2016

06

October 10, 2018

Career Fire Fighter Killed and Volunteer Fire Fighter Seriously

Wounded When Shot during a Civilian Welfare Check—Maryland

Executive Summary
On April 15, 2016, a 37-year-old male
career fire fighter/paramedic was killed
and a 19-year-old male volunteer fire
fighter was seriously wounded when
they were shot after a combination fire
department was dispatched for a check
on the welfare of a citizen. The fire
fighters were on the front porch
attempting to gain entry into the single
family dwelling when they were shot by
the resident. At approximately 1930
hours, the county 911 center received a
call from a civilian who reported that he
was outside of his brother’s house and
his brother was not answering his phone
calls or knocks on the front door. The
caller reported that he had spoken with Two Fire Fighters and a civilian were shot and two
his brother earlier in the day and that his other fire fighters injured when trying to perform a
brother’s vehicle was parked in the welfare check at this single-family residence.
driveway in front of his house. He (Photo source Local Police Department Homicide Unit)
further stated that his brother had known medical issues. He requested assistance in gaining entry into
his brother’s house. Rescue Engine 827 with six volunteer fire fighters and Paramedic Ambulance 823
with two career fire fighter/paramedics were dispatched at 19:35 hours. After arriving on scene, the fire
fighters met the homeowner’s brother in the driveway and observed that all visible windows were
covered. The fire fighters knocked on the front door, announced their presence several times and
checked for an open door, however they did not perform a 360-degree walk around. After again
announcing their presence, the fire fighters began to force open the front doors. Forcing both doors
took 5-8 minutes with multiple strikes from three fire fighters using a halogen tool, axe and a sledge.
The fire fighters forced the metal outer door but had trouble forcing the inner wooden door and ended
up knocking a lower panel out of the wooden door and reaching through the hole to open the door from
the inside. Four fire fighters, two medics and the homeowner’s brother were standing on the small
front porch and the steps in front of the door. As the door was opened the homeowner’s brother
entered. The homeowner fired a pistol multiple times through the open doorway striking his brother,
the fire fighter/paramedic and a volunteer fire fighter.

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The fire fighters and the civilian all tried to escape from the front porch area (see cover photo) and ran
to take cover behind the apparatus in the street. The career fire fighter/paramedic who was shot, ran to
Paramedic Ambulance 823 and collapsed at the unit. He was transported in Paramedic Ambulance 823
to a local hospital where he was later pronounced dead. The volunteer fire fighter who was shot ran to
Rescue Engine 827 where he was driven to a safe area, transferred to a medic unit, and then
transported by air ambulance to a local trauma center. The homeowner’s brother was taken by police to
the off-site command post and later transported by ambulance to a local hospital. Two other volunteer
fire fighters suffered minor injuries (not gunshot-related) during their escape from the porch and were
treated and released.

Contributing Factors
• Police were not on scene at time door was forced open
• Fire Fighter Identification (lack of standardized station uniform) and time of evening
• Lack of communication of important information to responders (presence of firearms in
residence)
• Resident did not acknowledge multiple attempts by fire department to contact him verbally and
by knocking on front door
• Fire fighters/paramedics not wearing ballistic vests or personal protective equipment.

Key Recommendations
• Fire, EMS, police departments, and dispatch agencies should ensure that police are the
primary agency initially assigned to “check on the welfare” of occupants and that information
regarding weapons in a residence are communicated to all of the responding agencies
• Fire and EMS departments should implement standard operating procedures requiring fire
fighters and EMS providers to present themselves in uniforms that readily identify them to be
emergency responders
• Fire, EMS, police departments and dispatch agencies should ensure important responder safety
information is requested during the call taking process and that information is transferred into
the dispatch system and provided to first responders.

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and
Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of
work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the
NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire
fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire fighter deaths in the future. The
agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or
assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH
investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop
a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and
interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH
report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's
recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

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06

October 10, 2018

Career Fire Fighter Killed and Volunteer Fire Fighter Seriously

Wounded When Shot during a Civilian Welfare Check—Maryland

Introduction
On April 15, 2016, a 37-year-old male career fire fighter/paramedic was killed and a 19-year-old male
volunteer fire fighter was seriously wounded when they were shot after a combination fire department
was dispatched for a check on the welfare of a citizen. A civilian (the homeowner’s brother) was also
shot and seriously injured. Two other volunteer fire fighters suffered minor injuries (not gunshot-
related) while trying to escape off the front porch. On April 18, 2016, the U.S. Fire Administration
notified the National Institute for Occupational Safety and Health (NIOSH) of this incident. On April
25, 2016, the Fire Department contacted the NIOSH Fire Fighter Fatality Investigation and Prevention
Program and requested assistance with an independent investigation of the incident. Over the next few
weeks, a number of phone conversations were held to exchange information and arrange the on-site
investigation. In early June, 2016, the Fire Chief requested that NIOSH place its investigation on hold
due to the complexity of the incident and the on-going criminal investigation. In December 2016, the
Fire Department again contacted the NIOSH Fire Fighter Fatality Investigation and Prevention
Program and requested that NIOSH re-open its investigation. Additional phone calls were held over
the next few weeks. On February 21, 2017, a Safety and Occupational Health Specialist, a Safety
Engineer with the NIOSH Fire Fighter Fatality Investigation and Prevention Program and a Research
Epidemiologist from the NIOSH Division of Safety Research traveled to Maryland to investigate this
incident. The NIOSH investigators met with senior staff officers and representatives of the fire
department, the International Association of Fire Fighters (IAFF) local 1619 and the volunteer fire
fighters association. The NIOSH investigators met with and interviewed the career fire fighters and
officers involved in the incident. The NIOSH investigators obtained and reviewed fire department
training records, standard-operating procedures, incident scene photographs and drawings, and training
records and medical records. On May 4, 2017, the NIOSH Occupational Safety and Health Specialist
and the Safety Engineer returned to Maryland to conduct additional interviews with current and
subsequently retired members of the career department. The volunteer fire fighters who responded on
Rescue Engine 827 along with chief officers from the volunteer fire department were not available to
be interviewed by NIOSH.

Fire Department
The fire department involved in this incident is a combination career and volunteer department
consisting of 860 career and 1072 volunteer uniformed members that provide fire suppression and
emergency medical service (EMS) protection. The fire department employes a total of 908 paid staff.

There are 45 fire stations located strategically throughout the county that serve a population of
approximately 909,535 in a geographic area of approximately 482 square miles. The department
responded to approximately 148,506 incidents in 2016. Some station houses are staffed by career fire

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Career Fire Fighter Killed and Volunteer Fire Fighter Seriously
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fighters, some station houses are staffed entirely by volunteer fire fighters and some station houses are
staffed by both career and volunteer fire fighters. These 45 stations house 163 apparatus, including 49
engines (including 5 paramedic units), 23 ladder trucks, 9 rescue trucks, five rescue engines, 43 basic
life support (BLS) and 18 advanced life support (ALS) ambulances, and 16 specialty units. Five
battalion chiefs are on duty per shift. The battalion chiefs and career fire fighters are assigned to one of
four shifts that work 24 hours on and 72 hours off duty. The fire department does not utilize chief’s
aides or incident command technicians. The station that the fatally injured fire fighter/paramedic’s
ambulance responded from is a career station that responded to 7697 emergency calls in 2016. The
station that the injured fire fighters responded from is a volunteer station that responded to 7172
emergency calls in 2016.

During calendar year 2016, the department responded to a total of 5959 "check on the welfare"
incidents resulting in 7654 individual unit responses. This equates to approximately 16 per 24-hour
shift. The department dispatched an engine with the EMS unit to assist in these incidents (force entry)
28 percent of the time.

The fire department estimated that less than 20 percent of all “check on the welfare” calls result in the
fire department providing patient care. It was also reported that 28 percent of these calls required
forceable entry.

The fire department was dispatched on tactical channel 8 per department standard operating
procedures. The response area is divided by a major east-west highway. Once dispatched, responding
units would switch to channel 8 alpha, bravo, or charlie dependng on the incident location. Channel 8
alpha is used for incidents on the north side of the highway, Channel 8 bravo is used for high
volume/high speed roadways and vehicle entrapment incidents and Channel 8 charlie is used for
incidents south of the highway.

The communication center operates 24 hours per day with call takers working 12-hour shifts from
06:30 to 18:30 hours and 18:30 hours to 06:30 hours. The communication center is staffed according to
the expected call volumne and time of day. The communciation center may have anywhere from 7 or 8
call takers and up to 24 persons at dedicated work stations at any time. The hours of 14:30 to 22:30
hours generally experience the most call volume and require the highest number of dispatchers.

Note: The fire department administrative office requested that NIOSH conduct an independent
investigation of this incident. The volunteer department number 27 did not participate in this
investigation. The volunteer department did not provide standard operating procedures, training
records or related information. The volunteer fire fighters involved in this incident were not made
available for the NIOSH interview process.

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Training and Experience

The state of Maryland requires training for volunteer fire fighters that meets or exceeds the
requirements of National Fire Protection Association (NFPA) 1001, Standard for Fire Fighter
Professional Qualifications, [NFPA 2013] for the topic areas of Fire Fighter I, Hazardous Materials
Awareness, Hazardous Materials Operations, and First Responder. The process requires annual
recertification.

The career fire department involved in this incident has a recruit school which is 18 weeks in length
and consists of NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter I, Fire
Fighter II, Hazardous Materials Awareness, Hazardous Materials Operations, and Emergency Medical
Technician (EMT).

In the state of Maryland, training requirements are as follows:

• Firefighter I is 108 hours
• Firefighter II is 60 hours
• EMT is 380 hours
• Hazardous Materials Operations is 24 hours
• Hazardous Materials Awareness is 12 hours.

The career fire fighter/paramedic fatally shot in this incident had 13 years of fire service experience.
Fire department training records indicated he had received training and certification in Fire Fighter I
Equivalency, Fire Fighter II Equivalency, Hazardous Materials Operations Equivalency, Emergency
Vehicle Operator, Pump Operator, Aerial Apparatus Operator, Truck Company Operations, National
Fire Academy Responding to Terrorism Basic Concepts, Emergency Medical Technician (EMT)
training and certification, and Paramedic training and certification. The career fire fighter/paramedic
was working an overtime shift at the time of the incident and was not working at his normal duty
station.

Training records for the volunteer fire fighter wounded in this incident were requested by NIOSH but
not provided by the volunteer fire department.

Equipment and Personnel

Units that initially responded to the check on the welfare incident:
• Rescue Engine 827 with six volunteer personnel including an officer (lieutenant).
• Paramedic Ambulance 823 with two career fire fighters (fire fighter/EMT driving and fire
fighter/paramedic (the shooting victim).

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Timeline
The following timeline is a summary of events that occurred as the incident evolved. This timeline is
not a formal record of events and not all incident events are included in this timeline. The times are
approximate and were obtained by studying the dispatch records, audio recordings, witness statements,
and information courtesy of the local police department and other available information. All times are
approximate and rounded to the closest minute.

Incident Conditions Time Response

Civilian repeatedly called his 1430- No answer on either line

brother’s cell phone and landline, 1915
feared a medical event may have hours
occurred

Civilian then went over to check on 1915 Couldn’t get his brother to answer his
his brother at incident location hours door and then knocked on windows
with no success

Civilian called 911 for assistance 1930 Dispatcher took information from the
civilian (brother of the occupant)

1933 Call was entered for “Check on the

Welfare”

Call was dispatched to Fire/Rescue 1935 Rescue Engine 827and Paramedic

Department Ambulance 823 assigned and
responded

Rescue Engine 827 arrived on scene 1946 Volunteers from Rescue Engine 827
met with the civilian (brother) and
walked up and started to force door

Paramedic Ambulance 823 arrived on 1948 The 2 career fire department EMT’s
scene from Paramedic Ambulance walked
up the yard to the front door while
the rescue engine was attempting to
force the front door

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Incident Conditions Time Response

PD unit 3K9 and 3K6 dispatched to 1949 Rescue Engine 827 and Paramedic
assist FD Ambulance 823 personnel were at the
front door (on the porch and steps)
with tools attempting to force the
door

PD unit 3K10 replaced 3K9 on the 1950 No PD units were on scene, just
incident and responded Rescue Engine 827 and Paramedic
Ambulance 823 and the civilian
The fire fighters broke out a panel of
the lower portion of the wooden front
door and a fire fighter reached in and
unlocked and opened the door and
yelled fire department

A responder on the radio advised 1950- Fire crews and civilian had just
“shots fired” (an additional shot 1951 entered the front door, then the home
could be heard in the background of owner fired a total of 5 shots at the
the dispatch tape during this responders and his brother
transmission)

Radio transmission “police step up” 1951 Fire fighters ran off the porch
(civilian ran too but did yell to his
brother to identify himself)

Radio transmission “One fire fighter 1953 Shooting suspect was still in the
down by the house, cannot get to house
him”

PD timeline noted 1954 hours 1951- Fatally injured career fire fighter
“Paramedic Ambulance 823, one shot 1954 from Paramedic Ambulance 823 ran
to chest, not conscious” to Paramedic Ambulance 823 in
street and told members he was shot,
then collapsed

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Incident Conditions Time Response

1951- Volunteer fire fighter from Rescue

1954 Engine 827 was shot 3 times and
tried to get down the sidewalk by
crawling, then rolled down driveway
to Rescue Engine 827

PD arrived on scene 1957

2009 Shooting suspect walked out of the

house and surrendered to PD

2038 Career fire fighter medic off of

Paramedic Ambulance 823 was
pronounced dead at local hospital
from gunshot wound to the chest

Rescue Engine 827 transported Unit ambulance 825 gave care to

injured volunteer fire fighter to meet Rescue Engine 827 fire fighter on the
ambulance 825. Staff from tailboard of Rescue Engine 827 then
ambulance 825 provided care on the transferred care to ambulance 829.
tailboard of Rescue Engine 827 until 829 then transported 2 volunteer fire
ambulance 829 arrived and took over fighters with minor injuries (non-
care. Transport to medic helicopter gunshot related) to hospital.
was initiated in ambulance 825.
Ambulance 829 took the
homeowner’s injured brother
(gunshot wound) to trauma hospital.

Weather
At approximately 1951 hours, the weather in the immediate area was reported to be approximately 54
degrees Fahrenheit, a dew point of 31.6 degrees F., and the relative humidity was 43%. Wind
conditions were 6.9 miles per hour from the southeast and clear with visibility of 10 miles [Weather
Underground 2017].

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Incident Location
This incident occurred at a one-story, 1,600-square foot, residential single-family dwelling located
within city limits. The structure included an in-basement garage and contained 4 bedrooms and 2
baths. The structure faced a two-lane city street (See Photo 1 and Diagram 1).

Photo 1. Incident Scene.

(Photo source Local Police Department Homicide Unit)

Diagram 1, first floor layout.

(Diagram derived from floorplan provided by the fire department.)

Investigation
At approximately 1930 hours on April 15, 2016, the county 911 center received a call from a civilian
who reported that he was outside of his brother’s house and his brother was not answering his phone

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calls or knocks on the front door. The caller reported that he had spoken with his brother earlier in the
day and that his brother’s vehicle was parked in the driveway in front of his house. He also stated that
his brother had known medical issues and had “blacked-out” at work the previous day. The caller also
reported the possibility of firearms inside the house, and requested assistance in gaining entry into his
brother’s house. Dispatch recorded the information and entered the call as a “Check on the welfare”
call.

At 1935 hours, Rescue Engine 827 and Paramedic Ambulance 823 were dispatched for the assignment.
Rescue Engine 827 responded from Station 27 with six volunteer fire fighters onboard, including one
officer. Paramedic Ambulance 823 responded at 1935 hours with two career fire fighters (fire
fighter/EMT driving and fire fighter/paramedic) onboard. Rescue Engine 827 arrived on scene at 1946
hours and met with the resident’s brother in the driveway in front of the house, and proceeded to the
front door. Paramedic Ambulance 823 arrived on scene at 1948 hours and joined the Rescue Engine
827 fire fighters at the front porch (see Photo 2). The resident’s brother joined the fire department
members on the front porch and urged them to force open the door so that they could gain entrance and
check on the status of the resident.

Fire fighters knocked on the front door and loudly announced that they were with the fire department
and checked the front door, however they did not perform a 360-degree walk around. It was reported
that they did not hear any response from inside the house. All the visible windows were covered over
from the inside so the fire fighters could not see inside the house. It was also reported that the
resident’s brother made several more calls from his cell phone in an attempt to reach the resident who
was assumed to be inside. After again announcing their presence, the fire fighters began to force open
the front doors.

At 1949 hours, two police department patrol units were added to the dispatch assignment and went
enroute. The Rescue Engine 827 crew members began to force open the front door using hand tools.
The fire fighters encountered some difficulties in forcing open the outer metal door and the main
wooden door. At approximately 1950 hours, one of the fire fighters used a sledge hammer and broke
out the bottom left panel of the four-panel wooden door (see Photo 3). The fire fighters again loudly
announced they were with the fire department. One of the fire fighters reached through the opening in
the door and unlocked the door from the inside.

The fire fighters opened the door and prepared to step inside. Six of the eight fire fighters on-scene
were standing on the front porch (approximately 6 feet by 6 feet) with one fire fighter standing on the
sidewalk and the driver of Rescue Engine 827 remained in the driver’s seat of the engine. One
volunteer fire fighter (wounded) and the resident’s brother (also wounded) were standing side-by-side
just outside the threshold when the door was swung open. Another volunteer fire fighter and the
fatally-wounded career fire fighter/paramedic (carrying a medical bag) were located right behind them.

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Photo 2. Incident Scene. Photo shows the 6 foot by 6 foot front porch area where fire fighters and
the resident’s brother were located just prior to the shooting. Medical bag and tools were
dropped as the fire fighters exited the area.
(Photo source Local Police Department Homicide Unit)

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Career Fire Fighter Killed and Volunteer Fire Fighter Seriously
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Photo 3. Incident Scene. Photo taken from inside the residence facing the front entrance shows
the front door which was forced open by the responding fire fighters. Numbered markers were
placed by the local police department.
(Photo source Local Police Department Homicide Unit)

Unknown to the fire fighters, the resident was located approximately 10 feet from the front door at the
hallway leading to the bedroom area (see Diagram 1). As the door was swung open, the resident began
firing a handgun, striking the fire fighter/paramedic, one of the volunteer fire fighters, and his brother.
None of the fire fighters were believed to have entered the house when the shooting occurred.

The fire fighter/paramedic from Paramedic Ambulance 823 was struck in the upper chest by a single
bullet. The volunteer fire fighter from Rescue Engine 827 was struck three times in the arm, abdomen
and upper leg. The resident’s brother was struck by a single bullet in the chin. The resident’s brother
reportedly called out to his brother and identified himself by name after the shooting. Note: It was
reported during NIOSH interviews and police photographs confirmed that some of the Station 27

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volunteer fire fighters (on Rescue Engine 827) were not wearing fire department uniforms. The Station
27 volunteers did not participate in the NIOSH interviews or information requests. Police photographs
showed athletic-type shorts, tee-shirts and athletic shoes being worn at the time of the incident. It was
also reported that the volunteer fire department did not have a uniform requirement.

All of the fire fighters immediately ran for cover. Two of the volunteer fire fighters suffered minor
injuries diving off the porch. The fire fighters ran toward the street to take cover behind the engine and
ambulance. The career fire fighter/EMT and the volunteer officer both dove behind Paramedic
Ambulance 823 at the same time. The volunteer officer got into the right front seat and radioed
dispatch that fire fighters had been shot. The career fire fighter/EMT got into the driver’s seat as
another Rescue Engine 827 volunteer fire fighter dove behind Ambulance 823 for cover. The wounded
fire fighter/paramedic (victim) reached the ambulance and walked around to the right side of the
ambulance. He reportedly said “I think I’m shot” and then collapsed as he was opening the side door.
The career fire fighter/EMT jumped out of the driver’s seat to assist his partner. The volunteer fire
fighter helped to pull the wounded fire fighter/paramedic into the ambulance through the side door.
The wounded fire fighter/paramedic was placed on the cot facing rearward. The career fire
fighter/EMT and the volunteer fire fighter began checking the fire fighter/paramedic for wounds as the
volunteer officer began driving away from the scene while radioing dispatch that Paramedic
Ambulance 823 was transporting the wounded fire fighter/paramedic to the hospital. The career fire
fighter/EMT hooked up a heart monitor and began to monitor the wounded fire fighter/paramedic’s
vital signs.

As Paramedic Ambulance 823 drove away from the scene, dispatch advised that a medic unit was
being dispatched to meet them. Paramedic Ambulance 823 briefly stopped, the three fire fighters
discussed the situation and then they decided to proceed immediately to the closest county hospital.
After arriving at the hospital, the wounded fire fighter/paramedic was immediately taken into the
emergency room for treatment. Unfortunately, the fire fighter/paramedic did not survive his wounds
and was pronounced dead at the hospital.

Rescue Engine 827 drove away from the residence with the wounded volunteer fire fighter and the
remaining three crew members onboard. Ambulance 825 was dispatched to meet Rescue Engine 827
at a local middle school. Ambulance 825 was staffed with two fire fighter/paramedics but was
operating as a basic-life-support (BLS) ambulance at the time of the incident. The fire
fighter/paramedics on Ambulance 825 treated the Rescue Engine 827 volunteer fire fighter’s gunshot
wounds and prepared him for transport. Medic 829 arrived and assisted with medical treatment. The
wounded fire fighter was placed in the police helicopter (Trooper 2) and transported to the shock
trauma hospital in Baltimore MD. One of the Rescue Engine 827 volunteer fire fighters rode in the
helicopter with the wounded fire fighter. The Ambulance 825 crew then treated the remaining injured
Rescue Engine 827 fire fighters and transported them to the local county hospital. One of the volunteer
fire fighters suffered a broken jaw and the other volunteer fire fighter suffered an ankle injury diving
off the porch during the shooting. The driver of Rescue Engine 827 suffered a knee injury when he
exited the driver’s seat of the engine. Ambulance 829 transported the resident’s brother from the off-

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site command post (where police had transported him) to the local trauma hospital to be treated for the
gunshot wound he sustained during the incident.

Occupation Related Violence

The Centers for Disease Control and Prevention estimates that 2,600 EMS workers received hospital
treatment in 2014 for injuries resulting from work-related violence out of a total of 21,300 EMS
medical treatment incidents for all types of work-related injuries [CDC 2014].

A survey conducted by the National Association of Emergency Medical Technicians (NAEMT) found
that 80 percent of emergency medical services (EMS) workers have experienced some form of injury
on the job [NAEMT 2005]. Further, the majority (52 percent) reported that they were injured from an
assault [NAEMT 2005]. In 2012, the overall private industry rate of injury requiring days away from
work for violence and other injuries by persons or animals was 4.0 per 10,000 full time employees
[BLS 2014]. The rate for EMTs and paramedics was over eight times greater (32.5) [BLS 2014].

Compared to 2012 numbers, the number of EMS workers seeking treatment for all work-related
injuries in 2014 decreased by 2,900, while the number seeking treatment for work-related assault
injures increased by 200 [CDC, 2012]. Although, not all assault-related injuries can be prevented, the
risk can be reduced by implementing recommendations included in this report.

Contributing Factors
Occupational injuries and fatalities are often the result of one or more contributing factors or key
events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH
investigators identified the following items as key contributing factors in this incident that ultimately
led to the fatality:
• Police were not on scene at time door was forced open
• Fire Fighter identification (lack of standardized station uniform) and time of evening
• Lack of communication of important information to responders (presence of firearms in
residence)
• Resident did not acknowledge multiple attempts by fire department to contact him verbally and
by knocking on front door.
• Fire fighters not wearing ballistic vests or personal protective equipment.

Cause of Death
According to the medical examiner report, the victim died from a gunshot wound to the chest.

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Recommendations
Recommendation #1: Fire, EMS, police department’s and dispatch agencies should ensure that
police are the primary agency initially assigned to “check on the welfare” of occupants and that
information regarding weapons in a residence are communicated to the responding agencies.
Discussion: In 2004, NIOSH released EMS specific recommendations on methods to best mitigate
violence following the investigation into the death of a female firefighter who responded to the scene
of a civilian shooting [NIOSH 2005]. Table 3 summarizes the recommendations from the 2005 NIOSH
report.

Table 3. NIOSH recommendations from Report F2004-11 [NIOSH 2005].

Fire departments should:
• Develop standard operating procedures for responding to potentially violent situations.
These should include, at a minimum, simultaneous dispatch of police and EMS.

• Develop integrated emergency communication systems that include the ability to

directly relay real-time information between the caller, dispatch, and all responding
emergency personnel.

• Make it standard operating procedure that any time weapons are mentioned during the
dispatch, EMS personnel stage a safe distance from the scene until police declare the
scene safe.

• Provide body armor or bullet-resistant personal protective equipment; train on,

and consistently enforce its use when responding to potentially violent situations
(including all check on the welfare calls).

• Ensure all emergency response personnel have the capability for continuous radio
contact, and consider providing portable communication equipment that has integrated
hands-free capabilities.

• Consider requiring emergency dispatch centers to incorporate the ability to archive

location, or individual, historical data, and provide pertinent information to responding
fire and emergency medical services personnel.

• Develop coordinated response guidelines for violent situations, and hold joint training
sessions with law enforcement, mutual-aid and emergency response departments.

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NIOSH recommends that employers train workers on recognizing and preventing workplace violence,
investigate all reports of violence, work with police to identify dangerous neighborhoods where special
precautions need to be taken, and provide that information to employees.

From the employee’s standpoint, NIOSH recommends the following in response to violent workplace
incidents: employees should participate in violence prevention training and report all incidents of
violence, no matter how minor [NIOSH Fast Facts, 2012]. Other recommendations include concurrent
dispatching of police in all high-risk situations associated with violence or the potential for violence
(e.g., suicide, homicide, domestic violence, intoxication, and psychiatric illness) [Corbett et al., 1998;
Mechem et al., 2002, USFA 2017b].

During this incident, the fire department members arrived on Rescue Engine 827 and Paramedic
Ambulance 823 before the police department arrived. Due to the urgency expressed by the resident’s
brother, the fire department members did not wait for the police department to arrive before beginning
to force open the front door.

Recommendation #2: Fire and EMS departments should implement standard operating procedures
requiring fire fighters and EMS providers to present themselves in uniforms that readily identify
them to be emergency responders

Discussion: The ability of the public to identify a fire fighter or EMS provider as someone who does
not pose a physical threat to them is vital for the safety of emergency responders and the public. Fire
fighters and all emergency responders should be easily identifiable and highly visible for both practical
and safety purposes. The National Fire Protection Association (NFPA) 1975 Standard on Emergency
Services Work Clothing Elements establishes requirements for fire fighter and emergency responder
work apparel and clothing be worn while performing their official duties. [NFPA 2014a]. This standard
does not apply to clothing that is intended to protect the wearer with primary protection from given
hazard exposures.

The uniform should make the fire fighter easily and readily identifiable as a member of the fire
department. The U.S. Fire Administration final report Mitigation of Occupational Violence to
Firefighters and EMS Responders provides emergency medical services best practices to avoid
violence to EMS and emergency responders based upon first-hand experience. One important
recommendation from this report states “Make sure ‘EMS’ is clearly stated in your appearance, so that
there is no confusion of your intentions” [USFA 2017b]. The uniform should make the fire fighter
easily and readily identifiable as members of the fire department. NFPA 1500 Standard on Fire
Department Occupational Safety and Health Program, Paragraph 7.1.4 states “Where station/work
uniforms are worn by members, such station/work uniforms shall meet the requirements of NFPA
1975, Standard on Station/Work Uniforms for Emergency Services [NFPA 2013b]. Annex A, Chapter
7.1.4 of NFPA 1500 states “Because it is impossible to ensure that every member, whether a volunteer,
call, or off-duty career member, will respond to an incident in a station/work uniform or will change
into station/work uniform clothing before donning protective garments, it is very important that

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members understand the hazards of some fabrics that more easily melt, drip, burn, shrink, or transmit
heat rapidly and cause burns to the wearer. Clothing made from 100 percent natural fibers or blends
that are principally natural fibers should be selected over other fabrics that have poor thermal stability
or that ignite easily. The very fact that members are fire fighters indicates that all clothing they wear
should be flame resistant to give a degree of safety if unanticipated happenings occur that expose the
clothing to flame, flash, sparks, or hot substances [NFPA 2013b].”

In this incident, it was reported that some members of the volunteer engine company who responded
on the initial dispatch were wearing athletic apparel (shorts) and tennis shoes. This could have
contributed to the resident failing to identify them as members of the responding fire department and
perceiving them as a threat. The resident did not call or request the fire department to respond so it is
possible the resident heard the sound of the fire department forcing open the front door and thought his
home was being burglarized. Easily identifiable fire service uniforms may have made the individuals
more easily recognizable as fire department members.

Fire departments should consider developing and implementing standard operating procedures or
guidelines requiring fire department members to be properly dressed in a professional manner while on
duty. Note: During the NIOSH interview process information was reported and police photographs
confirmed that some of the Station 27 volunteer fire fighters (on Rescue Engine 827) were not wearing
fire department uniforms. Police photographs showed athletic-type shorts, tee-shirts and athletic shoes
being worn at the time of the incident. It was also reported that the volunteer fire department did not
have a uniform requirement. The Station 27 volunteers did not participate in the NIOSH interviews or
respond to information requests.

Recommendation #3: Fire, EMS, police departments and dispatch agencies should ensure important
responder safety information is requested during the call taking process and that information is
transferred into the dispatch system and provided to first responders.

Discussion: Critical information, such as the suspected presence of weapons, that can assist first
responders with their safety needs to be obtained and transmitted to all of the responding units to an
emergency. This information can help establish the proper response urgency and put the responders in
the proper mind-set regarding their own safety. This incident was initiated when a civilian called 911
and expressed concern that his brother was not responding to repeated phone calls and attempts to
make contact. The caller reported that he was at his brother’s house and his brother’s vehicle was
parked in the drive way. The caller stated that he had knocked on the door but his brother did not
respond. The call taker asked the caller if any weapons were in the house and the caller stated that
there could be firearms inside the house.

The communications center did not have a process for entering this type of critical information into the
computer-aided-dispatch system. The information about the possibility of weapons in the house was
not forwarded to the responding units.

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Recommendation #4: Fire and EMS departments should ensure that important information
regarding an incident (such as weapons in the house) are communicated to individual responding
units and provide mobile data terminals (MDT) for reserve units.

Discussion: Fire departments and authorities having jurisdiction should ensure that critical information
that could impact responder safety is communicated to all responding units as part of the initial
dispatch and all subsequent dispatches to the incident. It is also important to relay this information by
radio as well as putting notes in the warning or information section of the MDT. Fire fighters and EMS
providers may not be sitting in front of a MDT or be able to scroll through notes and read important
cases notes such as this during an emergency response. These important messages should have a
priority screen presence with some sort of visual stimuli to ensure it is noticed. This is not only
important for the primary units assigned, but also fire department and EMS supervisors for those units.

When sensitive information cannot or should not be transmitted over the radio, the dispatcher should
verbally prompt responding units to check case notes and acknowledge to complete the
communications loop.

In this incident, the communications center did not have a process for entering this type of critical
information (possibility of weapons in the house) into the computer-aided-dispatch system. The
information about the possibility of weapons in the house was not forwarded to the responding units.
The resident’s brother had a conversation with the dispatcher and when the dispatcher asked if there
were any weapons in the residence, the brother said yes, but he (resident) wouldn’t hurt himself. This
information may have led to the information on weapons not being considered a priority and
transmitted over the radio.

Fire and EMS departments should train fire fighters to ask if weapons are in the structure before
forcing entry. This should be directed to the dispatch and also any civilians on the scene who may
know the location. Additionally fire and EMS departments should consider providing MDT’s for
reserve fire and EMS vehicles.

Recommendation # 5: Fire departments and authorities having jurisdiction should consider issuing
ballistic vests to fire fighters and emergency responders that meet, at a minimum, the requirements
of the National Institute of Justice, Standard-0101.06, Ballistic Resistance of Body Armor.

Discussion: Protective equipment (which includes ballistic vests, helmets, and eyewear) for both
civilian first responders and the military is designed and tested according to anticipated threats, injury
patterns, and existing technology. Historically, first responders have been primarily concerned with
protective equipment to counter firearm and, to a certain extent, chemical, biological, radiological, and
nuclear threats).

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First Responders

The development of standards and the manufacturing of this protective equipment for first responders
have only been available since the 1970s [Montanarelli et. al 1973, NIJ 2001]. The 126 percent
increase in police officer fatalities from 1966 to 1971 prompted the Department of Justice (DOJ) to
develop and evaluate concealable soft body armor for daily use that would protect against ballistic
threats while minimizing blunt trauma. [Hanlon & Gillich 2012, Montanarelli et al.] Handguns have
historically been the most common threat to police officers, but National Institute of Justice (NIJ)
ballistic vest testing parameters follow trends in threats, and updated testing parameters are added
based on new knowledge of vest performance and necessary test conditions [DOJ 2008, OTA 1992].

Currently there are five types of ballistic vests based on NIJ body armor standards. However, statistics
from the Bulletproof Vest Partnership/Body Armor Safety Initiative suggest that the majority of vests
used by first responders are Type II and IIIA. Descriptions of the body armor standards are listed
below, ordered by the level of protection. For instance, Type IIA provides protection against Type II
and IIA threats, whereas Type III vests provide protection for Type IIA, Type II, and Type IIIA
threats. All of the vests listed, with the exception of Types III and IV, are considered concealable body
armor and designed to fit under a normal uniform shirt [NIJ 2001].

NIJ Standard-0101.06 establishes five formal armor classification types [NIJ 2008, DOJ 2010]:
• Type IIA protects against 9 mm; .40 S&W
• Type II protects against 9 mm; .357 Magnum
• Type IIIA protects against.357 SIG; .44 Magnum
• Type III protects against Rifles; 7.62mm FMJ
• Type IV protects against Armor Piercing Rifles; .30 caliber AP

Some manufacturers also produce soft armor vests that accommodate “trauma packs”, which are
ballistic inserts added to a vest to provide added protection. These inserts are referred to as “in
conjunction” designs and are similar to military ballistic inserts. These “in conjunction” designs must
be threat level tested and labeled appropriately [NIJ 2001]. In other words, if a Type III vest provides
Type III protection only in conjunction with a trauma pack, then the system’s label must be marked
accordingly.

Recommendation #6: Fire and EMS departments should ensure that accountability is maintained
on all incidents.

Discussion: Although there is no evidence that the following recommendation would have prevented
this fatality, it is being provided as a reminder of best safety practice for the fire service. Fire and EMS
departments need to ensure accountability for all responding personnel. Accountability should be
maintained at the task, tactical and strategic level.

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An accountability system can be as simple as a team using the buddy system (task level) on a single
unit response to a formal command (tactical and strategic level) accountability function established. It
not only keeps track of where personnel are but can even be used as a protection element for
responders. An example would be sending two members to search a residence when no one answers
the door. Two responders can account for each other and perform a quick scan to make sure the
mission is complete. Not only are the two members maintaining accountability, they are also ensuring
mission integrity and security. Once an incident escalates and multiple units are dispatched,
supervisors need to be aware. This may mean supervisors are made aware of or sent to incidents when
multiple units are assigned.

A personnel accountability system can help to reduce exposure to hazardous areas and also potentially
hazardous areas such as this front porch. A personnel accountability system is a system that readily
identifies both the location and function of all members operating at an incident scene [NFPA 2014b].
The accountability system should be inclusive of all sizes and types of emergency incidents.

The philosophy of the personnel accountability system starts with the same principles of an incident
management system – company unity and unity of command. Unity can be fulfilled initially and
maintained throughout the incident by documenting the situation status and resource status on a tactical
worksheet. An integral part of the accountability system is to make sure the fire fighters who are
assigned and operating in the hazard zone are accounted for, starting with the initial operations and
throughout the entire incident. Also, a system should be in place to periodically check to make sure
that all members operating in the hazard zone are accounted for.

One of the most important functions of command safety is for the incident commander to initiate a
personnel accountability system that includes the functional and geographical assignments at the
beginning of operations until the termination of the incident. NFPA 1561, Standard on Emergency
Services Incident Management System and Command Safety states in Paragraph 8.12.4, “The incident
commander and members who are assigned a supervisory responsibility that involves three or more
companies or crews under their command shall have an additional member(s) (e.g., staff aide) assigned
to facilitate the tracking and accountability of the assigned companies or crews” [NFPA 2014b].

A functional personnel accountability system requires the following:

• Development and implementation of a departmental accountability SOP
• Necessary components and hardware, such as an accountability board, individual name tags,
and company name tags
• Training for all members on the operation of the system
• Strict enforcement during emergency incidents.

Resource accountability should be assigned to personnel who are responsible for maintaining the
location and status of all assigned resources at an incident. As the incident escalates, resource status
would be placed under the Planning Section. This function is separate from the role of the incident
commander. The incident commander is responsible for the overall command and control of the

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incident. Due to the importance of responder safety, resource status should be assigned to a dedicated
member as the size and complexity of the incident dictates.

An important aspect of a personnel accountability system is the personnel accountability report or

PAR. A PAR is an organized on-scene roll call in which each supervisor reports the status of their
crew when requested by the incident commander or accountability officer [NFPA 2014b]. The PAR
should be conducted every 15-20 minutes or when benchmark activities are met.

In situations where individual fire department units and EMS units may respond without a fire
battalion chief or EMS supervisor; the agencies need to insure appropriate levels of accountability are
in place and effective. Individual units should not be left alone or unaccounted for. This can easily
happen when single piece responses are dispatched without the battalion chief or ems supervisor being
aware of the initial response. In a recent incident in MD, a fire department safety officer was left in an
exposure after a fire and died from smoke inhalation. The safety officer was a single person emergency
response vehicle. It was not realized that he was unaccounted for until the following morning when his
vehicle was spotted outside of the original fire building [NIOSH 2014].

In situations where there are single piece fire and EMS units on scene and no supervisor responding,
departments should ensure that they are checked on even if it is by the dispatcher. This could be
considered task or tactical level accountability by the members on the ambulance or engine, and may
be the extent of the accountability needed. However, if a single unit is dispatched to a seemingly non-
hazardous or insignificant incident and doesn’t report in with dispatch or their supervisor a break down
in accountability at the strategic level can occur. To prevent this, supervisors such as Battalion Chiefs
and EMS supervisors as well as dispatchers should have a system to recognize when a unit never clears
the scene.

In this incident, task and tactical level command and control quickly deteriorated after the shooting
occurred and the two initial companies left the scene to seek safety. Once it was determined that the
shooting had occurred, responding chief officers struggled to determine what had happened, how many
fire fighters were wounded and who they were. This confusion continued for some time as conflicting
information was reported over the radio. When the volunteer fire fighter who was wounded was
airlifted, another member of the volunteer fire department rode in the helicopter, adding additional
confusion as chief officers attempted to get a personnel accountability report.

Recommendation #7: Fire and EMS departments should consider using field incident technicians
for command officers to help ensure an effective unified command post is established.

Discussion: Although there is no evidence that the following recommendation would have prevented
this fatality, it is being provided as a reminder of best safety practice for the fire service. A field
incident technician, staff assistant, or a chief’s aide is a position designed to assist an incident
commander with various operational duties during emergency incidents. The chief’s aide can be an
essential element for effective incident management. During an emergency incident, the staff assistant

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can assist with key functions such as: managing the tactical worksheet; maintaining personnel
accountability of all members operating at the incident (resource status and deployment location);
monitoring radio communications on the dispatch, command, and fireground channels; control
information flow by computer, fax, or telephone; and, access reference material and pre-incident plans.
The personnel accountability system is a vital component of the fire fighter safety process. The system
is designed to account and track personnel as they perform their fireground tasks. In the event of an
emergency or “Mayday,” the personnel accountability system must be able to provide the rapid
accounting of all responders at the incident. This is one of the chief’s aide’s essential responsibilities.
Another important function is the role of a driver in addition to their role as part of the command team.
Chief Officers are required to respond quickly to emergency incidents. In their response, they have to
be fully aware of heavy traffic conditions, construction detours, traffic signals, and other conditions.
The chief officer should also monitor and comprehend radio traffic to assess which companies are
responding, develop a strategy for the incident based upon input from first arriving officers, develop
and communicate an incident action plan which defines the strategy of the incident. A chief’s aide can
assist the battalion chief or chief officer in processing information without distraction and complete the
necessary tasks enroute to the scene [Ciarrocca & Harms, 2011].

The fire department involved in this incident does not employ field incident technicians, assistants or
aides for chief officers. Thus, Battalion Chiefs and above-ranking officers are responsible for the
operation of their vehicles during emergency responses, in addition to collecting and analyzing
information about the incident from a number of sources. Departments should consider the aide to be
an individual that has the experience and authority to conduct the required tasks. Other potential roles
for the chief’s aide include assisting with the initial size-up, completing a 360-degree size-up,
coordinating progress reports from sector/division officers and many others. The aide position can be
used as a training position to help facilitate officer development. There are non-emergency functions
for the chief’s aide that are vital to the daily operations of the department. Some jurisdictions assign an
incident command technician or chief’s aide to command officers to perform daily administration
functions (such as position staffing and leave management). In this incident, a chief’s aide or staff
assistant could have helped the Incident Commander manage a rapidly escalating emergency situation
following the shootings.

Recommendation # 8: Fire Departments should consider developing and implementing a workplace

violence prevention program with standard operating procedures and guidelines that support the
workplace violence prevention program.

Discussion: There have recently been numerous incidents involving violence against emergency
responders. Fire and EMS organizations need to ensure training in avoidance and protection for all
members.

The U.S. Fire Administration joined with the International Association of Fire Fighters (IAFF) and
Drexel University to research best practices for preventing and mitigating violence against firefighters
and other first responders. Their study supports the National Fallen Firefighters Foundation's Fire

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Fighter Life Safety Initiative 12 – Violent Incident Response [NFFF 2018]. Violence is a major
occupational challenge confronting the field of Emergency Medical Services (EMS). Firefighters and
EMS responders are increasingly called upon to meet community demands for this service. As a result,
firefighters and EMS responders are often expected to respond to incidents where they can be exposed
to violence. Violence against EMS responders has been recognized as an occupational hazard since the
early 1970s, and recent incidents are evidence that the problem continues.

Violence is a major occupational challenge confronting the EMS field. A review of the literature from
academic and industry trade journals shows an increase in attention to the issue over the years.
However, there is limited understanding of risk factors and preventive measures. The literature
provides insight into the characteristics of violence perpetrators, EMS responder risk factors, and best
practices. However, much of the available information on these factors is contradictory, or not rooted
in evidence-based assessment. The U.S. Fire Administration, in cooperation with the International
Association of Fire Fighters (IAFF) recently published a report titled Mitigation of Occupational
Violence to Firefighters and EMS Responders. The purpose of this report, released in June 2017, is to
document the causes and risk factors of violence and mitigation opportunities to reduce and prevent
violence to EMS responders [USFA 2017b].

In fire and EMS, there is an obvious need for training and interventions to prevent and mitigate
violence. There is limited evidence regarding the availability and effectiveness of such interventions
(Gates et al., 2011). Much of the current violence prevention training that exists consists of generic
programs that are not tailored to the unique setting of the patient care provider, and primarily focus on
self-defense techniques rather than prevention [Gates et al., 2011]. Researchers note the guidelines
developed for violence reduction in emergency department (ED) settings do not work well in the EMS
industry [Corbett et al., 1998]. It is incumbent on the U.S. fire service to work toward developing
standard operating procedures and guidelines that address workplace violence prevention measures.
While NIOSH has not developed an EMS specific intervention, several recommendations for fire
departments to prevent and mitigate violence at both the organizational and employee levels can be
found in the NIOSH Publication Workplace Violence Prevention Strategies and Research Needs which
is available at https://www.cdc.gov/niosh/docs/2006-144/.pdf) [NIOSH 2006].

The National Fire Protection Association (NFPA) is currently developing a new standard NFPA 1300
Standard on Community Risk Assessment and Community Risk Reduction Plan Development that is
intended to service as a source of information that communities can use to assess and plan for risks
within their own jurisdiction [NFPA 2018].

References
BLS [2014]. Occupational Injuries/Illnesses and Fatal Injuries Profile.
http://data.bls.gov/gqt/InitialPage. Accessed December 1, 2017.

Ciarrocca M & Harms T [2011]. Help on the scene. FireRescue Magazine. February 2011,
vol 29, issue 2. Pp 40-48.

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CDC [2014]. Emergency Medical Services Workers; Injury and Illness Data; 2014. Atlanta GA;
National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.
https://www.cdc.gov/niosh/topics/ems/data.html Date accessed: October 17, 2017.

CDC [2012]. Emergency Medical Service Workers: Injury and Illness Data: 2012. Atlanta GA;
National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.
https://www.cdc.gov/niosh/topics/ems/data2012.html Date accessed: November 29, 2017.

Corbett, S., Grange, J., & Thomas, T. [1998]. Exposure of Prehospital care providers. Prehospital
Emergency Care, 2(2), 127-131.

DHS [2015]. First Responder Guide for Improving Survivability in Improvised Explosive Device
and/or Active Shooter Incidents. U.S. Department of Homeland Security, Office of Health Affairs.
https://www.dhs.gov/sites/default/files/publications/First%20Responder%20Guidance%20June%2020
15%20FINAL%202.pdf. Date accessed: October 2017.

DOJ [2008]. NIJ Standards: Ballistic Resistance of Body Armor, Department of Justice, Washington
DC. NIH Standard-0101.06.

DOJ [2010]. Bulletproof Vest Partnership/ Body Armor Safety Initiative. U.S. Department of Justice;
Washington DC. https://ojp.gov/bvpbasi/award_reports/2007vests.html. Date accessed: October 2017.

Gates, D., Gillespie, G., Kowalenko, T., Succop, P., Sanker, M., & Farra, S. [2011]. Occupational and
demographic factors associated with violence in the emergency department. Advanced Emergency
Nursing Journal, 33(4), 303-31p

Lexipol [2017]. Webinar: Firefighters Under Fire. Learning from Active Shooter Incidents. July 18,
2017. http://info.lexipol.com/fire-active-shooter

Mechem, C., Dickinson, E., Shofer, F., & Jaslow, D. [2002]. Injuries from assaults on paramedics and
firefighters in an urban emergency medical services system. Prehospital Emergency Care, 6(4), 396-
401.

Montanarelli N., Hawkins C., Goldfarb M., & Ciurej T. [1973]. Protective Garments for Public
Officials. Aberdeen Proving Ground, MD: U.S. Army Land Warfare Laboratory; 1973.

NAEMT [2006]. Experiences with Emergency Medical Services Survey, 2005.

https://www.jems.com/articles/2006/07/naemt-survey-federal-ems-agenc.html?c=1. Date accessed:
December 01, 2017.

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NIJ [2001]. Selection and Application Guide to Personal Body Armor. Washington, DC: U.S.
Department of Justice; 2001.

NIJ [2008]. National Institute of Justice. Standard-0101.06, Ballistic Resistance of Body Armor.
https://www.ncjrs.gov/pdffiles1/nij/223054.pdf. Date accessed: October 2017.

NFFF [2018]. 16 Fire Fighter Life Safety Initiatives. National Fallen Firefighters Foundation,
Everyone Goes Home webpage. https://www.everyonegoeshome.com/16-initiatives/. Date accessed:
August 2018.

NFPA [2013a]. NFPA 1001 Standard for Firefighter Professional Qualifications, 2013 edition.
National Fire Protection Association, Quincy MA.

NFPA [2013b]. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program,
2013 edition. National Fire Protection Association, Quincy MA.

NFPA [2014a]. NFPA 1975 Standard on Emergency Services Work Clothing Elements, 2014 edition.
National Fire Protection Association, Quincy MA.

NFPA [2014b]. NFPA 1561: Standard on Emergency Services Incident Management System and
Command Safety, 2014 edition. National Fire Protection Association, Quincy MA.

NFPA [2018]. Draft standard NFPA 1300 Standard on Community Risk Assessment and Community
Risk Reduction Plan Development. (under development). National Fire Protection Association, Quincy
MA.

NIOSH [2005]. Career Lieutenant Killed and Fire Fighter Injured By Gunfire While Responding To
Medical Assistance Call – Kentucky. Morgantown, WV: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and
Health, FACE Report F2004-11. https://www.cdc.gov/niosh/fire/reports/face200411.html

NIOSH [2006]. Workplace Violence Prevention Strategies and Research Needs. Department of Health
and Human Services (DHHS) / (NIOSH) Publication Number 2006-144.
https://www.cdc.gov/niosh/docs/2006-144/

NIOSH [2012]. NIOSH Fast Facts, Home Healthcare Workers: How to Prevent Violence on the Job.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Institute for Occupational Safety and Health. Dhhs/NIOSH Publication No. 2012-
118. https://www.cdc.gov/niosh/docs/2012-118/pdfs/2012-118.pdf.

NIOSH [2014]. Shift Safety Officer Falls through Hole in Floor into Basement of

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Vacant Row House and Dies from Smoke Inhalation – Maryland. Morgantown, WV: U.S. Department
of Health and Human Services, Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health, FACE Report F2014-24.
https://www.cdc.gov/niosh/fire/pdfs/face201424.pdf

OTA [1992]. U.S. Congress, Office of Technology Assessment, Police Body Armor Standards and
Testing, Volume II: Appendices, OTA-ISC-535. Washington, DC: U.S. Government Printing Office.

Taylor J, et. al [2016]. Expecting the Unexpected: A Mixed Methods Study of Violence to EMS
Responders in an Urban Fire Department. American Journal of Industrial Medicine 59:150-163
(2016). Wiley Periodicals, Inc.

USFA [2017a]. Violence Against EMS Responders. US Fire Administration website: Current Events
and Emergent Issues. https://www.usfa.fema.gov/current_events/083117.html. Date accessed:
October 17, 2017.

USFA [2017b] Mitigation of Occupational Violence to Firefighters and EMS Responders. U.S. Fire
Administration Contract Number HSFE20-15-Q-0053. Department of Homeland Security,
Washington DC. June 2017.
https://www.usfa.fema.gov/downloads/pdf/publications/mitigation_of_occupational_violence.pdf.
Date accessed: September 12, 2018.

Weather Underground [2017]. Weather history for Largo, MD, April 15, 2016,
https://www.wunderground.com/history/airport/KADW/2016/4/15/DailyHistory.html?req_city=Upper
+Marlboro&req_state=MD&req_statename=Maryland&reqdb.zip=20774&reqdb.magic=1&reqdb.wm
o=99999

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Investigator Information
This incident was investigated by Stephen T. Miles Investigator/Safety and Occupational Health
Specialist; and Tim Merinar, Investigator/Safety Engineer; with the Fire Fighter Fatality Investigation
and Prevention Program, Surveillance and Field Investigations Branch; and Dan Hartley, Research
Epidemiologist, Analysis and Field Evaluation Branch; Division of Safety Research, NIOSH located in
Morgantown, West Virginia. This report was authored by Stephen T. Miles. An expert technical
review was provided Fire Chief Gary Ludwig. A technical review was also provided by the National
Fire Protection Association, Public Fire Protection Division. A technical review was also provided by
Lori Moore-Merrell, Dr.PH, MPH, EMT-P and Assistant to the General President of the International
Association of Fire Fighters.

Additional Information
International Association of Fire Fighters

Active Shooter Toolkit includes information on key criteria for local protocols, national organization
policies and examples of established and practiced active shooter protocols. Additionally, the site
includes a compendium of active shooter incidents.

http://client.prod.iaff.org/#page=activeshooter

International Association of Fire Chiefs

The IAFC Active Shooter Toolkit provides direct access to resources to prepare, respond and recover
from active shooter and associated incidents. IAFC members must remember the active shooter threat
spans a broad base of events from organized terrorist cells to the lone wolf actor. Developing local
response plans, procedures and policies collaboratively with all other local stakeholders is imperative
then—exercise, exercise, exercise—with total stakeholder participation.

The Active Shooter Toolkit was developed and the resources vetted by the IAFC Terrorism and
Homeland Security Committee. All resources and references provided are for member consideration
without qualification or recommendation.

https://www.iafc.org/topics-and-tools/large-scale-response/active-shooter-toolkit

Lexipol

This online webinar learning series focuses on fire service responses to active shooter events. In this
webinar, chief officers from three departments recount their experiences in responding to an active-
shooter situation.

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http://info.lexipol.com/fire-active-shooter

U.S. Department of Justice, Federal Bureau of Investigation

This FBI report, covering active shooter incidents in the United States between 2000 and 2013,
examines specific behaviors that may precede an attack and that might be useful in identifying,
assessing, and managing those who may be on a pathway to violence.

https://www.fbi.gov/file-repository/pre-attack-behaviors-of-active-shooters-in-us-2000-2013.pdf/view

Department of Homeland Security

DHS Report: First Responder Guide for Improving Survivability in Improvised Explosive Device
and/or Active Shooter Incidents:
Recent improvised explosive device (IED) and active shooter incidents reveal that some traditional
practices of first responders need to be realigned and enhanced to improve survivability of victims and
the safety of first responders caring for them. This Federal, multi-disciplinary first responder guidance
translates evidence-based response strategies from the U.S. military’s vast experience in responding to
and managing casualties from IED and/or active shooter incidents and from its significant investment
in combat casualty care research into the civilian first responder environment. Additionally, civilian
best practices and lessons learned from similar incidents, both in the United States and abroad, are
incorporated into this guidance. Recommendations developed in this paper fall into three general
categories: hemorrhage control, protective equipment (which includes, but is not limited to, ballistic
vests, helmets, and eyewear), and response and incident management.

https://www.dhs.gov/sites/default/files/publications/First%20Responder%20Guidance%20June%2020
15%20FINAL%202.pdf

U.S. Fire Administration

US Fire Administration Final report: (Contract: HSFE20-15-Q-0053) Mitigation of Occupational

Violence to Firefighters and EMS Responders.

In January 2016, Drexel University was subcontracted by the International Association of Fire Fighters
under their contract with the Department of Homeland Security/Federal Emergency Management
Agency contract number: HSFE20-15-Q-0053 for the final report: Mitigation of Occupational
Violence to Firefighters and EMS Responders. Violence is a major occupational challenge confronting
the field of Emergency Medical Services (EMS). Firefighters and EMS responders are increasingly
called upon to meet community demands for service. As a result, firefighters and EMS responders are
often expected to respond to incidents where they can be exposed to violence. Violence against EMS

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responders has been recognized as an occupational hazard since the early 1970s, and recent incidents
are evidence that the problem continues.

https://www.usfa.fema.gov/downloads/pdf/publications/mitigation_of_occupational_violence.pdf

NIOSH On-line Training: “Workplace Violence Prevention for Nurses”.

This free, interactive course is designed to help healthcare workers better understand the scope and
nature of violence in the workplace. Upon successful completion of the course, healthcare
professionals can earn continuing education units (CEUs). Course modules include: Definition, types,
and prevalence; WPV consequences; Risk factors for type II and type III violence; Prevention
strategies for organizations; Prevention strategies for nurses; and Post–event response.
https://www.cdc.gov/niosh/topics/violence/training_nurses.html

Army Testing of Personal Protective Equipment

Over the last several years, the U.S. Army Test and Evaluation Command (ATEC) has conducted
thousands of ballistic tests of protective equipment, including individual pieces of equipment
traditionally thought of as “body armor” (softer material vests containing hard armor plates), helmets,
bomb suits, eye and face protection, extremity and pelvic protection, and concealable body armor. In a
majority of these tests, the threats evaluated include 7.62mm to 9mm bullets, metallic fragments of
various sizes and shapes, stab tests using both blade and pick threats, blast tests, and blunt trauma tests.
Other types of testing are also conducted, such as durability, reliability, wear ability, and suitability.
Permission to review reports must be obtained from the test sponsor, since ATEC was contracted to
conduct the assessment and is thus not the owner of the subsequent test data. All reports can be
requested through the ATEC website www.atec.army.mil/foia.html [DHS 2015].

Disclaimer
Mention of any company or product does not constitute endorsement by the National Institute for
Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not
constitute NIOSH endorsement of the sponsoring organizations or their programs or products.
Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced
in this document were accessible as of the publication date.

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