides of the fire building. Advantages of a Typically, the IC logs the arriving units into the
command post are (1) stationary position, (2) a inventory and tracking system on a tactical worksheet
relatively quiet place in which to think and make in the stationary command post. The IC also enters
decisions, and (3) a vantage point to oversee the the units into a standard accountability system that
operation. A stationary command post also offers tracks where companies/crews are located in the
the potential for improved lighting, protection from hazard zone.
weather, space for additional staff, and access to
more powerful mobile radios, reference and pre- e. Strategy/incident action planning. A critical
planning materials, and portable computers (in some responsibility of the IC is to identify and manage the
instances). overall incident strategy (offensive or defensive). The
IC must continually evaluate the relationship between
b. Situation evaluation. The IC is the only person the level of hazards present and the basic capability
who has the exterior, stationary, command-post-position of the safety system to protect fire fighters from those
advantage that allows current and forecasted information hazards. The hazards present at structural fires
to be received, processed, evaluated, and then involve structural collapse, thermal and toxic insult,
translated into a series of decisions that control the becoming trapped and running out of air, and
position and function of the fire fighters working in and becoming disoriented, lost, and running out of air.
around the hazard zone. This information management Given the conditions present at this incidentlarge,
function becomes a major reason why the IC should vacant building with multiple levels, very few openings
stay at the command post. It is difficult for an IC to to the outside, maze-like interior, numerous freezer
receive, decipher, and then react effectively to reports rooms of varying size with doorscombined with
from all over the incident site if he/she is moving around, an active fire, created an environment with numerous
in proximity to operational noise, distracted by direct hazards.
face-to-face communications with fire fighters, and
limited to a portable radio as opposed to a more f. Organization. The ICS creates three standard
powerful mobile radio. levels of operation: the strategic level managed by
Page 10
Massachusetts
the IC, the tactical level commanded by the sector Officer to assess the incident scene for hazards or
officers, and the task level where fire companies potential hazards. The Incident Safety Officer (ISO),
conduct fire fighting activities. The organizational by definition, is an individual appointed to respond
design provides a system where the strategic and to or assigned at an incident scene by the Incident
tactical levels provide direction and support to the Commander to perform the duties and responsibilities
fire fighters who conduct fire fighting activities. In specified in this standard. This individual can be the
small incidents (single family dwellings and small health and safety officer or it can be a separate
commercials buildings) the situation is generally function. According to NFPA 1521, paragraph 2-
manageable enough for the IC to operate on both 1.4.1, an Incident Safety Officer shall be appointed
the strategic and tactical levels, and to directly manage when activities, size, or need occurs. Each of these
fire companies performing standard functions. This guidelines compliments the others and indicates that
incident occurred in a complicated six-floor building the Incident Commander is in overall command at
with a basementessentially a high-rise building. A the scene; however, oversight of all operations is
high-rise type of incident organization could have difficult. An ISO can assist the Incident Commander
been implemented to manage the operations. A by providing oversight for on scene fire fighter health
standard high-rise organization would involve, but and safety.
not be limited to, a lobby control sector to log
resources into the building, sector assignments on Recommendation #4: Fire departments should
each floor, a vertical water supply function, stairway ensure that Standard Operating Procedures
support, and a safety officer. (SOPs) and equipment are adequate and
sufficient to support the volume of radio traffic
Recommendation #3: Fire departments should at multiple-alarm fires. 3
ensure that a separate Incident Safety Officer,
independent from the Incident Commander, is Discussion: At times, fireground communications
appointed when activities, size of fire, or need become ineffective because of congested radio traffic
occurs such as during multiple-alarm fires, or and inadequate radio equipment on the fireground.
responds automatically to pre-designated fires.3-5 Although IC#2 had Central Dispatch clear the radio
channel for emergency traffic, most radio operators
Discussion: According to NFPA 1561, paragraph continued to use the same channel. Also, during the
4-1.1, The Incident Commander shall be half-hour period immediately following the first
responsible for the overall coordination and direction victims emergency message, Central Dispatch made
of all activities at an incident. This shall include overall eight dispatches regarding problems with radio
responsibility for the safety and health of all personnel emergency buttons. Standard operating procedures
and for other persons operating within the incident (SOPs) should be written and implemented, and
management system. Although the Incident communications equipment should be of sufficient
Commander (IC) is in overall command at the scene, quantity and quality to support the volume of
certain functions should be delegated to ensure that communications encountered at the fire scene. In
adequate scene management is accomplished. the event of Maydays or emergencies on the
According to NFPA 1500, paragraph 6-1.3, As fireground, fire fighters should switch radio operations
incidents escalate in size and complexity, the Incident to a new frequency or other channels. This would
Commander shall divide the incident into tactical- open the main channel for communication in case of
level management units and assign an Incident Safety an emergency or lost fire fighters.
Page 11
Massachusetts
Recommendation #5: Fire departments should but safety is a team effort and should be ensured by
ensure that Incident Command always the Incident Commander and sector and company
maintains close accountability for all personnel officers. In this incident, sector officers could have
at the fire scene. 3,4,6,7 been assigned to the four sides (A, B, C, and D) of
the building thereby improving the accountability
Discussion: Accountability on the fireground is of system.
paramount importance. It is the responsibility of all
officers to account for every fire fighter assigned to Recommendation #6: Fire departments should
their company and relay this information to Incident use guide ropes/tag lines securely attached to
Command. Accountability on the fireground can be permanent objects at entry portals and place
maintained by several methods. One system uses high-intensity floodlights at entry portals to
individual tags for every fire fighter and officer assist lost or disoriented fire fighters in
responding to an incident, and another uses a emergency escape. 8
company officers riding list which states the names,
assigned tools, and duties of each member responding Discussion: In a dark, smoky environment, large open
with every fire company. One copy of the list should areas, or maze-like construction, fire fighters often
be posted in the fire apparatus and one copy carried become lost or disoriented, and too often they are
by the company officer. The list posted in the unable to escape. The use of guide ropes/tag lines
apparatus is used if the company officer or the entire securely attached to permanent objects at entry
company is reported missing. Additionally, fire portals and held by fire fighters as they enter smoke-
fighters should not work beyond the sight or sound filled environments can become lifelines for
of the supervising officer unless equipped with a emergency escape. Also, the use of high-intensity
portable radio. These fire fighters should floodlights at entry portals could assist fire fighters in
communicate with the supervising officer by portable situations requiring emergency escape. In this
radio to ensure accountability and indicate completion incident a Lieutenant from Ladder 2 radioed
of assigned duties. SOPs should address Command: Chief, get a company up the stairwell
accountability, including the location and the duties to the fifth floor. We cant locate the stairwell, or
of the responding fire companies. Just as company give us some sign as to which way to go. We are
officers should know the location of all fire fighters running low on air, and we want to get out of here.
assigned to the company, the Incident Commander At 1914 hours, the victims from Ladder 2 radioed
should know the operating locations of officers and the following: Send someone up to the stairwell to
companies assigned on the first-alarm assignment. the fifth floor and stand in the doorway and start
As a fire increases and additional fire companies yelling. We cant find the door.
respond to the fire, a communication assistant with a
command board should assist the Incident Recommendation #7: Fire departments should
Commander with accounting for all fire companies ensure that a Rapid Intervention Team is
at the scene, at the staging area, and at the established and in position upon arrival. 4
rehabilitation area. One of the most important aids
for accountability at a fire scene is an incident Discussion: A Rapid Intervention Team (RIT) should
management system, and it should be established by respond if all companies are engaged in active fire
the Incident Commander. An Incident Commander fighting activities, multiple alarm fires, and other
bears the overall responsibility for safety at a fire, incidents where fire department members are subject
Page 12
Massachusetts
to hazards that would be immediately dangerous to 1500, should include development of fire service
life and/or health in the event of an equipment failure, occupational health programs as outlined in both NFPA
sudden change of conditions, or mishap.9 The team 1500 and 1582. At the time of this incident, a formal
should report to the officer in command and remain written safety and occupational health program was not
at the command post until an intervention is required available. Note: Since the incident, the department
to rescue a fire fighter(s) in distress. involved has developed a Structural Fire Fighting
Development Program. The Program address the
A RIT is specially trained in search-and-rescue following: (1) Operational Tactics and Strategies
techniques. In addition to standard fire fighting gear, Within the Incident Command System, (2) Rapid
the RIT is equipped with search-and-rescue tools Intervention Teams, (3) Search and Rope Rescue
and equipment, including a first-aid kit and a Procedures, (4) Thermal Imaging Technology, (5)
resuscitator for aiding injured fire fighters. Many fire Radio Communications on the Fire Ground and
fighters who are overcome by smoke or who are Emergency Procedures, (6) Building Construction
caught or trapped by fire actually become disoriented in the Fire Service, and (7) High Rise Fires.
first. They are lost in smoke and cannot find their
way to an exit, or their SCBAs run out of air. They Recommendation #9: Fire departments should
become trapped, and then fire or smoke kills them. consider using a marking system when conducting
The primary contributing factor, however, is searches. 10
disorientation.
Discussion: Several methods of marking searched
When the IC orders the RIT to conduct an rooms can be used by the fire service: chalk or crayon
emergency search or rescue, the companies can marks, masking tape, specially designed door
regroup and take roll call. With a RIT in place, they markers, and latch straps over doorknobs. SOPs
can respond immediately to the location given by usually dictate the method of marking; however, any
lost or disoriented fire fighters to conduct rescue method used must be known to and clearly
operations. understood by all personnel who may participate in
the search. It is recommended that search crews
Recommendation #8: Implement an overall use a two-part marking system. The crew affixes
health and safety program such as the one half of the mark when entering the room and
recommended in NFPA 1500, Standard on Fire completes the mark when exiting the room. This
Department Occupational Safety and Health avoids duplication of effort by alerting other rescuers
Program.4 that the room is being or has been searched. If a
search crew becomes lost, this mark will serve as a
Discussion: NFPA 1500 provides the framework for a starting point for others to begin looking for them.
safety and health program for fire departments. The
specified goal of the standard is to reduce the probability Recommendation #10: Fire departments should
of occupational fatalities, illnesses, and disabilities among identify dangerous vacant buildings by affixing
fire fighters. NFPApoints out that the standard is meant warning placards to entrance doorways or other
to be appropriate for voluntary compliance tailored to openings where fire fighters may enter.1
the needs of each individual department. Formal
implementation of the standard, particularly the Discussion: Vacant buildings can and do pose
development of a written plan for compliance with NFPA numerous hazards to fire fighters health and safety.
Page 13
Massachusetts
Hazards should be identified and warning placards Discussion: Since carbon monoxide (CO) is given
affixed to entrance doorways or other openings off in varying quantities during all fires, and other toxic
to warn fire fighters of the potential dangers. materials are typically present, it is paramount that
Hazards can be structural as the result of building officers enforce and fire fighters follow the
deterioration or damage from previous fires. departments guidelines for the wearing of masks at
Structural hazards can occur when building owners structure fires. In this incident, a number of fire
or salvage workers remove components of the fighters reported not wearing their masks inside the
building such as doors, railings, windows, electric structure even while encountering moderate smoke
wiring, utility pipes, etc. Abandoned materials conditions. Far more fire deaths occur from carbon
such as paper and flammable or hazardous monoxide than from any other toxic product of
substances and collapse hazards constitute combustion. This colorless, odorless gas is present
additional dangers fire fighters may encounter. in every fire. The poorer the ventilation and the more
Collapse hazards can be chimney tops, parapet inefficient the burning, the greater the quantity of
walls, slate and tile roof shingles, metal and wood carbon monoxide formed. Concentrations of carbon
fire escapes, advertising signs, and entrance monoxide in air above five hundredths of one percent
canopies. For example, a warning placard may (0.05 percent) (500 ppm) can be dangerous. When
be a 12-inch-square piece of metal painted the level is more than 1 percent, unconsciousness
reflective yellow so that it glows in the dark and and death can occur without physiological signs. Even
indicates to fire fighters that hazards exist inside at low levels of exposure fire fighters should not use
the building. Following are examples of warning signs and symptoms for safety factors. Headaches,
placards developed and used by the New York dizziness, nausea, vomiting, and cherry-red skin can
City Fire Department. occur at many concentrations, based on an individuals
dose and exposure. Therefore, these signs and
symptoms are not good indicators of safety.7 Table 1
The building is unoccupied but structurally lists the toxic effects of carbon monoxide.10
sound.
A 1-percent concentration of carbon monoxide in a
The building is unoccupied, and a hazard room will cause a 50-percent level of
exists. carboxyhemoglobin in the blood stream in 2½ to 7
minutes. A 5-percent concentration can elevate the
The building is unoccupied, and more than carboxyhemoglobin level to 50 percent in only 30 to
one interior hazard exists. Defensive outside 90 seconds. Because the newly formed
fire fighting operations are permitted. carboxyhemoglobin may be traveling through the
body, a person previously exposed to a high level of
carbon monoxide may react later.8 If fire fighters
develop any of these signs, they should immediately
Recommendation #11: Fire departments should exit the structure and receive the proper medical care.
ensure that officers enforce and fire fighters Severe exposures to carbon monoxide can cause
follow the mandatory mask rule per nerve injury or brain damage. If fire fighters are
administrative guidelines established by the overcome with carbon monoxide, they should not
department.10 be allowed to re-enter a smokey atmosphere. If fire
Page 14
Massachusetts
fighters suspect they have been exposed to carbon myriad of fire-related situations. In a search-and-
monoxide, they should notify their officer or the IC. rescue operation, a fire fighter can use the TIC to
In this incident, several fire fighters stated they scan a room in seconds rather than crawl across
experienced nausea, dizziness, and disorientation; the entire floor in search of civilians or downed
however, some of these fire fighters re-entered the fire fighters. TICs can be used to conduct size-
structure to search for the victims. ups and to find the source of fire upon arrival at
the scene. They can also be used to provide vital
Recommendation #12: Fire departments should information for planning fire attack, overhaul, and
explore the use of thermal imaging cameras to ventilation. TICs are also useful at hazmat
locate lost or downed fire fighters and civilians incidents, and they can be used to scan large areas
in fire environments.11 for hot spots in wildland fires. TICs should be used
in a timely manner, and fire fighters should be
Discussion: Thermal Imaging Cameras (TICs), as properly trained in their use and be aware of their
reported by their manufacturers, can be used for a limitations.
Carbon Monoxide Carbon Monoxide in air Symptoms

(CO)(ppm) (percent)
100 0.01 No symptoms-no damage
200 0.02 Mild headache; few other symptoms
400 0.04 Headache after 1 to 2 hours
800 0.08 Headaches after 45 minutes; nausea,

collapse, and unconsciousness after 2 hours.
1,000 0.10 Dangerous; unconscious after 1 hour
1,600 0.16 Headache, dizziness, nausea after 20 minutes.
3,200 0.32 Headache, dizziness, nausea after 5 to 10

minutes; unconsciousness after 30 minutes.
6,400 0.64 Headache, dizziness, nausea after 1 to 2

minutes; unconsciousness after 10 to 15 minutes.
12,800 1.26 Immediate unconsciousness, danger of death

in 1 to 3 minutes.
Table 1. Toxic Effects of Carbon Monoxide.10
Page 15
Massachusetts
Recommendation #13: Manufacturers and occupational safety and health program. Quincy,
research organizations should conduct MA: National Fire Protection Association.
research into refining existing and developing
new technology to track the movement of fire 5. National Fire Protection Association [1997].
fighters on the fireground. NFPA 1521, standard on fire department safety
officer. Quincy, MA: National Fire Protection
Discussion: Fire fighter fatalities often are the result Association.
of fire fighters becoming lost or disoriented on the
fireground. The use of systems for locating lost 6. Morris GP, Brunacini N, Whaley L [1994].
or disoriented fire fighters could be instrumental Fire ground accountability: the Phoenix system.
in reducing the number of fire fighter deaths on Fire Engineering 147(4):45-61.
the fireground. One such system, a wireless
tracking system, requires locating three accurately 7. Dunn V [1998]. Managing and controlling
placed spread-spectrum transmitters around a fireground risks and dangers-Part 1. Firehouse
building to provide positioning information. Other Magazine. August 1998, pp. 26-29.
systems may include a UHF Radio system or an
Infrasound Low Frequency Detector. Research 8. Norman J [1998]. Fire officers handbook of
into refining existing systems and developing new tactics. 2 nd ed. Saddle Brook, NJ: Fire
technologies for tracking the movement of fire Engineering Books and Videos.
fighters on the fireground should continue.
9. Massachusetts Firefighting Academy. Rapid
REFERENCES intervention crew: impact series student handout.
1. Dunn V [2000]. Vacant building fires. Stow, MA: Massachusetts Firefighting Academy.
Firehouse Magazine. May 2000, pp. 20-26.
10. International Fire Service Training Association
2. Brunacini, AV [2000]. Written expert review [1995]. Essentials of fire fighting. 4th ed.
of NIOSH FACE report 98F-47 of August 21, Stillwater, OK: Fire Protection Publications,
2000, from AV Brunacini, to R Braddee, Division Oklahoma State University.
of Safety Research, National Institute for
Occupational Safety and Health, Centers for 11. http://www.firehouse.com/news/99/10/
Disease Control and Prevention, Public Health 19_camera.html
Service, U.S. Department of Health and Human
Services. INVESTIGATOR INFORMATION
This investigation was conducted by Richard W.
3. National Fire Protection Association [1995]. Braddee, Team Leader; Frank C. Washenitz,
NFPA 1561, standard on fire department incident Thomas P. Mezzanotte, and Nancy T. Romano,
management system. Quincy, MA: National Fire Safety and Occupational Health Specialists; and
Protection Association. Theodore Pettit, Senior Fire Fighter Investigator,
Fire Fighter Fatality Investigation and Prevention
4. National Fire Protection Association [1997]. Program, Division of Safety Research, NIOSH,
NFPA 1500, standard on fire department and Tim R. Merinar, Engineer, and Tom
Page 16
Massachusetts
McDowell, Physical Scientist, Respirator Branch,

Division of Respiratory Disease Studies, NIOSH.
EXPERT REVIEW
Expert review was provided by Francis L. (Frank)
Brannigan, Society of Fire Protection Engineers
(Fellow); Alan V. Brunacini, Chief, City of Phoenix
Fire Department; and Vincent Dunn, Deputy Chief
(Ret.), FDNY.
Page 17
Massachusetts
1st Alarm 2nd Alarm 3rd Alarm 4th Alarm 5th Alarm
1815 hours 1819 hours 1842 hours 1854 hours 1929 hours
Engine 1 Engine 2 Engine 3 Engine 8 Engine 5

Captain Lieutenant Lieutenant Captain Lieutenant
3 Fire Fighters 4 Fire Fighters 4 Fire Fighters 2 Fire Fighters 3 Fire Fighters
Victims 5, 6
Engine 6 Engine 16 Engine 7 Engine 15 Engine 10

Lieutenant 3 Fire Fighters Lieutenant Lieutenant Lieutenant
2 Fire Fighters 2 Fire Fighters 3 Fire Fighters 3 Fire Fighters
Engine 12 Aerial Scope 2 Ladder 2 Ladder 4

Lieutenant 3 Fire Fighters Lieutenant Captain
3 Fire Fighters 3 Fire Fighters 2 Fire Fighters
Victims 3, 4
Engine 13 Car 2 (IC#2) Car 1 (Chief)

3 Fire Fighters Deputy Chief Chief
1 Fire Fighter
Ladder 1
Captain
4 Fire Fighters
Ladder 5
3 Fire Fighters
Rescue 1
Lieutenant
4 Fire Fighters
Victims 1, 2
Car 3 (IC#1)
District Chief
1 Fire Fighter
Table 2. Fire Alarms for Cold-Storage and Warehouse Building Fire - Massachusetts
Page 18
Massachusetts
C SI
DE
GL ASS-B OARD
POLY ST YR EN E
6 "-1 8" ASPHALT -
IM PREG NAT ED CO RK
18 " M ASONR Y B R IC K BUI

LDIN
G
A BUI
LDI N
G
B
6th
5th
IDE
4th
BS
UU
3rd
PP DDE
E
2nd NN
WALL SECTION
DE
NO T T O S C AL E
1st
D SI
BA
SE
ME
NT
A SI
FRA D E
NK
L IN
ST.
N OT T O S C AL E
Figure 1. Cold Storage and Warehouse Building Layout, Plain View
Page 19
Massachusetts
KEY
E = ELEVATOR SHAFT
OFF. = OFFICES C SIDE
TRAIN TRACKS 3RD FLOOR
TRAIN TRACKS
STAIRWAY
TO 3RD
LOADING DOCKS
FLOOR
E E
L UP UP
H
STAIRWAY
B O D I
TO ROOF BUILDING BUILDING
A G
D A B
S S H
I OFF. OFF.
I UP UP I W
N OFF.
D E D A
E G OFF. E Y
OFF.
E
D OFF.
OFF. O
O APPROXIMATE ORIGIN V
C OF FIRE OFF. E
K OFF.
OFF. R
S P
DN DN
A
OFF. OFF. OFF. S
S
A SIDE
FRANKLIN ST.
NOT TO SCALE
FIRE WALL
Figure 2. Cold Storage and Warehouse Building, 2nd Floor Layout, Plain View
Page 20
Massachusetts
C SIDE
TRAIN TRACKS 3RD FLOOR

E-13
TRAIN TRACKS 2ND FLOOR

E-1
COVERED EXTERIOR DOCKS TO 2ND
2 1/2" FLOOR
E E H
UP UP I
3" 1 3/4" G
STAIRS TO 2ND FLOOR H
TO ROOF W
L-3 B UP UP D A
3"
Y
S BUILDING BUILDING S
I A B I O
D D V
E E E
L-1 R
P
E-2 UP A
TO 3RD FLOOR
UP
S
OFF. OFF. S
2 1/2"
E-12 A SIDE L-2 E-3 E-7
2 1/2" L-4
2 1/2" E-16
E-6
FRANKLIN STREET
L-5 NOT TO SCALE

E-8
R-1 E-15
Figure 3. Cold Storage and Warehouse Building, Hoseline/Apparatus Layout,

First Floor View
Page 21
Massachusetts
N
ELEVATOR SHAFT
KEY
AIR FLOW
6TH FLOOR
WINDOW
DOCK DOOR 5TH FLOOR

DOORS
THROUGH 4TH FLOOR
FIREWALL
3RD FLOOR
2ND FLOOR
1ST FLOOR
GROUND LEVEL
BASEMENT
STAIRWELL TO
ROOF
B SIDE
NOT TO SCALE
Figure 4. Cold Storage and Warehouse Building, B Side, Exterior Section View
Page 22
Massachusetts
Foam
Brick Wall Glass
Asphalt-Impregnated
Cork Styrofoam
Photo 1. Interior Insulation of Cold-Storage and Warehouse Building
Page 23
Massachusetts
Windows in Stairwell
Docks C Side Docks B Side
Photo 2. Corner B/C of Cold-Storage and Warehouse Building
Page 24
Massachusetts
Elevator Shaft
Approximate Point of Origin Heavy Timber Supports
Photo 3. Second Floor B Building
Page 25
Massachusetts
Photograph by Roger B. Conant.
Photo 4. Cold-Storage and Warehouse Building Shortly After First Alarm - 1825 Hours
Page 26
Massachusetts
Photo 5. Cold-Storage Freezer Room
Page 27
Massachusetts
C Side
D Side
Firewall
Building B
Building A
A Side
B Side
© 1999 Photograph by Telegram & Gazette Staff/Paul Kapteyn
Photo 6. Firewall Between Building A and B, Cold-Storage and Warehouse Building
Page 28
Massachusetts
Photograph by Roger B. Conant.
Photo 7. Cold-Storage and Warehouse Building After Third Alarm - 1842 Hours
Page 29
Massachusetts
© 1999 Roger B. Conant

All rights reserved
Photo 8. Cold-Storage and Warehouse Building at 2030 Hours
Page 30
Massachusetts
ATTACHMENT
DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service
NIOSH Reference: TN-11472 Centers for Disease Control

and Prevention (CDC)
National Institute for Occupational
Safety and Health - ALOSH
1095 Willowdale Road
Morgantown, WV 26505-2888
Phone: (304) 285-5907

Fax: (304) 285-6030
May 1, 2000
Dear Chief:
During our visit to the Fire Department on April 20, 2000, Tim Merinar and I had the opportunity
to evaluate your fire departments self-contained breathing apparatus (SCBA) maintenance
program. The objectives of our visit were to evaluate your SCBA maintenance program and to
make recommendations for improvement. This evaluation consisted of visiting the SCBA mainte-
nance area, interviewing fire department personnel associated with the maintenance of SCBA,
reviewing SCBA maintenance records and procedures, and evaluating the compressed-air and
oxygen cylinder refilling stations located at your training and equipment maintenance facility. Our
evaluation process benefitted substantially from the cooperation of your staff. Their cooperation
was instrumental in providing us with information necessary for the evaluation of your SCBA
maintenance program.
Your current SCBA maintenance program was evaluated and compared to the respirator and
SCBA maintenance requirements listed in the following recognized national standards:
Title 29, Code of Federal Regulations (CFR) Part 1910.134 known as The OSHA
Respirator Standard.
National Fire Protection Association (NFPA) 1404, Standard for a Fire Department
Self-Contained Breathing Apparatus Program, 1996 Edition.
National Fire Protection Association (NFPA) 1500, Fire Department Occupational

Safety and Health Program, 1997 Edition.
American National Standards Institute, Inc. (ANSI), American National Standard for
Respiratory Protection, ANSI Z88.2-1992.
Page 31
Massachusetts
ATTACHMENT (continued)
These standards specify the minimum benchmark requirements that all fire department respirator
programs should strive to meet or exceed. Compliance with these standards is considered to be
essential to maintain SCBA in a condition meeting the certification requirements of the National
Institute for Occupational Safety and Health (NIOSH) found in Title 42, Code of Regulation,
Part 84, Subpart H, as well as the National Fire Protection NFPA 1981 Standard on Open-
Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition. Failure to
maintain your SCBA in an approved condition voids the NIOSH approval until such time as each
affected SCBA can be inspected, serviced, and returned to an approved condition.
The following areas were identified within the Fire Department SCBA maintenance program as
areas where improvement is needed in order to comply with the referenced national standards:
1) NIOSH recommends that your SCBA maintenance program be under the direct control of one
designated individual who is a Fire Department employee and who has no other fire fighting or
administrative responsibility. In general, this individuals area of responsibility could be tailored to
meet the departments needs, but should include supervision and control of all aspects of the
program including the SCBA preventive maintenance program, repair, testing, record keeping, and
auditing. Our evaluation revealed no documented policy designating an authority with jurisdiction
over the SCBA maintenance program. It was also noted that personnel currently responsible for
the SCBA maintenance program have numerous responsibilities in other areas.
Title 29, Code of Federal Regulations (CFR), Part 1910.134 (the OSHA Respirator
Standard) at 1910.134(c) requires each respirator program to be administered by a
suitably trained program administrator.
2) The Fire Department should establish written standard operating procedures for managing its
various SCBA maintenance, repair, and testing functions. During our visit, we provided draft copies
of generic standard operating procedures and record keeping forms that may assist you in
developing your program documents. Procedures should be developed to address each of the
following areas:
a. SCBA Maintenance Training

b. SCBA Inspection
c. SCBA Maintenance
d. Air Quality Program
e. Recharging Cylinders
f. Record Keeping
g. Identification of Defective SCBA and Removal from Service
Page 32
Massachusetts
NFPA 1404, Chapter 1-5.5 and 1-5.6 require the authority having jurisdiction to establish
written standard operating procedures and training policies for members responsible for
respiratory protection use, cleaning, and maintenance.
NFPA 1404, Chapter 1-5.7 specifies that the authority having jurisdiction shall establish
written standard operating procedures for inspection, maintenance, repair, and testing of
respiratory protection equipment.
NFPA 1404, Chapter 7-2.3 specifies that written policies shall be established to ensure
that air is obtained only from a source that meets the requirements of CGA G7.1,
Commodity Specifications for Air.
NFPA 1404, Chapter 7-2.5 specifies that proper cylinder recharging procedures and
safety precautions shall be posted in a conspicuous location at each fill station.
The OSHA Respirator Standard 29 CFR 1910.134(c)(1)(v) and 1910.134(h)(4) require

the employer to develop schedules and procedures for inspecting respirators and ensuring
that respirators that fail inspection or are otherwise found to be defective are removed
from service.
3) A preventive maintenance program should be established to ensure regularly scheduled

preventative maintenance is conducted on each SCBA at least annually. It is noted that the Fire
Department does not operate a preventive maintenance program but rather attempts to repair
defective SCBA on an as-needed basis.
The OSHA Respirator Standard 29 CFR 1910.134(c)(1)(v); 1910.134(c)(1)(vi); and

1910.134(h) require the employer to develop and implement a written respiratory
protection program that includes specific procedures and schedules for cleaning and
disinfecting, storage, inspection, maintenance, and repair of respirators used by employees.
NFPA 1404, Chapter 6-1.2 and 6-1.3 require annual inspection and servicing of SCBA
by qualified personnel. Chapter 6-1.3 requires annual servicing to be conducted following
the manufacturers recommendations and should include :
a. Disassembly of the SCBA into major components

b. Flow testing of the regulator
c. Disassembly and cleaning of the regulator
d. Replacement of worn parts, or those recommended by the manufacturer in the
regulator assembly.
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Massachusetts
e. Disassembly of the low-air alarm and cleaning and replacement of component parts as
necessary.
f. Cleaning and replacement of components of the facepiece and harness assembly, and
replacement of component parts as necessary.
g. Reassembly of the entire SCBA and testing for proper operation of all components.
h. Proper recording of all performed maintenance on record keeping forms.
NFPA 1404, Chapter 6-2.1 specifies that a preventative maintenance program shall be
established by the authority having jurisdiction for all SCBA used in the organization.
NFPA 1404, Chapter 6-2.2 specifies that the SCBA preventative maintenance program
shall be conducted in order to prevent SCBA malfunction and failures of equipment
during use.
NFPA 1500, Chapter 5-3.1 specifies the fire department shall adopt and maintain a
respiratory protection program that addresses the selection, inspection, safe use, and
maintenance of respiratory protection equipment, training in its use, and the assurance of
air quality testing.
NFPA 1404, Appendix A, A-6.2 states that an SCBA should be rebuilt by its manufac-
turer or by a person trained and certified by the manufacturer at intervals as recom-
mended by the manufacturer.
Specific guidelines for determining and scheduling preventive maintenance actions can best be
compiled with assistance from your SCBA manufacturer. Frequency of complete SCBA overhaul
should be based on the manufacturers recommendation. If no manufacturers recommendation is
provided, NIOSH recommends that rebuilding of SCBA assemblies be performed every 3 years.
It is apparent that in order for the Fire Department to establish a comprehensive preventive
maintenance program, the department will need to acquire additional resources. It would be
impossible for your current SCBA maintenance staff to continue to complete repairs on mobile
apparatus, power tools, and other equipment as well as perform all tasks necessary for repair and
comprehensive preventive maintenance for nearly 150 SCBA. In addition to increased staff, the
acquisition of spare SCBA would allow your SCBA maintenance staff to perform preventative
maintenance without interruptions to emergency response.
4) Records should be maintained for each SCBA, facepiece, and cylinder at the department.
During our visit, we were shown a filing system where repair and testing information was
maintained for each SCBA and filed according to company assignment. Some electronic files had
Page 34
Massachusetts
also been developed to help track some SCBA services such as cylinder hydrostatic test sched-
ules. NIOSH recommends that the computerized records system be expanded to address the
following standard excerpts:
NFPA 1404, Chapter 2-2.3 specifies that an individual record of each SCBA regulator
and harness assembly shall be maintained. This record shall include the inventory or serial
number, date of purchase, date of manufacture, date placed into service, location,
maintenance and repairs, replacement parts used, upgrading, and test performance.
NFPA 1404, Chapter 2-2.4 specifies that an individual record of each SCBA cylinder
shall be maintained. This record shall include the inventory or serial number date of
purchase, date of manufacture, date placed into service, location, hydrostatic test pressure
and dates, and any inspection and repairs. The hydrostatic test dates shall appear on each
cylinder according to the manufacturers instructions and applicable government agencies.
NFPA 1404, Chapter 2-2.5 specifies that an individual record of each SCBA facepiece
shall be maintained. This record shall include the inventory or serial number, date of
purchase, location, maintenance and repairs, replacement parts, upgrading, and test
performance.
NFPA 1500, Chapter 2-7.5 specifies that each fire department shall assure that inspec-
tion, maintenance, repair, and service records are maintained for all vehicles and equipment
used for emergency operations and training.
The OSHA Respirator Standard 29 CFR 1910.134(h)(3) lists the requirements for
respirator inspections. 1910.134(h)(iv)(A and B) list the requirements for documenting
each inspection.
The American National Standard for Respiratory Protection, ANSI Z88.2-1992,

Chapter 10.2 specifies that the SCBA user shall inspect the respirator, and that a record
of inspection dates shall be kept for each respirator.
It is apparent that the computer support at the Fire Department would have to be substantially
upgraded to permit the development of an effective electronic filing and information management
system.
5) A program should be developed to ensure that all SCBA cylinders meet the US Department of
Transportation (DOT) standards for periodic requalification and service life limitations. These
standards are listed in Title 49, Code of Federal Regulations (CFR), Part 173.34(e). A review
Page 35
Massachusetts
of the records kept at the Training Center indicated that some in-service cylinders had past-due
hydrostatic test dates. DOT requirements for the fiberglass-wrapped cylinders utilized by the Fire
Department require that each cylinder be submitted every three years to a DOT-certified retester
for inspection and hydrostatic testing. The DOT requirements limit the service life for these
cylinders to 15 years from the date of manufacture, regardless of the last date of requalification.
NFPA 1500, Chapter 5-3.8 specifies that SCBA cylinders shall be hydrostatically tested
within the periods specified by the manufacturers and the applicable governmental
agencies.
NFPA 1404, Appendix A, A-6.2 specifies that breathing gas cylinders be tested as
prescribed in Title 49, Code of Federal Regulations (CFR), Part 178, Shipping
Container Specification Regulations.
Title 42, Code of Federal Regulations (CFR), Part 84.81(a), NIOSH Requirements
for Respiratory Protection Devices requires cylinders used on NIOSH-approved
SCBA to meet the minimum DOT requirements.
6) The Fire Department should develop and implement a standard operating procedure that
specifies that air samples will be collected from each SCBA cylinder filling station and analyzed by
an accredited laboratory on a quarterly basis.
NFPA 1500, Chapter 5-3.1 specifies the fire department shall adopt and maintain a
respiratory protection program that includes provisions for air quality testing.
NFPA 1500, Chapter 5-3.7.1 specifies that when a fire department manufacturers its
own breathing air, the fire department shall be required to provide documentation that a
sample of the breathing air obtained directly from the point of transfer from the filling
station to the SCBA cylinders has been tested at least quarterly.
NFPA 1404, Chapter 7-1.1 specifies that written policies shall be established to ensure
that air is obtained only from a source that meets the requirements of CGA G7.1,
Commodity Specifications for Air.
NFPA 1404, Chapter 7-1.2 requires each fire department to have its breathing air tested
by an accredited laboratory at least every three months.
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Massachusetts
7) The Fire Department should develop and implement an SCBA facepiece fit-testing program to
ensure that all SCBA users are able to achieve a proper face-to-facepiece seal.
The OSHA Respirator Standard 29 CFR 1910.134(f) requires employers to have all
employees who wear tight-fitting facepiece respirators fit-tested with the same make,
model, style, and size facepiece used by the employee.
NFPA 1404, Chapter 4-11(b) specifies that the authority having jurisdiction shall evaluate
the ability of each of its department members to demonstrate that a proper face-to-
facepiece seal has been achieved.
8) Annual evaluations of the SCBA Maintenance Program should be conducted to monitor and
evaluate the effectiveness of the overall SCBA maintenance program.
The OSHA Respirator Standard 29 CFR 1910.134(h)(3)(1)(ix) requires the employer

to develop and maintain as part of the overall written respiratory protection program,
procedures for regularly evaluating the effectiveness of the program.
NFPA 1404, Chapter 8-1.1 specifies that the authority having jurisdiction shall review the
organizations respiratory protection program annually for the purposes of determining the
need to upgrade or change various aspects of the program.
These recommendations are based upon the premise that all SCBA are life-saving devices which
will only perform as well as they are maintained. Since they are expected to function and perform
properly each time they are used, it is important that SCBA maintenance and inspection be given
the utmost priority at the department level.
During our visit, we provided your SCBA maintenance personnel with a copy of the peer-
reviewed document Respirator Maintenance Program Recommendations for the Fire Service
developed by NIOSH and published in the Journal of the International Society for Respiratory
Protection. We also provided draft copies of generic standard operating procedures and record
keeping forms that may assist you in developing improvements to your overall SCBA maintenance
program.
During our visit, we also inspected and evaluated the oxygen cylinder refilling station located at
your training and equipment maintenance facility. Oxygen cylinders are typically refilled for use in
Page 37
Massachusetts
oxygen resuscitators and other emergency medical equipment used to administer oxygen therapy.
The OSHA Respirator Standard 29 CFR 1910.134 as well as the NFPA 1404 Standard for a Fire
Department Self-Contained Breathing Apparatus Program, do not specifically address these types
of medical devices. However, safe handling practices dictate that oxygen refilling systems as well as
oxygen equipment be stored in a clean, dry, air-conditioned location that is locked to limit access only
to those individuals who have been properly trained and qualified to work with oxygen equipment. All
cleaning, repair, and refilling operations should be conducted using the appropriate special tools which
are cleaned, maintained, and dedicated only for use on oxygen equipment. The oxygen cylinder refilling
station that we examined failed to meet the above requirements.
The NIOSH Fire Fighter Injury Investigation Report 98F-23, Oxygen Regulator Flash Severely
Burns One Fire Fighter - Florida, and the joint FDA and NIOSH Public Health Advisory: Explo-
sions and Fires in Aluminum Oxygen Regulators both contain a number of recommendations on
safe handling procedures for handling and filling portable oxygen cylinders. Both documents address
special precautions which should be taken for oxygen cylinder filling stations. A copy of each document
is enclosed.
The Compressed Gas Association pamphlet CGA G-4 (1996 revision) Oxygen (especially chapter
4) and the NFPA 53 Guide on Fire Hazards in Oxygen-Enriched Atmospheres, 1994 Edition are
also excellent sources of information on oxygen cylinder storage and safe handling procedures.
I trust this information is beneficial to your needs. If you have any questions or require additional
information, please contact me at (304) 285-6337.
Sincerely yours,
Thomas W. McDowell
Physical Scientist
Respirator Branch
Division of Respiratory Disease Studies
Page 38

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99 Death in the

DQG3UHYHQWLRQ3URJUDP line of duty...

Six Career Fire Fighters Killed in Cold-Storage and Warehouse

The Fire Fighter Fatality Investigation and Prevention

Photograph by Roger B. Conant. http://www.cdc.gov/niosh/firehome.html

INTRODUCTION The Fire Department involved in the incident serves a

Carbon Monoxide Carbon Monoxide in air Symptoms

100 0.01 No symptoms-no damage

200 0.02 Mild headache; few other symptoms

400 0.04 Headache after 1 to 2 hours

800 0.08 Headaches after 45 minutes; nausea,

1,000 0.10 Dangerous; unconscious after 1 hour

1,600 0.16 Headache, dizziness, nausea after 20 minutes.

3,200 0.32 Headache, dizziness, nausea after 5 to 10

6,400 0.64 Headache, dizziness, nausea after 1 to 2

12,800 1.26 Immediate unconsciousness, danger of death

Table 1. Toxic Effects of Carbon Monoxide.10

McDowell, Physical Scientist, Respirator Branch,

Engine 1 Engine 2 Engine 3 Engine 8 Engine 5

Engine 6 Engine 16 Engine 7 Engine 15 Engine 10

Engine 12 Aerial Scope 2 Ladder 2 Ladder 4

Engine 13 Car 2 (IC#2) Car 1 (Chief)

18 " M ASONR Y B R IC K BUI

Figure 1. Cold Storage and Warehouse Building Layout, Plain View

TRAIN TRACKS 3RD FLOOR

TRAIN TRACKS 3RD FLOOR

TRAIN TRACKS 2ND FLOOR

L-5 NOT TO SCALE

Figure 3. Cold Storage and Warehouse Building, Hoseline/Apparatus Layout,

DOCK DOOR 5TH FLOOR

Photo 1. Interior Insulation of Cold-Storage and Warehouse Building

Docks C Side Docks B Side

Photo 2. Corner B/C of Cold-Storage and Warehouse Building

Approximate Point of Origin Heavy Timber Supports

Photo 3. Second Floor B Building

Photograph by Roger B. Conant.

Photo 5. Cold-Storage Freezer Room

© 1999 Photograph by Telegram & Gazette Staff/Paul Kapteyn

Photo 6. Firewall Between Building A and B, Cold-Storage and Warehouse Building

Photograph by Roger B. Conant.

© 1999 Roger B. Conant

Photo 8. Cold-Storage and Warehouse Building at 2030 Hours

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

NIOSH Reference: TN-11472 Centers for Disease Control

Phone: (304) 285-5907

National Fire Protection Association (NFPA) 1500, Fire Department Occupational

a. SCBA Maintenance Training

The OSHA Respirator Standard 29 CFR 1910.134(c)(1)(v) and 1910.134(h)(4) require

3) A preventive maintenance program should be established to ensure regularly scheduled

The OSHA Respirator Standard 29 CFR 1910.134(c)(1)(v); 1910.134(c)(1)(vi); and

a. Disassembly of the SCBA into major components

The American National Standard for Respiratory Protection, ANSI Z88.2-1992,

The OSHA Respirator Standard 29 CFR 1910.134(h)(3)(1)(ix) requires the employer

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Photo 2. Corner B/C of Cold-Storage and Warehouse Building

Photo 3. Second Floor B Building