REPORT F2021-11 • May 2025

Firefighter Dies and Lieutenant Seriously Injured at a Multi-Family

Residential Structure Fire – Connecticut
Executive Summary
On May 12, 2021, a 30-year-old
career firefighter died, a lieutenant
was seriously injured, and two
firefighters suffered minor injuries
while fighting a fire in a two-story
multi-family residential structure.
At 00:46 hours, the city’s fire
dispatch center transmitted a box
alarm assignment for Box 1501 for
a residential structure fire. The first
Alarm dispatched was Car 34,
Engine 15, Engine 9, Engine 6,
Truck 4, Truck 1, Rescue 1, Special
Operations Command (SOC) 1, and
Emergency 2 (EMS 2). At 00:50
hours, the fire dispatcher alerted Car
34 there was an occupant still in the
house on the 1st floor and the fire
was in the basement. At 00:51 hours, Photo 1: Truck 4 conducting roof ventilation at Box 1501.
Engine 15 advised this was a (Courtesy of the fire department)
“working” fire. At 00:52 hours,
Engine 9 indicated a female occupant was trapped in a bedroom on Side Delta and Side Charlie. Engine 6
arrived on-scene at 00:53 hours and backed down the street to Engine 15, which was the attack piece.
Engine 6 Hydrant (deceased firefighter) took five lengths of 1¾-inch hoseline to Engine 15 and made the
connection for fire attack. Engine 6 stretched the hoseline into the house to the 2nd floor. Engine 6 (PAR 3)
got to the 2nd floor via the front stairs at 01:02 hours. Engine 6 Lieutenant (who was carrying a thermal
imager), Engine 6 Pipe, and Engine 6 Hydrant also got to the 2nd floor using the front stairs. Engine 6
Lieutenant called for the hoseline to be charged and had Engine 6 Pipe cool down the front room (living
room), which was also located on the 2nd floor. Engine 6 Lieutenant went into the Side Delta bedroom
which was very hot. The End of Service Time Indicators (EOSTIs) for the Engine 6 firefighters began to
sound and Engine 6 Lieutenant told Engine 6 Pipe and Engine 6 Hydrant that they needed to leave to change
air cylinders. Engine 6 Pipe left the hoseline and exited the 2nd floor. Engine 6 Lieutenant and Engine 6

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Hydrant became separated. In this confusion, Engine 6 Lieutenant’s facepiece and helmet became
dislodged. Eventually, Engine 6 Hydrant ran out of air, became disoriented, and was trying to get out of the
room. Engine 6 Hydrant walked/crawled and got between a radiator and a couch in the living room
underneath two windows on Side Alpha. He was running low on air and called a Mayday at 01:16 hours,
which was acknowledged by the incident commander (IC). At 01:17 hours, Engine 6 Lieutenant called IC
and said “I have a firefighter down on the 2nd floor.” At 01:18 hours, Engine 6 Lieutenant called a Mayday.
Engine 6 Lieutenant was located by Rescue 1 Hook. The firefighter found Engine 6 Lieutenant in the living
room near the entrance to the kitchen. Engine 6 Lieutenant had his facepiece off and was standing when the
firefighter found him. He said, “Help me,” and then fell into the firefighter. Engine 6 Lieutenant’s helmet
was found in the Side Alpha/Side Bravo corner near Engine 6 Hydrant and his gloves were off.

Rescue 1 Hook was trying to get Engine 6 Lieutenant to the stairs but ended up in a bedroom (Side
Delta/Side Alpha corner) at approximately 01:20 hours. Rescue 1 Hook knocked the glass out of a window
with a gloved hand. Firefighters from Engine 4 and Engine 9 got ground ladders to the windows. Rescue 1
Hook tried to get Engine 6 Lieutenant out the window, but he was too heavy. Rescue 1 Hook had to leave
due to being low on air. Once he was on the ground, he advised Car 31 where Engine 6 Lieutenant was
located. At approximately 01:21 hours, Rescue 1 Irons made his way into the living room. He found Engine
6 Hydrant lying prone near a couch with his facepiece on, but he was out of air. Rescue 1 Irons attempted to
drag Engine 6 Hydrant to the front windows. The officer from Truck 1 climbed into the front window on
Side Alpha at 01:23 hours. When he got into the front room (living room), he heard a personal alert safety
system (PASS) alarm sounding. He found Rescue 1 Irons trying to get Engine 6 Hydrant out from between
the couch and a radiator underneath the front windows. The firefighters tried to take Engine 6 Hydrant out
through the front windows but were not able to do so. Rescue 1 Irons and the Truck 1 officer had to leave
due to being low on air. Once outside, the Truck 1 officer described Engine 6 Hydrant’s location to Engine
11. Engine 11 entered the building, went up the front stairs, and found Engine 6 Hydrant behind the couch.
Engine 11 brought him down the front stairs to the outside at 01:33 hours. Firefighters from Engine 4 and
Engine 9 got Engine 6 Lieutenant out of the house at at the same time. Both Engine 6 Lieutenant and Engine
6 Hydrant were transported to a local university trauma center at 01:36 hours. Engine 6 Hydrant was
declared deceased at 02:12 hours. Engine 6 Lieutenant was later transferred to a trauma hospital with a
hyperbaric chamber for treatment and recovery. The fire at Box 1501 was declared under control at 03:23
hours.

Contributing Factors
• Scene size-up and risk assessment
• Crew integrity
• Air management and firefighter survival
• Basement/below-grade fire operations
• Mayday management
• Rapid intervention crew/team
• Incident Safety Officer (ISO)
• Incident Command Technician (ICT)
• Professional development

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Key Recommendations
Fire departments should ensure:
• Initial and ongoing size-ups and risk assessments are conducted throughout the incident.
• Company officers and firefighters maintain crew integrity when operating in the hazard zone.
• Fire officers and firefighters are properly trained and utilize the principles of air management and
fireground survival procedures.
• Fire department operations include Standard Operating Procedures (SOPs)/Standard Operating
Guidelines (SOGs) for operating at basements and below-grade fires.
• Fire officers and firefighters are trained in Mayday operations.
• A rapid intervention team/crew is dedicated, assigned, and in place before interior firefighting
operations begin and throughout an incident.
• Response plans include a dedicated and trained ISO.
• Operational battalion chiefs are staffed with an ICT or staff aide.
• Implementation of a training, education, and professional development program that is based upon
each rank.

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine
deaths of firefighters in the line of duty so that fire departments, firefighters, fire service organizations, safety experts and researchers could learn from these
incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations
are intended to reduce or prevent future firefighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any
other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to
develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH
summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and
recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

For further information, visit the program at http://www.cdc.gov/niosh/firefighters/fffipp/ or call 1-800-CDC-INFO (1-800-232-4636).

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 REPORT F2021-11 • May 2025

Firefighter Dies and Lieutenant Seriously Injured at a Multi-

Family Residential Structure Fire – Connecticut
Introduction
On May 12, 2021, a 30-year-old career firefighter died, a lieutenant was seriously injured, and two
firefighters suffered minor injuries while fighting a fire in a two-story multi-family residential
structure. On May 14, 2021, the United States Fire Administration (USFA) notified the National
Institute for Occupational Safety and Health (NIOSH) of this incident. On May 23–30, 2021,
investigators representing the NIOSH Fire Fighter Fatality Investigation and Prevention Program
(FFFIPP) traveled to Connecticut to conduct the investigation which included a site visit and
photographs of the fire building. During the visit, NIOSH investigators met with the fire chief, deputy
chiefs, battalion chiefs, captains, firefighters, and the training chief involved in this incident. NIOSH
investigators also met with other investigators from the Connecticut State Police, dispatchers at the
department’s fire alarm office, Connecticut Office of the Chief Medical Examiner, and the director of
the Connecticut Fire Academy.

The NIOSH investigators reviewed the fire department’s SOPs; training records for Engine 6 Hydrant
and Engine 6 Lieutenant; the fire incident report, witness statements and photographs; and dispatch
and tactical channel radio transmissions. The investigators evaluated and photographed the structural
firefighting turnout ensembles of the firefighters involved. The fire department requested NIOSH to
evaluate the self-contained breathing apparatus (SCBA) worn by Engine 6 Hydrant. The NIOSH
investigators transported the SCBA to the NIOSH National Personal Protective Technology
Laboratory (NPPTL) in Morgantown, West Virginia for further inspection.

Fire Department
The fire department provides fire protection and emergency medical services (EMS) to a population of
over 134,000 people. The city has a total area of 20.1 square miles, 18.7 square miles is land, and 1.4
square miles is water. The fire department operates out of 10 fire stations, located throughout the city
and is organized into two battalions: Car 33 (East Battalion) and Car 34 (West Battalion). The fire
department operates with 10 engine companies, four truck companies, a heavy rescue company, mobile
command unit, hazardous materials unit, brush truck, foam tender, fireground rehabilitation unit, three
paramedic emergency medical units, and a fireboat along with several special units. The fire
department has 400 members. The staffing number for each division (shift) is 72 members. The fire
department has an Insurance Service Office (ISO) Fire Protection Class 1 rating.

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Each engine and truck company are staffed by an officer and three firefighters/Emergency Medical
Technicians (EMTs). Rescue 1 is staffed by an officer and four firefighters/EMTs. SOC 1 is staffed by
an officer and a firefighter/EMT. Each EMS unit is staffed by a firefighter/paramedic and a
firefighter/EMT. The hazardous materials unit and the rehab unit are crossed-staffed by the officer and
firefighter/EMT from SOC 1. Each battalion is staffed by a battalion chief. The deputy chief serves as
the city-wide tour commander. Truck 1 is a tower ladder, Trucks 2 and 4 are tractor drawn aerials, and
Truck 3 is a rear mount aerial.

The Fire Suppression & EMS Division works three-night tours (0800–1800 hours) and three days off.
The fire department operates four divisions or platoons. The fire department also provides advanced
life support (ALS) and basic life support (BLS) to the city with three paramedic-staffed vehicles. EMS
transport services are conducted by a private agency. The transport units provide response to medical
emergencies with BLS (EMT) and ALS (EMT-Paramedic) capabilities. The fire department rank
structure is shown in Table 1.

Table 1: Fire Department Rank Structure

Staff Chiefs Fire Suppression Fire Marshals Training Division

Chief of Department Deputy Chief Fire Marshal Director of
Training/Safety
Assistant Chief of Battalion Chief Deputy Fire Marshal Drillmaster
Administration
Assistant Chief of Captain Supervisor of Fire EMS Supervisor
Operations Investigators
Lieutenant Life Safety Assistant Drillmaster
Compliance Officer
Private/Fireman 1st Public Assembly
Grade Inspector
Probationary Fire
Firefighter Inspector/Investigator

In 2021, the fire department responded to 31,314 incidents of which 25,921 incidents (83%) were EMS
calls and 5,393 (17%) were fire incidents. Fire investigators investigated 198 fires.

Training, Education, and Professional Development

To become a Connecticut career firefighter, individuals first apply for a position at the city or town that
is hiring or posting for the entry position. For the city involved in this incident, the hiring process is
managed by the Department of Human Resources (DHR). The hiring process includes a written
examination, an oral interview, a physical ability test, and a medical examination that meets the
requirements of NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire
Departments. Upon successfully meeting the requirements for recruit firefighter, a candidate is notified
of hiring and is scheduled to attend the next recruit school. Table 2 outlines the qualifications for each
position in the fire department.

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Table 2: The various ranks in the fire department in Operations Division

Position Time in Grade Qualifications

Recruit Firefighter NONE 22 weeks; NFPA 1001, Standard for Fire
Fighter Professional Qualifications, Fire Fighter
I & II; NFPA 470, Hazardous
Materials/Weapons of Mass Destruction (WMD)
Standard for Responders Incidents, Hazardous
Materials Awareness & Operations; (All
ProBoard®); State of Connecticut EMT/B
Probationary Firefighter 30 weeks Completed 1 year from date of employment; No
examination or practical testing at the completion
of probation
Firefighter (Private/1st Appointment upon completion of probation
Grade)
Chauffeur/Engineer Two Years 10 hours of driving Code 3 (emergency
response); “Q” License of Tiller position;
Written examination (70% passing); Practical
skills
Lieutenant 30 months as a Test application submitted to the DHR; Written
Firefighter examination; Oral interview
Captain 12 months as a Test application submitted to the DHR; Written
Lieutenant examination; Oral interview
Battalion Chief 12 months as a Test application submitted to the DHR; Oral
Captain interview
Deputy Chief 12 months as a Test application submitted to the DHR; Oral
Battalion Chief interview
Assistant Chief Executive level Selected by the Fire Chief and the Board of Fire
position Commissioners

Engine 6 Hydrant (deceased firefighter) was hired by the fire department in July 2019 and was
assigned to the 62nd Recruit Class. He successfully completed recruit school on November 26, 2019,
and was assigned as a probationary firefighter to Engine 6. He held certifications as National Registry
of Emergency Medical Technicians – EMT; NFPA 1001 Fire Fighter I and Fire Fighter II (Pro
Board®); and NFPA 1072 Hazmat Awareness and Operations (Pro Board®). The other fire service
training and certifications he completed were related to incident command, rescue technician core, and
various company level training.

Engine 6 Lieutenant was hired by the fire department in February 2018 and assigned to 61st Recruit
Class. He successfully completed recruit school in June 2018 and was assigned to Engine 11. He was
promoted to lieutenant in March 2021. He held certifications as National Registry of Emergency
Medical Technicians – EMT; NFPA 1001 Fire Fighter I and Fire Fighter II (Pro Board®); NFPA 1072

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Hazmat Awareness, Operations, and Technician (Pro Board®); NFPA 472 Hazardous
Materials/Weapons of Mass Destruction Incidents (Pro Board®); NFPA 1041 Fire and Emergency
Services Instructor I, II, and III (Pro Board®); and NFPA 1035 Public Fire and Life Safety Educator I
(Pro Board®).

Building Construction
The structure in this incident was a single-family dwelling built in 1935. It was a 2½-story structure
balloon frame, Type V construction with a full lookout basement. The exterior consisted mainly of
grey colored horizontal vinyl siding exterior with a poured slab and concrete walled basement. The
roof was gable pitched with asphalt shingles and wood underlayment. This residential structure was
3,358 total square feet. The basement was 918 square feet, the 1st floor was 984 square feet, the 2nd
floor was 989 square feet, and the attic was 467 square feet.

It is unknown when the structure was converted into individual apartments on the 1st and 2nd floor.
The 1st floor apartment was only accessible via the rear door (Side Charlie) because the occupant had
placed a bookcase in front of the entrance door on Side Alpha. The basement and attic were used for
storage and accessible from the 1st floor rear stairs (Side Charlie). The Connecticut State Police fire
investigators termed the storage area in the basement as “excessive storage” (see Diagrams 1, 2, 3 and
4).

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Diagram 1. Floor plan of the basement. Note: Identified as Floor 1 in the diagram
provided by Envision Forensics.

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Diagram 2. The floor plan of the 1st floor apartment. The red circle indicates the
doorway that was blocked with a bookcase for security reasons. The only access into
this apartment was through Side Charlie. Note: Diagram provided by Envision
Forensics labeled this Floor 2.

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Diagram 3. The floor plan of the 2ndnd floor apartment. Note: Diagram provided
by Envision Forensics labeled this Floor 3.

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Diagram 4. The floor plan of the attic containing storage. Note: Diagram
provided by Courtesy of Envision Forensics labeled this Floor 4.

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The structure was heated by heating oil and natural gas. All meters and panels for the utilities were in
the basement on Side Alpha/Side Bravo corner walls. There were smoke detectors found in the 1st and
2nd floor apartments. Because the smoke detectors were damaged during the fire, investigators could
not determine if the smoke detectors functioned properly during the incident.

Apparatus, Staffing, and Communications

At 00:46 hours on May 12, 2021, the city’s communications center dispatched Box 1501 for a
residential structure fire. Car 34, Engine 15, Engine 9, Engine 6, Truck 4, Truck 1, Rescue 1, SOC 1,
and EMS 2 were dispatched. The staffing for each engine and truck was an officer, chauffeur, and two
firefighters. Additionally:
• Rescue 1 – officer, chauffeur, and three firefighters.
• Car 34 – battalion chief
• SOC 1 – one officer and one firefighter
• EMS 2 – staffed by a firefighter/EMT and firefighter/paramedic.
Company riding positions are shown in Table 3:

Table 3: Company Riding Positions

Engine Truck Rescue

• Officer • Officer • Officer
• Chauffeur • Chauffeur • Chauffeur
• Pipe • Inside firefighter • Irons
• Hydrant • Tiller/vent • Hook
• Can

Each firefighter and fire officer was assigned a portable radio, which was identifed by their riding
position at each company. Each portable radio was equipped with an emergency alert button (EAB),
monitored by the fire dispatcher at Public Safety Communications.

The Division of Public Safety Communications is the public safety answering point for the city’s 9-1-1
and dispatches for the fire depatment, police department, and EMS response. In 2021, Public Safety
Commuinicaitons dispatched more than 130,000 incidents for fire, EMS, and law enforcement
response. Upon receipt of a 9-1-1 call, the call taker sends the information to the fire dipatcher. The
computer aided dispatch (CAD) system formulates a box alarm response to the incident. For a multi-
company response, a tactical channel is assigned.

Timeline
The timeline is a summary of events that occurred as the incident evolved. Not all incident events are
included in this timeline. This timeline lists the dispatch communications, fire department response,
fireground communications, and fireground operations. The times to the second were taken from the
fireground radio transmissions, the fire alarm office communications records, and the data log
information from Engine 6 Hydrant’s SCBA.

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Time Fireground Operations, Response, and Details

May 12,
2021
00:44 Hours • The original 9-1-1 call received at 9-1-1 Position 8 stated a house was on
fire and someone was trapped inside.
00:45 Hours • CAD Event created for Box 1501.
• A second 9-1-1 call was received at 9-1-1 Position 9 reporting a house on
fire.

00:46 Hours • Fire Dispatch transmitted Box 1501 for a residential structure fire.
o Car 34, Engine 15, Engine 9, Engine 6, Truck 4, Truck 1, Rescue 1,
SOC 1, and EMS 2 were dispatched.

00:47 Hours • A third call 9-1-1 call was received at 9-1-1 Position 1 reporting a house on
fire.
• Engine 15, Engine 6, and Truck 4 enroute.

00:48 Hours • Engine 9, Rescue 1, Truck 1, and Car 34 enroute.

00:49 Hours • EMS 2 enroute, but never arrived. Was replaced by EMS 3.
• SOC 1 enroute.

00:50 Hours • Fire Dispatch reported to all companies responding on Box 1501, that a
person was in the house on the 1st floor rear and the fire was in the
basement.

00:51 Hours • Engine 15 arrived on-scene and transmitted a “working fire” for Box 1501.
• Engine 9 on-scene.
• Fire Dispatch transmitted a “working fire” for Box 1501.
• Engine 4, Car 32 (Duty Deputy Chief), EMS 3, FM3 (Fire Marshal), and
Car 86 (Safety Officer) were dispatched.

00:52 Hours • Engine 4 and Car 32 enroute.

• Engine 9 reported to IC there was one person trapped in a window on Side
Delta near the corner of Side Charlie.
• Car 34 on-scene and assumed IC at Box 1501.

00:53 Hours • EMS 3 and Engine 6 on-scene.

00:54 Hours • Rescue 1 and Truck 1 on-scene.

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Time Fireground Operations, Response, and Details

00:55 Hours • IC provided Fire Dispatch with a follow-up radio report.
o IC stated, “This is a 2½-story wood frame. This is a working fire and
there is fire showing from a basement window on Side Delta.”

00:56 Hours • SOC 1 and Truck 4 on-scene.

00:57 Hours • Engine 9 had a female occupant out of the house and on the back deck on
Side Charlie. Firefighters provided patient care to the occupant.
• Car 32 on-scene.

00:58 Hours • Engine 4 on-scene.

00:59 Hours • Car 32 assumed IC at Box 1501.

• Engine 6 called Engine 6 Lieutenant saying he was going to charge the
hoseline, if needed.
o Engine 6 (PAR 3) was assigned to the 2nd floor on Side Alpha.
o No response from Engine 6 Lieutenant.

01:02 Hours • Engine 6 Lieutenant reported heavy smoke conditions and high heat on the
2nd floor.
o IC instructed Engine 6 to get to the Side Charlie/Side Delta corner and
open up the walls.
o Engine 6 Lieutenant asked to have the hoseline charged.

01:03 Hours • Car 31 (Fire Chief) responded to Box 1501.

• Car 34 was assigned as “Interior Division.”
• Interior Division was assigned to Engine 15, Engine 9, and Engine 6.
Emergency 3, Truck 1, and Truck 4 were assigned to IC.

01:06 Hours • IC called Engine 6 Lieutenant for a status report.

o Engine 6 Lieutenant reported high heat on the floor.
o Engine 6 was still searching the 2nd floor.

01:08 Hours • Engine 9 attempted to make entry into the basement.

01:09 Hours • Car 31 arrived on-scene.

• IC advised Engine 9 not to make entry into the basement.
• Companies attempted to knock down the fire in the basement from the
exterior on Side Charlie and Side Delta.

01:11 Hours • IC directed Engine 6 to the Side Alpha/Side Delta corner to open up the
walls.

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Time Fireground Operations, Response, and Details

o IC also advised Engine 6 to have their hoseline charged and ready.

01:12 Hours • IC requested a 2ndnd Alarm for Box 1501.

• Fire Dispatch transmitted a 2nd Alarm for Box 1501. Engine 5 and
Engine 11 were dispatched.

01:14 Hours • Engine 5 and Engine 11 enroute.

01:15 Hours • Engine 6 Hydrant told Engine 6 Lieutenant that he was disoriented on the
2nd floor (Division 2).

01:16 Hours • Engine 6 Hydrant transmitted a Mayday from Division 2.

• IC advised Engine 6 Hydrant to get to a window so the rescue company
could locate him.

01:17 Hours • Engine 6 Lieutenant told IC that he had a firefighter down on the 2nd floor.

01:18 Hours • IC directed companies not involved with the Mayday to switch to the
Tac Channel 3 and report to Car 31.
• Interior Division advised IC that the fire has extended to the 1st floor.
• Engine 6 Lieutenant declared a Mayday. Truck 4 officer radioed to the
Mayday to activate his PASS alarm.
• Engine 5 and Engine 11 arrived on-scene.

01:19 Hours • Rescue 1 Hook heard the Engine 6 Lieutenant calling for help.
o Rescue 1 Hook was near Engine 6 Lieutenant in the living room close
to the kitchen entrance.

01:21 Hours • Rescue 1 Irons found Engine 6 Hydrant.

o Rescue 1 Irons attempted to drag/pull to Engine 6 Hydrant to a window
on Side Alpha on the 2nd floor.

01:23 – • Rescue 1 Hook drug Engine 6 Lieutenant towards the front stairs, but
01:24 Hours accidentally went into the bedroom, off the living room on Side Delta.
• Rescue 1 Hook knocked a window out to get help.

01:25 Hours • Rescue 1 Irons and Truck 4 Officer moved Engine 6 Hydrant to the
window on Side Alpha.
o Due to being low on air, Truck 4 Officer left the room by going out
the front window to a ground ladder.
• Truck 1 Officer entered the living room.

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Time Fireground Operations, Response, and Details

01:26 Hours • Rescue 1 Hook was trying to get Engine 6 Lieutenant to the window, but
Engine 6 Lieutenant was too heavy.

01:28 Hours • Rescue 1 Irons and Truck 1 Officer got Engine 6 Hydrant to the
window.
o Truck 1 Officer and Rescue 1 Irons left the 2nd floor due to being
out of air.
o Truck 1 Officer communicated to Engine 11 where Engine 6
Hydrant was located on the 2nd floor.

01:29 Hours • Ambulances arrived on-scene.

01:30 – • Rescue 1 Hook had to leave due to low air.

01:31 Hours o He exited through the bedroom window on the second floor onto a
ground ladder.
o On the ground, he told Car 31 where Engine 6 Lieutenant was located
in the bedroom.

01:33 Hours • Firefighters from Engine 4 and Engine 9 climbed two ground ladders to the
2nd floor bedroom. They removed Engine 6 Lieutenant to the outside.
• Engine 6 Hydrant was removed from the building by Engine 11 via Side
Alpha stairs. BLS and ALS patient care were initiated on the firefighter.

01:36 Hours • Engine 6 Lieutenant and Engine 6 Hydrant were transported to the
university trauma center.

01:39 Hours • Car 31 advised IC the basement was fully involved.

01:42 Hours • Car 31 assigned Car 34 as Delta Division supervisor.

01:51 Hours • All companies have PAR.

01:52 Hours • Delta Division advised IC the 2nd floor was now on fire.

01:53 Hours • IC initiated Fire Dispatch; all companies were operating in the defensive
strategy.

02:15 Hours • Engine 6 Hydrant declared deceased at the university trauma center.

03:23 Hours • IC advised Fire Dispatch to mark the fire under control at Box 1501.

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Personal Protective Equipment

At the time of the incident, Engine 6 Lieutenant and Engine 6 Hydrant were wearing structural
firefighting turnout gear and SCBA. The structural firefighting turnout gear was not considered a
contributing factor to the fatalities in this incident. NIOSH investigators conducted no further
evaluation or testing of the turnout gear. The fire department requested that the SCBA worn by Engine
6 Hydrant be evaluated. NIOSH investigators transported the SCBA to NPPTL in Morgantown, WV.
On June 15, 2021, the SCBA was visually examined, component by component, in the condition
received to determine the conformance of the unit to the NIOSH Approved® configuration. The unit
was identified as a NIOSH Approved Scott® Safety Air-Pak Model 4.5, 30-minute, 4500 psi unit,
bearing NIOSH approval number TC-13F-76CBRN. NIOSH determined that there was no need for
corrective action with regards to the approval holder or users of SCBAs manufactured under the
approval numbers granted to these products [NIOSH 2022a]. The entire evaluation, NPPTL Report
Number TN-25967, is available on the NIOSH website.

Weather Conditions
On May 12, 2021, the weather was fair with a temperature of 53°F at 23:53 hours. The dew point was
38°F, the humidity was 57%, the winds were from the NW at a speed of 5 mph, and the barometric
pressure was 30.17 inches. There had been no precipitation in the past 24 hours [Weather Underground
2021].

Investigation
At 00:46 hours, the city’s communications center dispatched Box 1501 for a residential structure fire.
Car 34, Engine 15, Engine 9, Engine 6, Truck 4, Truck 1, Rescue 1, SOC 1, and EMS 2 were
dispatched. At 00:50 hours, the fire dispatcher told Car 34 there was an occupant still in the house on
the 1st floor and the fire was reported to be in the basement.

At 00:51 hours, Engine 15 arrived on-scene and said this was a “working” fire. Engine 15 laid dual 3-
inch supply lines from a hydrant east of the structure. Engine 15 pulled past the fire building and the
officer of Engine 15 observed a lot of police officers around the house. Engine 15 Officer advised there
was smoke showing from the 1st floor and fire showing from a basement window on Side Delta.
Engine 15 stretched a 1¾-inch hoseline and forced open the front door. Engine 6 arrived on-scene at
00:51 hours and backed down the street to Engine 15, which was the attack piece. Engine 6 Pipe took
five lengths of 1¾-inch hoseline to Engine 15 and made the connection for fire attack. Engine 6
stretched the hoseline down Side Bravo to Side Charlie. Car 34 arrived on-scene and assumed IC.
Engine 15 got into the front stairwell and tried to force the door to the 1st floor apartment. The door
was blocked and the Engine 15 Officer advised IC they could not make entry through the front door.
Engine 15 then went to Side Charlie.

At 00:52 hours, Engine 9 indicated that one occupant was trapped in a bedroom on Side Delta near the
Side Charlie corner. Engine 9 officer went to Side Delta. Engine 9 stretched a 1¾-inch hoseline to Side
Delta. The Engine 9 Officer was told there was an occupant in the back bedroom (Side Delta/Charlie
corner) by several city police officers. He climbed in the window and did a primary search. He could

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not find the occupant and went outside through the window he originally entered. Engine 9 was
coming down Side Delta with a 1¾-inch hoseline. He ordered Engine 9 Pipe to put water in the
basement window that had fire showing on Side Delta. The Engine 9 Officer and Engine 9 Hydrant
entered the house through the rear door and found the female occupant, removing and placing her on
the deck.

Truck 4 arrived on-scene at 00:56 hours. The Truck 4 Officer and Truck 4 firefighter went to Side
Charlie. The Truck 4 Chauffeur and Tiller went to vent the roof via the aerial ladder. When Truck 4
arrived on Side Charlie, they took the female occupant to Side Alpha for medical treatment and
transport. The time was approximately 00:58 hours. Engine 6 was ordered to the 2nd floor apartment
by IC. Engine 6 took the hoseline and went to the 2nd floor via the front stairs on Side Alpha at 01:02
hours. Engine 6 Lieutenant (who was carrying a thermal imager) was with the two firefighters from
Engine 6. He ordered Engine 6 Pipe to cool down the front room (living room). Engine 6 Pipe penciled
the fire 4–5 times. Engine 6 Lieutenant went into the bedroom located on Side Delta, which he stated
was very hot.

Car 31 arrived on-scene at 01:09 hours and did a “360,” observing fire in the basement showing from a
window on the Side Delta/Alpha corner. Car 31 borrowed a portable radio from SOC 1 for use on the
fireground. After Truck 4 vented the roof, Engine 9 and Truck 4 were assigned to the basement. Car 31
asked “Interior Division” (i.e., Car 34) where the fire was located. Car 34 said that crews could not
locate the fire. Then Engine 4 and Truck 1 were assigned to the basement and Engine 9 and Truck 4
were out. The Engine 9 Officer and the Truck 4 Officer went to the basement with a hoseline to try and
knock down the fire. Engine 9 Pipe was going into the basement, but had to leave due to an issue with
his SCBA. The Engine 9 Officer went into the basement, but struggled to move around the excessive
clutter. The Truck 4 Officer had to leave due to his EOSTI sounding. The fire was spreading and the
basement was very hot. The Engine 9 Officer, who was alone in the basement, managed to get back to
the stairwell and up the stairs to the 1st floor. The officer was trying to transmit a condition, actions,
and needs (CAN) report but his portable radio got changed to Bank “C.” A CAN report of the
deterioring conditions in the basement was never transmitted to IC. The Engine 9 officer went to Side
Alpha to change cylinders. The time was approximately 01:10 – 01:11 hours (see Diagram 5).

The EOSTIs on all Engine 6 firefighters’ SCBAs were sounding. Engine 6 Lieutenant told the
firefighters they needed to leave to change air cylinders and to stay on the hoseline. He then radioed IC
that Engine 6 was coming out for air. Engine 6 Lieutenant couldn’t find Engine 6 Hydrant. Engine 6
Pipe handed Engine 6 Lieutenant the nozzle and looked for Engine 6 Hydrant with the thermal imager.
Engine 6 Pipe left the apartment due to low air at 01:15 hours. Engine 6 Hydrant had radioed he was
disorientated and could notfind his way out of the room. Further, in the confusion that emerged during
the search and rescue, Engine 6 Lieutenant’s facepiece and helmet became dislodged.

Engine 6 Hydrant walked/crawled and got between a couch and radiator in the living room underneath
two windows on Side Alpha. He was running low on air and called a Mayday at 01:16 hours stating
“Mayday, Mayday, Mayday, Engine 6 Hydrant,” which was acknowledged by IC. At 01:17 hours,
Engine 6 Lieutenant called IC and advised, “I have a firefighter down on the 2nd floor.” At 01:18
hours, Engine 6 Lieutenant called a Mayday, stating “Mayday, Mayday, Mayday” (see Photo 2).

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Engine 6 Lieutenant was located by Rescue 1 Hook who found Engine 6 Lieutenant in the living room
near the entrance to the kitchen. Engine 6 Lieutenant had his facepiece and gloves off and was standing
when the firefighter found him. He said, “Help me,” and then fell into the firefighter. Engine 6
Lieutenant’s helmet was found in the Side Alpha/Side Bravo corner near the firefighter from Engine 6.
Rescue 1 Hook tried to get Engine 6 Lieutenant to the stairs but got him into a bedroom (Side
Delta/Side Alpha corner) at approximately 01:23–01:24 hours. Rescue 1 Hook knocked the glass out
of a window. Firefighters from Engine 4 and Engine 9 got ground ladders to the windows. Rescue 1
Hook tried to get Engine 6 Lieutenant out the window, but he was too heavy. Low on air, Rescue 1
Hook had to leave, using the window and ground ladder set up by Engine 5 and Engine 9. Once he was
on the ground, he advised Car 31 where Engine 6 Lieutenant was located. Firefighters from Engine 4
and Engine 9 got Engine 6 Lieutenant out of the house at 01:33 hours.

At approximately 01:21 hours, Rescue 1 Irons made his way into the living room. He found Engine 6
Hydrant lying prone with his facepiece on but out of air. Rescue 1 Irons tried to move Engine 6
Hydrant from between the couch and a radiator underneath the front window. Truck 1 Officer came
into the front room (living room) and heard a PASS alarm sounding. He assisted Rescue 1 Irons and
Truck 1 Officer with dragging Engine 6 Hydrant to the window. The firefighters tried but were unable
to get Engine 6 Hydrant out through the front windows. Rescue 1 Irons and Truck 1 Officer went
outside due to being low on air. Truck 1 Officer met Engine 11 and described Engine 6 Hydrant’s
exact location in the living room. Engine 11 entered the building, went up the fronts stairs, and found
Engine 6 Hydrant behind a couch near the windows on Side Alpha. Engine 11 brought Engine 6
Hydrant down the front stairs to the outside at 01:33 hours. Both Engine 6 Lieutenant and Engine 6
Hydrant were transported to a local university trauma center. Engine 6 Hydrant was declared deceased
in the emergency room at 02:12 hours. Engine 6 Lieutenant was later transferred to a trauma hospital
with a hyperbaric chamber for treatment and recovery. IC advised Fire Dispatch that the fire was under
control at Box 1501 at 03:23 hours.

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Diagram 5. On the 2nd floor, the location of Engine 6 Hydrant and the Engine 6
Lieutenant (labeled as officer) after the Mayday occurred. The arrows indicate the
paths of Engine 6 Officer took to the bedroom and Engine 6 Hydrant to the front
window. (Prepared by NIOSH)

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Photo 2. The 2nd floor window on Side Delta where Engine 6 Lieutenant was rescued
from by Engine 4 and Engine 9
(Courtesy of the fire department)

Fire Origin and Cause

Connecticut State Police’s fire origin and cause investigation determined that the fire at Box 1501
started in the basement of the structure and spread to the 1st and 2nd floors, causing severe fire and
collapse damage. Investigators have not been able to determine the cause of the fire due to the extent
of damage and lack of physical evidence, but there is no criminal aspect.

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 and serious injury:

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• Scene size-up and risk assessment

• Crew integrity
• Air management and firefighter survival
• Basement/below-grade fire operations
• Mayday management
• Rapid intervention crew/team
• ISO
• ICT
• Professional development

Cause of Death
According to the death certificate from the State of Connecticut, Department of Public Health, Office
of the Chief Medical Examiner, the cause of death for Engine 6 Hydrant was asphyxiation and his
death was accidental.

Recommendations
Fire departments should ensure:

Recommendation #1: Initial and ongoing size-ups and risk assessments are conducted throughout
the incident.

Discussion: At this incident, the initial focus of the first-due companies was to rescue the female
occupant located on the 1st floor. There was no initial scene-size-up or risk assessment conducted that
was communicated to IC.

Continuous communication supports effective risk assessments. It also allows the IC and all personnel
operating at an incident to be aware of changing conditions and adjust to avoid hazards or mitigate
risks. Performing a 360-degree is an important component of the scene size-up and can be used in the
risk assessment. The International Association of Fire Chiefs’ Rules of Engagement for Structural
Firefighting recommends that the first rule for ICs is to rapidly conduct or obtain a 360-degree
situational size-up of the incident. Many incidents contain obstacles that prevent the viewing of all
sides of a structure. When 360-degree reconnaissance is achieved, it provides the IC and personnel
knowledge of the building layout, construction, access/egress points, fire location and direction of
spread, and obstacles or hazards [NIOSH 2017].

An ISO can perform initial and ongoing size-ups throughout the incident. Expectations and authority
for the ISO include determining hazardous incident conditions, advising the IC to modify control zones
or tactics to address corresponding hazards, communicating fire behavior and forecasting growth, and
estimating building/structural collapse hazards. The ISO also has the authority to stop or suspend
incident operations based on imminent threats to firefighter safety [NFPA 1550 2024]. The ISO should
be separate from the IC, operations, or accountability positions so they can focus on their
responsibilities and the primary objective of continually assessing all on-scene hazards to firefighter
life and safety [NIOSH 2025a].

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Recommendation #2: Company officers and firefighters maintain crew integrity when operating in
the hazard zone.

Crew integrity is essential to fireground accountability. NFPA 1550, Standard for Emergency
Responder Health and Safety, states in Paragraph 10.5.6 that company officers shall maintain an
ongoing awareness of the location and condition of all company members. Paragraph 10.5.7 states that,
where assigned as a company, members shall be responsible to remain under the supervision of their
assigned company officer [NFPA 1550 2024]. It is the responsibility of every firefighter and company
officer to always stay in communication or contact with crew members by visual observation, voice, or
touch while operating in the hazard zone. All firefighters should maintain the unity of command by
operating under the direction of their company officer. The ultimate responsibility for crew integrity
and ensuring no members get separated or lost rests with the company officer. A Mayday should be
called if any member cannot be accounted for during a personnel accountability report [NIOSH 2024].

The International Association of Fire Chiefs’ Safety, Health, and Survival Section redefined the Rules
of Engagement for Structural Fire Fighting. One of the objectives is for firefighters to enter a burning
building as a team of two or more members and another is that no firefighter be alone at any time while
operating in or exiting a building. These objectives align with the definition of crew integrity (i.e.,
staying together as a team of two or more) [IAFC 2012].

Recommendation #3: Fire officers and firefighters are properly trained and utilize the principles of
air management and fireground survival procedures.

The only respiratory protection for firefighters in the toxic smoke environment is the air in their SCBA
cylinder. [Gagliano et al. 2008]. Air management is a program that the fire service can use to ensure
that firefighters have enough breathing air to complete their primary mission and escape an unforeseen
emergency.

Air management happens at the individual firefighter level, the crew level, and the command level.
Aspects of air management for which firefighters are responsible include:
• Ensure their air supply is adequate (full cylinder) at the start of the shift
• Monitor their air usage during an event
• Recognize the 50% heads-up display (HUD) light flash and communicate this information to
crew members
• Exit an IDLH atmosphere before they go into their emergency reserve air and their EOSTI
alarms
A low-air emergency for one crew member should be treated as an emergency for the entire team,
requiring the entire team to exit simultaneously, maintaining crew integrity. If they are not out of the
IDLH atmosphere and go into their emergency reserve air, they need to immediately communicate this
emergency with their crew and IC. Firefighters should not wait until their EOSTI alarms activate or
they are out of air to communicate or address this situation.

NFPA 1404, Standard for Fire Service Respiratory Protection Training states that firefighters should
exit from an IDLH atmosphere before the consumption of reserve air supply begins. It is critical that

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firefighters understand that the initial 67% of the air supply is the "working and exiting air" [NFPA
1404 2018]. This includes air used for gaining access, working toward the tactical objectives, and
exiting the hazard zone.

Firefighters may not pay attention to their air usage until they get into their emergency reserve air and
their EOSTI sounds or vibrates. Once the SCBA air supply reaches approximately 50%, the light
begins to flash. Some change color to yellow when below 50% then change to red in the EOSTI mode.
This is designed to alert the firefighter to take action that would ensure they have enough escape time
to exit the building with their reserve air intact. Once the air supply reaches the EOSTI level, the
SCBA will provide another signal (bell, whistle, and/or vibration signal) that alerts the user they are
nearing the end of the usable air in the cylinder. On pre-2013 edition SCBAs, this level was
approximately 25% (+/-2). For SCBAs manufactured to the 2013 edition of NFPA 1981 and newer
edition SCBAs, the EOSTI level was increased to 33% (+/-2).

Repetitive skills training with an SCBA is vital for the safety of firefighters working inside an IDLH
atmosphere. Training should be performed regularly to ensure that firefighters "know their SCBA."
Repetitive skills training with an SCBA may provide increased comfort and competency levels,
decreased anxiety, lower air consumption, increased awareness of the user's air level (noticing and
using the HUD), and an automatic muscle memory response for the vital function controls, such as the
don/doff buttons, main air valve, emergency bypass operating valve, and auxiliary air connections (i.e.,
RIC/universal air connection and the buddy breather connection). Repetitive skills training also
provides the user with an increased ability to operate these functions and controls in a high-anxiety
moment or an emergency. Many times, using these skills is necessary with gloved hands, limited
vision, and reduced ability to hear commands from others. Performed in conditions that are non-IDLH,
repetitive skills training helps build the firefighters muscle memory so their hands will be able to
activate the controls with gloves on and the operation will be a conditioned or second-nature response
in case of an emergency [NIOSH 2011; NIOSH 2012].

Every firefighter should be equipped with a portable radio provided by the fire department when
operating in the hazard zone [NFPA 1550 2024]. If a firefighter becomes lost or trapped in a hazard
zone, the firefighter should activate the EAB on the portable radio prior to transmitting a Mayday. This
action will provide the best chance for the dispatcher and/or IC to acknowledge the Mayday in a timely
manner. This process should be supported by a SOP/SOG and practical training [NIOSH 2022b].

The rescue of a lost, missing, trapped, or injured firefighter is time sensitive. A very narrow window of
survivability exists for a firefighter who is out of air or trapped in a hazardous environment.
Firefighters must not delay in communicating a Mayday, ensuring the IC is notified. When it comes to
rapid egress or removing a downed firefighter, the most appropriate action due to conditions may be to
use a window in the immediate area. A task such as this can be challenging if it is not trained on or
practiced regularly. It is important to remember that the safest way to remove a downed firefighter
from an upper level of a building is by using a staircase if at all feasible.

Firefighters may be forced to use windows for removal for a variety of reasons. The route taken into
the structure may have been altered or changed during operations by collapse, deteriorating fire

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conditions, the malfunction of a SCBA, an air-supply issue or disorientation. Factors such as

surroundings, fire conditions, collapse or building construction can further increase the challenges that
must be overcome. A constricted-space window removal requires at least three rescuers. These
maneuvers are labor intensive and require a rapid intervention crew (RIC) to be operating on the
exterior as well as the interior. Communication between these crews is of highest priority. The exterior
RIC will need to know the specific equipment and exact location necessary to affect the rescue. This
will normally take place after the initial RIC locates the downed firefighter. Two of the most common
ways to perform a removal of this nature are the "Denver" and "Fulcrum" techniques [Pindelski 2010].

Recommendation #4: Fire department operations include SOPs/SOGs for operating at basements
and below-grade fires.

Discussion: At this incident, the fire department had no defined tactics for fighting a basement fire.
The only access to the walkout basement was via the stairs on Side Charlie.

Early identification of basements and their access points are critical during the initial on-scene size up
and a component of the 360-degree size up. If the use of basements is a common component of
building design within a particular community, then a basement should be considered as part of the
scene size-up. The presence or lack of a basement must be communicated to everyone involved to
minimize or eliminate the opportunity for fire crews to end up working above a basement without their
knowledge. The immediate dangers include falling through the floor and working in the exhaust
portion of a flow path.

Between 1998 and 2017, NIOSH documented 24 below grade fires that resulted in 32 firefighter
fatalities and 19 serious injuries. Typically, these cases involved the firefighters falling through a wood
floor assembly into a burning basement or firefighters being overwhelmed by high velocity hot gases
flowing from the basement on to an upper level [Madrzykowski and Weinschenk 2018]. Project
Mayday conducted by Don Abbott reported that one of the top causes of a Mayday is falling into
basements. From more than 2,700 career department Maydays reported to the project, 19%
were attributed to falling into the basement. Similarly, of the more than 1,900 volunteer department
maydays reported to the project, 24% were due to falling into a basement [Mayday Monday 2021].

Recognizing a below-grade fire is essential to developing proper strategy and tactical objectives. If
there is a chance of a basement fire, tactics should reflect this scenario during risk management
decisions. Below-grade fires, particularly those in private dwellings, are one of the most dangerous and
difficult fires for firefighters to locate and fight. These types of fires are low frequency/high risk events
for several reasons. Below-grade fires may be difficult to detect initially; may be difficult to access;
require additional staffing for hoseline placement, operation, and ventilation; and firefighters may be
working over the fire [NIOSH 2018; NIOSH 2022c]. There is increased risk to firefighters due to:

• Limited entry and egress into a basement

• Unusual and/or unanticipated void spaces
• Working above the fire on potentially weakened floor joists and flooring materials
• Being caught in the fire’s exhaust portion of the flow path

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• Unknown and frequently excessive fire loading

• Restricted ventilation options
• Utility panels and meters plus connections
• Separate areas connected by non-fire stopped utility penetrations
• Hanging wires and ductwork
• Distribution of contents (e.g., furniture, appliances).

When developing an SOP/SOG for basement or below-grade fires, consider the following topics
[Madrzykowski and Weinschenk 2018]:
• Community risk assessment
• Pre-incident planning
• Scene size-up
• Building construction
• Strategy and tactics
• Use of a thermal imager
• Ventilation considerations
• Proper size and adequate hoselines

If the size-up indicates there is a fire in the basement (e.g., floor to ceiling smoke not lifting
significantly once the basement walk-out door was opened) the basement needs to be investigated and
cleared before crews can safely operate above it. Opening a door is ventilation and will increase the
size of a ventilation-limited fire. Basement fires need to be considered ventilation limited until proven
otherwise so if the fire location is not known, then ventilation should be limited until sufficient water
can be applied to what is burning.

Recommendation #5: Fire officers and firefighters are trained in Mayday operations.

Firefighters should be trained and have confidence in how to call a Mayday when in danger [IAFF
2010]. Any delay in calling a Mayday reduces the chance of survival and increases the risk to other
firefighters trying to rescue the “downed” firefighter. When a Mayday is transmitted, ICs have a
narrow window of opportunity to locate the lost, trapped, or injured member(s) and may need to
restructure the strategy and tactics to include a priority rescue [NFPA 1550 2024]. A Mayday tactical
worksheet can serve as a tailored guide to any fire department’s Mayday procedures such as a reminder
to prompt the firefighter to activate their emergency alert button for priority radio transmissions and
other important items such as personal alert safety system activation, air status, and location
information. This worksheet can be easily located on the back of a tactical worksheet to assist ICs in
ensuring the necessary steps are taken to clear the Mayday as quickly and safely as possible. This
process is too important to operate from memory and risk missing a vital step that could jeopardize the
outcome of the rescue of a firefighter who is missing, trapped, or injured [IAFF 2010; NIOSH 2024].

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Recommendation #6: A rapid intervention team/crew is dedicated, assigned, and in place before
interior firefighting operations begin and throughout an incident.

Effective RIC operations are dependent on proactive efforts. Upon arrival, the RIC officer,
accompanied by one member of the RIC, receives a report from the IC before performing an incident
scene survey while the remaining RIC members assemble the RIC equipment. During the 360-degree
survey, the RIC officer and members should look for ways in and out of the structure, including
window configurations, fire escapes, and construction features. The RIC officer should note the
feasibility for placement of ground ladders for rescue or escape purposes. The RIC officer has a
responsibility to set up and secure a suitable secondary egress for interior crews [Rowett 2018; Toledo
Fire & Rescue Department 2012]. After these tasks are completed, the RIC equipment is put in place
and the RIC officer informs the IC that a 360-degree survey is complete and the RIC is ready to
intervene, if necessary. The entire RIC should stay in an area immediately accessible to the building
for rapid deployment and maintain radio contact with the IC. The RIC officer should brief all RIC
members with the results of the incident scene survey [Toledo Fire & Rescue Department 2012]. The
RIC officer and members will coordinate with the IC to formulate rescue plan contingencies and to
monitor radio and fireground conditions. RIC protection is not a passive assignment. This is a process
of ongoing information gathering and diligent scene monitoring until the unit is released by the IC
[NIOSH 2024; NFPA 1407 2020].

Additionally, fire departments should provide and utilize a rapid intervention operation training
program consistent with the requirements outlined in NFPA 1407. In this incident, firefighters were
able to locate Engine 6 Hydrant and Engine 6 Lieutenant multiple times. However, they struggled to
get them out of the building. This program may include declaring a Mayday, enhanced search
techniques, access and extrication, air supply, ropes, protecting the downed firefighters in place and
getting them to safety, and firefighter self-rescue techniques. The established RIC teams should be
trained along with all of the firefighters on scene as research shows most Maydays are rescued by the
individual calling the Mayday, their crew, or other crews already operating in the building [NFPA
1407 2020].

Recommendation #7: Response plans include a dedicated and trained ISO.

An ISO should be trained to NFPA 1550 which defines the requirements for the IC, including
establishing a fixed command post, personnel accountability, the use of staff aides and RICs, and the
appointment of an ISO and assistant safety officer(s) (as needed). The standard addresses the
expectations and authority of the ISO. Expectations and authority include determining hazardous
incident conditions, advising the IC to modify control zones or tactics to address corresponding
hazards, communicate fire behavior and forecast growth, and estimate building/structural collapse
hazards. This also includes the authority to stop or suspend incident operations based on imminent
threats posed to firefighter safety [NFPA 1550 2024]. The ISO should be separate from the IC,
operations, or accountability positions so they can focus on their responsibilities and the primary
objective of continually assessing any and all on-scene hazards to firefighter life and safety [NIOSH
2025b].

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Recommendation #8: Operational battalion chiefs are staffed with an ICT or staff aide.

An ICT can also be known as a field incident technician, emergency incident technician, staff aide, or
staff assistant. An ICT is defined by NFPA 1550 as a firefighter or fire officer assigned to an
operational chief officer to assist with the logistical, tactical, and accountability functions at an
emergency incident. The duties and responsibilities of an ICT are divided into two functions:
administration and operations. Though the administration component is important, the command and
control of an emergency incident is critical to firefighter safety and health [NFPA 1550 2024].

When an incident is dispatched, the accountability begins while resources are enroute and monitoring
tactical activities of the first-arriving companies. An initial essential role of the ICT is function as the
driver or chauffeur for the battalion chief. This allows the battalion chief to initiate documentation of
the incident on a tactical worksheet. This also allows the IC to start developing the incident action plan
for the incident. Without an ICT, this process doesn’t start until arrival on-scene [NIOSH 2025c].

The key functions of an ICT include but are not limited to [NIOSH 2025c]:
• maintain radio and other communications
• maintain the tactical worksheet
o personnel accountability
o diagram of incident operations
• May be assigned with the battalion chief to the hazard zone as part of a tactical assignment
(e.g., division or group supervisor).

Recommendation #9: Implementation of a training, education, and professional development

program that is based upon each rank.

Fire departments should make sure that training and professional development are offered to any
personnel who may be expected to perform outside of their normal functional area but within their
experience level. In this specific incident, the lack of experience and knowledge prevented critical task
level information from being shared with the IC as it relates to the rapidly changing fire conditions and
environment. The primary focus of training, education, and professional development programs is to
reduce injuries, illnesses, and fatalities in the fire service by providing the needed technical and
academic competencies. Fire departments need to incorporate both technical skill and hands-on task
completion, while also addressing academic knowledge and the understanding of “why” things are
happening in their training [NIOSH 2025d].

When developing a professional development plan, each department must recognize the needs of the
community, services offered by the fire department, and available resources such as funding, staffing,
and experience levels. A goal to establishing a professional development plan should be to meet or
exceed the NFPA professional qualifications. NFPA 1550, Standard for Emergency Responder Health
and Safety, states in paragraph 7.1.2 that the fire department should provide training, education, and
professional development for all department members commensurate with the duties and functions that
they are expected to perform [NFPA 1550 2024].

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Professional development plans should be customized to fit within a fire department’s resources and
capabilities while striving to reach a national standard. A successful professional development plan
might include [NIOSH 2025d]:

• Training programs on technical competencies (hands-on skills)

• Task and mentoring books (technical and academic competencies)
• Mentorship programs (experience)
• Self-guided study classes and programs (academic competencies)

The primary goal of all training, education, and professional development programs is to reduce
occupational injuries, illnesses, and fatalities. As members progress through various duties and
responsibilities, the department should make sure knowledge, skills, and abilities (KSAs) are
introduced to members who are new in their position while continuing development of existing skills.
A successful training plan is developed in a systematic and functional manner. Training occurs in the
fire service to improve the KSAs and competencies of firefighters and fire officers. The results
enhance the overall response capabilities of the department while meeting national standards. A
structured plan should meet all these criteria [Clark 2017].

Every fire department should have a professional development plan. NFPA 1201, Standard for
Providing Fire and Emergency Services to the Public states in 4.11 Professional Development, “The
fire and emergency services shall have training and education programs and policies to ensure that
personnel are trained, and that competency is maintained in order to effectively, efficiently, and safely
execute all responsibilities” [NFPA 1201 2020].

When developing a formal training plan, the first step is to evaluate and build upon existing training
standards, such as the NFPA professional qualifications standards. Each fire department is structured
differently to meet the needs of their community. Therefore, training plans must be designed based on
services provided by a fire department and the department’s mission statement. NFPA 1550, Chapter
6, “Fire Department Administration,” states in paragraph 6.2.2, “The fire department shall prepare and
maintain written policies and standard operating procedures that document the organization structure,
membership, roles and responsibilities, expected functions, emergency operations. and training
requirements, including the following [NIOSH 2025d]:

• The types of standard evolutions that are expected to be performed and the evolutions that must
be performed simultaneously or in sequence for different types of situations.
• The minimum number of members who are required to perform each function or evolution and
the manner in which the function is to be performed in accordance with NFPA 1710 or NFPA
1720.
• The number and types of apparatus and the number of personnel that will be dispatched to
different types of incidents in accordance with NFPA 1710 or NFPA 1720.
• The procedures that will be employed to initiate and manage operations at the scene of an
emergency incident.
• Post-incident control and mitigation of emergency scene contaminants”.

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These programs should include information to make sure members are trained prior to performing
individual duties, and that members receive ongoing professional development to maintain
competency. The training plan serves as a comprehensive all-hazards approach that meets or exceeds
federal, state, and local regulations as well as the needs of fire department personnel. This approach
allows the department to maintain operational and response capabilities to the customers they serve.
The plan is designed to be specific yet allow flexibility in the event training is made available or as
departmental needs dictate. The plan includes a detailed calendar for the year, which allows the
company officers and command staff to balance other duties and priorities throughout the course of the
year [Clark 2017].

The responsibility of the fire service is to save lives, stabilize incidents, and conserve property. This is
accomplished through effective and structured training before emergency response. A well-developed
annual training plan will ensure continuity across a fire department and will maintain and improve the
KSAs of all members. All members must continually improve and train new fire service members so
the department can respond effectively to any emergency incident [NIOSH 2025d].

Post-Incident Fire Department Prevention Actions

After this incident, the fire department implemented changes to incident response and fireground
operations. These changes included:
• Size-ups/risk assessments: As part of their annual NFPA 1403 live fire training, the
department started to focus more on refreshing and enforcing size-up/risk assessment skills of
firefighters and fire officers. This includes mock incidents and conducting after action reviews.
The department also provides a size-up class for every newly promoted fire officer.
• Crew integrity: Crew integrity and PARs are now completed as a part of the annual NFPA
1403 live fire training to refresh and enhance skills for real incidents.
• Air management/firefighter survival: The department conducts a weekly Mayday drill in
each battalion and companies are rotated to ensure they each perform the fully interactive drill.
Air management techniques are coached in this drill, status of air must be announced during the
mayday as well as techniques to self-extricate and survive. PASS devices are used as well and
radio “panic buttons.”
• Basement/below grade fires: The department has developed new basement fire and tunnel
SOGs.

References
Clark M [2017]. A fire department annual training plan. American Military University.

Gagliano M, Phillips C, Jose P, Bernocco S [2008]. Air management for the fire service. Tulsa, OK:
Penn Well Corporation, Fire Engineering.

IAFF [2010]. IAFF fire ground survival training program. Washington, DC: International Association
of Fire Fighters.

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IAFC [2012]. Rules of engagement for structural firefighting: Increasing firefighter survival. Draft 10
developed by the Safety, Health and Survival Section International Association of Fire Chiefs.

Madrzykowski D and Weinschenk C [2018]. Understanding and fighting basement fires. Columbia,
MD: Underwriters Laboratories, Fire Safety Research Institute.

Mayday Monday [2021]. Mayday monday: Project mayday. Fire Engineering.

NFPA [2018]. NFPA 1404, Standard for fire service respiratory protection training. Quincy, MA:
National Fire Protection Association.

NFPA [2020]. NFPA 1201, Standard for providing fire and emergency services to the public. Quincy,
MA: National Fire Protection Association.

NFPA [2020]. NFPA 1407, Standard for training fire service rapid intervention crews. Quincy, MA:
National Fire Protection Association.

NFPA [2024]. NFPA 1550, Standard for emergency responder health and safety. Quincy, MA:
National Fire Protection Association.

NIOSH [2011]. Career lieutenant dies after being trapped in the attic after falling through a roof while
conducting ventilation—Texas. Morgantown, WV: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
F2011-20.

NIOSH [2012]. Volunteer fire fighter caught in a rapid-fire event during unprotected search, dies after
facepiece lens melts—Maryland. Morgantown, WV: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
F2011-02.

NIOSH [2017]. NIOSH fire fighter fatality investigation helps incident commander choose strategy
and tactics to control flow path and protect fire fighters. By Bowyer M., Loflin M., Merinar T., Miles
S., Moore P., Wertman S., Orr B., and Webb S. Morgantown, WV: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Institute for Occupational
Safety and Health, DHHS (NIOSH) Publication 2017–200.

NIOSH [2018]. Preventing deaths and injuries of fire fighters working at basement and other below
grade fires. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH)
Publication 2018- 154.

NIOSH [2022a]. PPE CASE: Evaluation of a self-contained breathing apparatus involved in a fatality
while operating at a structure fire. By Tarley J and Andrews A. Morgantown, WV: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health, NPPTL TN-24967.

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NIOSH [2022b]. The importance of understanding and training on the portable radio emergency alert
button (EAB) during a mayday. Morgantown, WV: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
Publication No. 2023-100.

NIOSH [2022c]. Fire fighter dies after falling through a floor at a large area residential structure fire –
Maryland. By Loflin M, Hales TR, and Bowyer M. Morgantown, WV: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Institute for Occupational
Safety and Health, F2018-13.

NIOSH [2024]. Volunteer firefighter killed after becoming trapped at an assisted living facility fire and
two firefighters injured – New York. By Loflin M and Attwood W. Morgantown, WV: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health, F2021-10.

NIOSH [2025a]. Career firefighter dies in collapse involving lightweight construction with two
separate maydays – South Carolina. By Attwood WR, Montague PR, and Richardson MR.
Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Institute for Occupational Safety and Health, F2023-07.

NIOSH [2025b]. Career firefighter seriously injured during search operations in a residential structure
fire – Oregon. By Attwood WR, Lago LR, Stakes K, and Montague PR. Morgantown, WV: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health, F2024-03.

NIOSH [2025c]. Career candidate firefighter found unresponsive at a residential structure fire and dies
5 days later – Illinois. By Loflin ME and Saunders R. Morgantown, WV: U.S. Department of Health
and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational
Safety and Health, F2021-20.

NIOSH [2025d]. Lieutenant Dies from a Floor Collapse in Residential Structure Fire with Unpermitted
Renovations – Illinois. By Loflin ME, Attwood WR, Austin E. Morgantown, WV: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health, F2022-09.

Pindelski, J. [2010]. Fire fighter Rescue: Rapid Removal Through a Window. Firehouse. Date
accessed: September 8, 2023.

Rowett A [2008]. The proactive RIT. Firehouse.

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Weather Underground [2021]. Weather History. The Weather Underground. Date accessed: August 14,
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Investigator Information
This report was written by Murrey E. Loflin (retired), Investigator, Dr. Wesley R. Attwood,
Investigator and Program Advisor, and Jeff Funke, Team Lead, with the Fire Fighter Fatality
Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of
Safety Research, NIOSH. A subject matter expert technical review was provided by Robert Opett,
Assistant Director of Field Operations, Public Safety Training and Certification, Bucks County
Community College, Pennsylvania.

Additional Information
International Association of Fire fighters Fire Ground Survival Program
The IAFF Fire Ground Survival Training addresses Mayday prevention and Mayday operations for
firefighters, company officers, and chief officers. Firefighters must be trained to perform potentially
life-saving actions if they become lost, disoriented, injured, low on air, or trapped. Funded by the IAFF
and assisted by a grant from the U.S. Department of Homeland Security through the Assistance to Fire
fighters (FIRE Act) grant program, this comprehensive fireground survival training program applies
the lessons learned from fire fighter fatality investigations conducted by the NIOSH. It was developed
by a committee of subject matter experts from the IAFF, the IAFC, and NIOSH.

Disclaimer
The information in this report is based upon dispatch records, audio recordings, witness statements,
and other information that was made available to the National Institute for Occupational Safety and
Health (NIOSH). Information gathered from witnesses may be affected by recall bias. The facts,
contributing factors, and recommendations contained in this report are based on the totality of the
information gathered during the investigation process. This report was prepared after the event
occurred, includes information from appropriate subject matter experts, and is not intended to place
blame on those involved in the incident. Mention of any company or product does not constitute
endorsement by NIOSH, Centers for Disease Control and Prevention (CDC). 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. NIOSH
Approved is a certification mark of the U.S. Department of Health and Human Services (HHS)
registered in the United States and several international jurisdictions.

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