Excerpts from labor.illinois.gov:
INSPECTION #: 1569882
REPORT DATE: 1/12/2024
The Marmora Incident: Firefighter Seriously Injured and Later Dies After Loss of Accountability at a Residential Fire
SUMMARY: IL OSHA opened an inspection to investigate the death of a 30- year-old male firefighter who was separated from his team during fire suppression operations at a multi-family dwelling basement fire. The firefighter experienced an emergency and declared a mayday. He was located and removed from the structure by firefighters from multiple fire companies. Advanced life support and critical care measures were provided; however, the firefighter died five days later.
CONTRIBUTING FACTORS: Key contributing factors identified in this investigation include:
• The initial fire suppression team did not enter together and stay together.
• No other members in the structure or on scene had communication with the firefighter when he suffered a life-threatening emergency.
• There was a delay between the firefighter in distress declaring a mayday and the incident commander confirming a mayday emergency.
RECOMMENDATIONS (DEFENSES): To reduce the risk of similar occurrences:
• Interior teams go in as a team, stay in visual or voice contact, and leave as a team.
• Prior to entering a hazard zone, firefighters must perform a radio check to establish communication with a member outside the hazard zone.
• Company officers must provide close supervision of inexperienced members during high hazard operations.
• Incident commanders must treat a potential mayday as an actual mayday until proven otherwise.
SUMMARY: On December 16, 2021, at 6:31 AM, the Illinois Department of Labor – Division of Occupational Safety and Health (IL OSHA) received notice of an occupationally related injury of a firefighter that occurred earlier in the morning. IL OSHA opened an inspection to investigate the circumstances involving a 30-year-old male firefighter found unresponsive and out of breathing air on the first floor of a multi-family residential structure after a mayday call. The firefighter was removed from the structure by firefighters from several fire companies of the involved department. The firefighter received advanced life support care, was transported to a nearby hospital, and was subsequently transferred to another hospital for critical care. Despite these measures, he succumbed to his injuries five days after the incident.
FINDINGS: Direct Cause: Exposure to respiratory hazards. The victim’s breathing air supply was completely depleted. According to the coroner’s report, death was attributed to complications of carbon monoxide toxicity and thermal injuries due to inhalation of smoke and soot.
Indirect Causes:
1. Based on evidence, firefighters from E1 entering the interior were not checked to see that they were operating on the designated fireground radio channel.
2. Close supervision of FF#1, who had only six months of field experience, was not provided by the E1 company officer.
3. Firefighters from E1 did not enter the structure together, stay together, and exit together.
4. FF#1 was not in direct visual or voice contact with another firefighter when he suffered a SCBA emergency involving the rapid loss of breathing air. As a result, no firefighters were able to immediately identify that FF#1 was experiencing a life-threatening emergency and provide assistance.
5. FF#1 had not established radio communication with a member outside the hazard zone. As a result, FF#1 was not able to receive immediate assistance after experiencing a life-threatening emergency.
6. The SCBA emergency experienced by FF#1 was so significant, it is unlikely that he, or any firefighter, could have corrected the situation and restored the SCBA to normal operation inside the structure.
7. The E1 company officer lost accountability of FF#1 for approximately ten minutes.
8. Most members on scene, including the incident commander and the E1 company officer did not hear FF#1’s mayday call.
9. Once the RIT chief heard FF#1’s mayday call on an unknown channel, there was a delay between receiving the call and the incident commander declaring a mayday emergency.
10. The mayday call did not include a unique identifier (or one was not heard by personnel).
11. Despite learning of a possible mayday call, the incident commander declared “no mayday.”
12. Based on evidence, not all members operating on scene were aware of a mayday emergency
13. At least one member assigned to search for FF#1 was not aware that he was searching for a missing firefighter. He heard a PASS device in alarm but discounted it as a false alarm.
14. The third of three civilian victims were being removed from the building while firefighters were searching for FF#1 presenting a small degree of confusion.
15. Once located, FF#1 did not receive emergency breathing air.
CONCLUSION: This incident highlights the critical importance of firefighters entering a structure together, staying together, and exiting together. It is also critically important that firefighters establish radio communications with members outside a structure prior to entry, and that inexperienced firefighters have close supervision during high hazard operations. Additionally, the report of a potential mayday should be treated as an actual mayday until proven otherwise. With a team member and with established communications, FF#1 would have received immediate assistance when he experienced the SCBA emergency, significantly reducing the risk of serious injury
RECOMMENDATIONS (DEFENSES):
Interior Firefighters:
• Perform radio check prior to entry.
• Teams enter together, stay together, exit together. No exceptions.
• Say your name when calling mayday, repeat until command confirms. Rapid Intervention Teams:
• Immediately provide a downed firefighter with breathing air.
• One member of RIT is assigned as “air” firefighter. Company Officers:
• Ensure their members are on the appropriate radio channel prior to entry.
• Ensure close supervision of inexperienced members. Incident Commanders and Command Team Members:
• Establish radio communication with teams prior to entry. •
Have zero tolerance for interior firefighters operating alone.
• If an emergency (mayday, evacuation, collapse) is declared on scene, ensure all members on scene receive the message immediately.
• Treat any potential mayday as an actual mayday until proven otherwise.
• Ensure that PASS alarms are treated as firefighter distress alarms and combat the prevalence of false PASS alarms on the fireground.
Fire Department Leaders:
• Program portable radios capable of providing a unique identifier with an emergency button that alerts members (including dispatch) outside the hazard zone of a firefighter in distress.
• Ensure company and command officers that are serving in acting roles have high quality training at the levels that they are temporarily expected to operate at.
• Ensure defenses identified by IL OSHA are captured in department policies.
