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Executive Summary
On April 12, 2015, a 38-year-old male
volunteer fire fighter died in a floor collapse
while working above a residential basement
fire. At 22:09 hours, the local volunteer fire
department, neighboring mutual aid volunteer
fire department, county emergency
management, and a medic unit were dispatched
to a residential house fire with an occupant
inside. The caller reported to Dispatch that the
fire was in the basement. Due to the similarity in
street names, the address was corrected a minute
later by Dispatch. The fire chief was first on-scene and was informed that the male homeowner would
be near the master bathroom. The chief reported smoke coming from the garage and requested mutual
aid from two other volunteer departments. The first engine on-scene took a 1¾-inch hoseline and
forced the front door. Heavy, brown smoke was banked to the floor. The crew searched the bathroom
then heard erratic breathing and located the homeowner on the floor near the bed. The homeowner was
stuck on something but they moved him toward the bedroom double doors. After approximately 20
minutes on-scene, a third crew was able to get him out. A crew with a 1¾-inch hoseline from the
neighboring department made entry on the first floor through the garage. They went through the
laundry room, across the hallway, and into the kitchen where they encountered heavy heat, smoke, and
fire. The third fire fighter on the line yelled to get out, then the other two fire fighters heard a loud
explosion and were surrounded by fire. They backed out, following the hoseline. Once outside, they
thought the third fire fighter was already out. An evacuation order was given and a personnel
accountability report was called. Responding companies all gave a positive report, including the
neighboring department. Finally, it was realized that the third fire fighter was missing. A crew made
entry down to the basement via the interior stairs and were searching for the fire but was driven back
by heat, smoke, and water that had collected in the basement. Crews searched and noticed that the floor
had collapsed in an area in the hallway on Side D and in the kitchen. A hole was cut in the exterior
wall on Side D above the collapsed floor in the hallway, exposing a view into the basement. The crew
noticed the reflective trim on the downed fire fighter’s turnout gear in the debris in the basement. A
recovery was made at 09:37 hours, after the local urban search and rescue team arrived to shore up the
structure so the fire fighter could be safely removed.
Fire structure.
(Courtesy of Fire Marshall.)
Page ii
Volunteer Fire Fighter Dies in a Floor Collapse While Working
Above a Residential Basement Fire—South Dakota
Report # F2015-21
Contributing Factors
• Delay in notification to the fire department
• Delay in fire suppression
• Blood alcohol level above the legal limit
• Concealed basement fire
• Crew integrity
• Self-contained breathing apparatus operation/maintenance
• Fireground communications
Key Recommendations
• Fire departments should ensure that a fire attack is conducted concurrently with rescue
operations and a risk-versus-gain analysis is done after the rescue is completed.
• Fire departments should ensure that officers and fire fighters are trained in current basement
fire strategies and tactics.
• Fire departments should ensure that a zero-tolerance alcohol policy is established and
enforced.
• Fire departments should ensure that an accountability system is established prior to entry and
personnel accountability reports are accurate.
• Fire departments should ensure that a respiratory protection program is established and
maintained.
• Fire departments should ensure that SCBAs are functional and maintained in accordance with
manufacturer guidelines.
• Fire departments should ensure that fire fighters wear proper personal protective equipment on
the fireground.
• Fire departments should ensure that a staging area manager is assigned to the staging area to
release crews once assignments are given.
Additionally, local governments should:
• Consider requiring fire fighters be trained to state minimum training requirements.
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).
Page 1
2015
21
November 1, 2017
Volunteer Fire Fighter Dies in a Floor Collapse While Working
Above a Residential Basement Fire—South Dakota
Introduction
On April 12, 2015, a 38-year-old male volunteer fire fighter died in a floor collapse while working
above a residential basement fire. On March 18, 2016, the county emergency management director, the
county fire chiefs association, and the chief from the fallen fire fighter’s volunteer fire department sent
a letter to the National Institute for Occupational Safety and Health (NIOSH) requesting an
investigation. On April 24–28, 2016, a general engineer and a safety engineer from the NIOSH Fire
Fighter Fatality Investigation and Prevention Program traveled to South Dakota to investigate this
incident. The NIOSH investigators conducted an opening meeting with the county emergency
management director, the investigating deputy state fire marshal, and the president of the county fire
chiefs association. The NIOSH investigators visited the incident scene and conducted interviews with
fire chiefs, officers, and fire fighters who were at the incident. The NIOSH investigators reviewed the
two primary fire departments’ standard operating guidelines, officers’ and fire fighters’ training
records, dispatch audio tapes, the county medical examiner’s autopsy report, and the state fire
marshal’s report.
Fire Department
The county’s fire service consists of 13 volunteer fire departments, 1 career fire department, and 3
public service organizations. The Office of Emergency Management (OEM) assists the response and
recovery activities of these departments and organizations involved in providing emergency services.
The OEM is the principal source of information on emergency management, including the
identification of training needs and developing and providing training programs. The OEM also assists
all county agencies in obtaining surplus governmental equipment (vehicles, tools, etc.). The county’s
fire chiefs association was created in 1968 to coordinate and assist the efforts of the fire departments
across the county. The association coordinates the initial fire service training for new members and
provides a dedicated training officer to assist the departments in finding and establishing training
programs. The county’s fire service serves a population of approximately 185,000 in an area of 814
square miles. Mutual aid agreements are a key component to the success of the county’s fire service.
The county has been progressive in establishing radio policies, training opportunities, and financial
support.
The district volunteer fire department where the fire occurred was established in 1958 and currently
has about 25 active members but is set up to have 40 certified fire fighters on their roster, of which,
about a third are EMTs. They serve a community of approximately 9,000 people, which covers 5.37
square miles. They operate out of one station with two rescue trucks, two engines, two wildland trucks,
two tenders, a command vehicle, and a fire all-terrain vehicle. The department trains the first and third
Page 2
Volunteer Fire Fighter Dies in a Floor Collapse While Working
Above a Residential Basement Fire—South Dakota
Report # F2015-21
Monday of every month. They attend state fire schools and have been the host site for the state fire
school. They provide mutual aid for five other fire departments in the area.
The mutual aid volunteer fire department that had the fatality was established in 1898 and operates out
of one station with 30 active members. They serve a population of 1,700 people, covering 56 square
miles. They operate two engines, two tenders, two wildland trucks, and a rescue truck.
Training and Experience
The state of South Dakota does not have prerequisite training or education requirements for an
individual to become a fire fighter. The state Fire Marshal’s Office assists fire departments via the
State Fire Service Training Program, which coordinates training for the state fire school, district fire
schools, National Fire Academy courses, and other special training classes. The program provides for
the certification of fire fighters, fire instructors, fire apparatus drivers/operators, and fire officers
through certified training programs. The Fire Service Training Program is also a resource for training
materials.
Table 1 summarizes the documented training of the Engine 1 fire fighter (Mutual Aid) and the fire
chief (incident commander).
Fire Fighter Training Courses Years of
Experience
Fire Fighter
(Engine 1 Mutual Aid)
Basic Fire Fighting (Fire Fighter I and Fire Fighter
II), Introduction to the Incident Command System
(IS-100), ICS for Single Resources and Initial Action
Incidents (IS-200), Intermediate ICS for Expanding
Incidents (ICS-300), Hazardous Materials Awareness
Level, various fire-fighting procedures, and various
other administrative and technical courses.
14
Table 1. Training records for the Engine 16 fire fighter (Mutual Aid) and fire chief (incident
commander)
Page 3
Volunteer Fire Fighter Dies in a Floor Collapse While Working
Above a Residential Basement Fire—South Dakota
Report # F2015-21
Fire Fighter Training Courses Years of
Experience
Fire Chief
(Incident Commander)
Fire Fighter I, Emergency Medical Technician-Basic,
Introduction to the Incident Command System (IS100), ICS for Single Resources and Initial Action
Incidents (IS-200), National Incident Management
System (NIMS) an Introduction (IS-700), Leadership
Command Presence, Incident Safety Officer, State
Certified Fire Officer, State Certified Fire Instructor,
Fire Attack-Strategy and Tactics of Initial Company
Response, Firefighter Survival and Rapid
Intervention, Basic Wildland Firefighter (S-130),
Introduction to Wildland Fire Behavior (S-190),
Engine Boss (Single Resource)(S-231), Interagency
Incident Business Management (S-260), and various
other administrative and technical courses.
22
Structure
The incident involved a ranch style, single-family home with a two-car, attached garage, which was
built in 1994. The ground floor accounted for 1,759 square feet of living space, and most of the
basement had been finished to add another 1,500 square feet. The home was wood frame construction
on a concrete block foundation. The exterior was vinyl siding with brick and brick veneer. The roof
was gabled 2 inch x 6 inch rafters with OSB sheathing covered with asphalt shingles (see Photos 1 and
2). The interior was drywall with carpet and vinyl flooring. Natural gas was used for the forced air
furnace and hot water heater, which shared a single-walled metal chimney pipe. The basement area
contained an unfinished utility room area on Side D of the home (see Diagrams 1 and 2). The basement
had no exterior man door. Side B had a window near the A/B corner and there were several small
windows on Side C.
Page 4
Volunteer Fire Fighter Dies in a Floor Collapse While Working
Above a Residential Basement Fire—South Dakota
Report # F2015-21
Photo 1. Front, side A, view of fire structure.
(Courtesy of the Fire Marshall’s Office.)

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