Posts Tagged NIOSH report

NIOSH report released on LODD of CFD Captain Herbie Johnson (more)

The Chicago Tribune has an article about the NIOSH Report on the LODD of CFD Captain Herbie Johnson:

Chicago firefighters failed to properly coordinate and communicate their strategy for extinguishing a blaze that killed a 32-year veteran of the department last year, a federal investigation found.

The report marks the second time in as many years that the National Institute for Occupational Safety and Health has cited poor communications as a contributing factor in a Chicago firefighter’s death. Though not as scathing as the findings from a December 2010 blaze that killed two firefighters, the latest NIOSH report indicates there are still questions about how the department communicates while battling fires.

The report also describes the harrowing scene inside a burning Gage Park neighborhood two-flat on Nov. 2, 2012, where Capt. Herbert Johnson repeatedly ordered his men to safety after suffering severe burns to his hands, face and the inside of his mouth.

“He was trying to get us out but he couldn’t get himself out,” said firefighter-paramedic Mike Imparato, who yelled “mayday” — he had no radio — after Johnson fell to the floor.

Both the Fire Department and the firefighters union have reviewed the report, which does not specifically state which, if any, issues had a direct bearing on Johnson’s death. Instead it lists a series of “contributing factors” that include poor communication, staffing shortages and inefficient coordination at the scene.

A union official said the report, while an important learning tool, also shows that fires are filled with hidden dangers beyond anyone’s control.

“They got on the scene and there was minimal fire showing from the first hole in the roof,” said Thomas Ryan, president of Chicago Fire Fighters Union Local 2. “It looked as though they had it under control, then all hell broke loose. Johnson’s first instinct was to tell the members to get out. He looked out for the safety of his fellow firefighters. Unfortunately he didn’t make it out.”

Johnson, who had been promoted to captain that summer, was in the house for only six minutes when things went terribly wrong, according to investigators. As Johnson carried a hose inside, the scene commander announced over department radios that other firefighters were ventilating the building and blasting water into the attic.

Johnson, who was carrying a radio, never confirmed that he got that message. But the plan proceeded anyway. The report specifically chastises scene commanders for failing to confirm that Johnson knew the plan to attack the fire.

“Everyone has to know the strategy that is being implemented and understand their role by acknowledging via radio their position and role,” the report states.

The federal investigators also took issue with the strategy employed that day, saying that firefighters on the scene failed to consider that horizontal ventilation — doors were opened on either end of the building, and there was a hole in the roof — would cause the fire and heat to intensify and become dangerous, federal investigators said.

Around the same time as the ventilation plan was enacted, Johnson ordered firefighters on the second floor to get out of the building. His order was followed by a loud noise, as Johnson collapsed on the second floor.

The report confirms that the firefighter-paramedic who found Johnson did not have a radio and was reduced to screaming “mayday” to call attention to Johnson’s injuries, according to federal investigators. The report notes that on the day of the fire the city was still awaiting a shipment that would have provided a radio to every member of the department.

Those additional radios were recommended by NIOSH after an investigation into a December 2010 fire in a vacant South Side building that killed two firefighters. The lack of radios was cited as a contributing factor in that blaze.

Chicago Fire Department spokesman Larry Langford on Monday initially insisted that all firefighters involved in the Gage Park fire had radios. After reading the report Monday, he conceded that some firefighters at the scene did not have radios but said it would have made little difference.

“That had nothing to do with this incident,” Langford said. “Communication was not the issue in this incident from what I determined.”

Every Chicago firefighter now has a digital radio, Langford said. Most were distributed on Nov. 18, 2012, about two weeks after Johnson’s death.

Imparato, who made the mayday call without a radio, told the Tribune he yelled for about 10 seconds before help arrived. He tried to grab Johnson’s radio to call for assistance but couldn’t reach it, he said.

“Ten seconds seemed like an eternity,” he said. “I could hear footsteps on the stairs, so I knew others were coming. I was screaming ‘mayday’ the entire time.”

Imparato said he doesn’t believe a radio would have changed Johnson’s fate.

Tags: , , , , ,

NIOSH report released on LODD of CFD Captain Herbie Johnson

NIOSH Report o the LODD of Chicago FD Captain Herbie Johnson

Career Captain Sustains Injuries at a 2-1/2 Story Apartment Fire then Dies at Hospital – Illinois

Executive Summary

On November 2, 2012, a 54-year-old male career captain sustained injuries at a 2-1/2 story apartment building fire then died at a local hospital. The fire occurred only blocks from the victim’s fire station. Battalion Chief 19 (BC19) was the first to arrive on scene and reported heavy smoke coming from the rear and front of the structure’s attic. BC19 surveyed the interior of both floors, while the captain and a fire fighter from Engine 123 stretched a 2½-inch line with a gated wye to 1¾-inch hoseline to the 2nd floor. BC19 radioed the captain from the rear of the 1st floor apartment that there was heavy fire in the rear covered porch and stairwell. The captain (victim) and the fire fighter stretched the hoseline towards the rear of the second floor apartment. Before water could be applied to the fire the captain told the fire fighter they had to “get out.” Engine 49 (2nd due engine) had stretched a 2½-inch hoseline down the alley to the rear and get into position to put water through the attic window. The captain moved halfway back in the hallway towards the kitchen and yelled out that he needed help. As the fire fighter drug the captain to the kitchen, additional fire fighters who reached the 2nd floor heard the Captain and fire fighter collapse on the floor in front of them. A Mayday was called by the Squad 5 Lieutenant on the second floor and the victim was carried down the stairs to the front yard. The victim responded to basic life support measures and was moved to Ambulance 19 for advanced life support. The victim was transported to the local hospital where he had complications during airway management and died.

Contributing Factors

  • Modified building construction with multiple ceilings and a multi-story enclosed rear porch
  • Horizontal ventilation contributed to the rapid fire growth
  • Fireground communications
  • Lack of proper personal protective equipment
  • Lack of a sprinkler system in the residential rental building.

Key Recommendations

  • Ensure that fireground operations are coordinated with consideration given to the effects of horizontal ventilation on ventilation-limited fires
  • Ensure that the Incident Commander communicates the strategy and Incident Action Plan to all members assigned to the incident
  • Ensure that the Incident Commander establishes a stationary command post during the initial stages of the incident for effective incident management, which includes the use of a tactical worksheet, enhanced communications, and a personnel accountability system
  • Ensure use of risk management principles at all structure fires
  • Ensure proper personal protective equipment is worn
  • Ensure that communications are acknowledged and progress reports are relayed
  • Ensure that Incident Commanders are provided chief aides to help manage information and communication
  • Ensure that staffing levels are maintained.

Per department procedures the following companies were dispatched to the initial report of this structure fire through the time of the Mayday:

Still Alarm
Engine 123 (E123): Captain (victim), engineer, 3 fire fighters
Tower Ladder 39 (TL39): Lieutenant, driver, 2 fire fighters – Note: The company was riding one fire fighter short, which is referred to as a variance. 
Engine 49 (E49):  Lieutenant, engineer, 2 fire fighters – Note: Also on a variance.
Truck 33 (T33):  Captain, driver, 3 fire fighters
Battalion Chief 19 (BC19): Incident Commander (IC)
RIT Alarm
Truck 52 (T52): Lieutenant, driver, 3 fire fighters
Squad 5 (SQ5): Lieutenant and five fire fighters – Note: A squad consists of one heavy rescue vehicle and a 55- foot Snorkel; Staffing includes an officer and three fire fighters on the heavy rescue vehicle and two fire fighters on the Snorkel.
Battalion Chief 15 (BC15): RIT Chief
Ambulance 19 (A19): 2 Paramedics
Unit 455: EMS Field Officer
Unit 273: Command Van


An approximate timeline summarizing the significant events in this incident is listed below. The times are approximate (rounded to the nearest minute) and were obtained by studying the available dispatch channel records, witness statements, run sheets and fire department records. The timeline is not intended, nor should it be used, as a formal record of events. Only those dispatch channel communications directly related to the fatal incident are included. Note: This department uses the following terminology to designate the geographical sides of a structure/building: Sector 1 – front of the building, address side of the structure, or where “Command” is located; Sector 2 – side to the left of Sector 1(going clockwise); Sector 3 – rear of the building or opposite of Sector 1; Sector 4 – side to the right of Sector 1 when facing Sector 1.

  • 1716 Hours
    Dispatch for a Still Alarm for “Smoke in the area:” E123; TL39; E49; T33; BC19. BC19 assumes incident command enroute, verifies working fire, and Dispatch initiates RIT response dispatching T52, SQ5, BC15, A19, 455 EMS Officer, and Command Van 273.
  • 1717 Hours
    E123, E49, TL39, and T33 enroute; BC19 on scene in less than a minute; BC19 enters structure to size-up scene.
  • 1719 Hours
    E123 on scene
  • 1720 Hours
    E49, T33, and TL39 on scene and reported black smoke out front attic window and heavy smoke and flame in rear.
  • 1721 Hours (approximate)
    E123 crew made entry with 1 ¾-inch hoseline to second floor; E49 pulls 2 ½-inch hoseline down alley in Sector 3; T33 sets up ground ladder on Sector 2; TL39 sets up aerial to go to the roof; A fire fighter from SQ5 and T33 assisted TL39; Approximately 30 seconds later, a TL39 firefighter went to Sector 3, entered the Sector 3 first floor exterior enclosed porch door and noticing fire light up in the stairwell; He preceded to kick in the mud room door to the first floor apartment then backed out to Sector 3
  • 1723 Hours
    IC radios victim that there is heavy fire in rear stairway and covered porch and that E49 is going to put water on fire from Sector 3; No reply heard from victim.
  • 1724 Hours
    E49 in Sector 3 puts water on the fire at the attic window with 2½-inch hoseline
  • 1725 Hours
    SQ5 makes entry on Sector 1
  • 1727Hours
    TL39 had just completed first hole in roof on Sector 4; After hearing the Mayday over the radio from the SQ5 Lieutenant, the IC calls “Mayday” into dispatch and requests 2-11 Assignment; Dispatch initiates a 2-11 Alarm
  • 1728 Hours (approximate)
    IC in Sector 1 and runs to get A19’s crew
  • 1729 Hours
    Fire fighters carry the victim outside to Sector 1 and perform CPR.
  • 1738 Hours
    A19 enroute to hospital with victim


On November 2, 2012, a 54-year-old male career captain sustained injuries at a 2-1/2 story apartment building fire then died at the hospital. At 1716 hours, dispatch called a Still alarm for smoke in the area. Battalion Chief 19 was the first to leave the station that was just blocks away. He approached the fire structure by driving behind it then around to the front arriving on scene at 1717 hours. He reported a working fire with heavy smoke coming from the rear (Sector 3) and front (Sector 1) of the structure’s attic. Per fire department standard operating procedures, dispatch initiated a RIT response. At 1718 hours, E123 arrived on scene and BC19 was on scene and had assumed incident command. The IC spoke with one of the occupants who stated everyone was out. The IC made entry through the front door to the stairwell to survey the interior of the 2nd floor. He noticed only a light haze throughout and glow around the Sector 3 door to the covered porch. The IC came back to the front door and met the E123 Captain (victim) and a fire fighter (pipeman). They had stretched a horseshoe load which is 100 feet of 2 ½ -inch , a gated wye, and 150 feet of 1 ¾-inch hoseline to go to the 2nd floor, which is a standard department hose lay for this type occupancy. At 1720 hours, E49, T33, and TL39 arrived on scene (see Diagram 1).

The IC made entry to the 1st floor apartment and worked his way to Sector 3. He opened the back door to the covered porch and noticed heavy fire in the covered porch and rear stairwell area (see Photo 2). At 1721 hours, the Victim and fire fighter were on the 2nd floor where they flaked out, charged, and began advancing the hoseline to the rear door of the apartment. The E49 crew had stretched a 2 ½-inch hoseline down the alley to Sector 3. The T33 crew set a ground ladder on Sector 2 and TL39 set the aerial to the roof about a third of the way back on Sector 2. A TL39 fire fighter went to Sector 3 to check doors. He first went to the basement door which he was unable to force open. Then, he went to the first floor exterior enclosed porch door which was unlocked and he opened it up. He stated that he noticed fire light-up in the stairwell. He kicked in the locked door to the first floor apartment, preceded to walk in, saw no fire then backed out.

At 1723 hours, the IC radioed the victim that there was heavy fire in the covered porch and attic area and that E49 was going to put water on the fire, around the Sector 3 attic window, but there was no acknowledgement from the victim. E49 proceeded to put water on the Sector 3. The IC returned out front to the command post and donned his turnout gear.

The Lieutenant from TL39, the Lieutenant and 2 fire fighters from SQ5, and a E123 firefighter/paramedic (FF/PM) were near the kitchen area on the 2nd floor when they heard a loud commotion. The FF/PM heard the victim yell “get out of here” (see Photo 3 and Photo 4). The FF/PM felt the victim’s air cylinder and noticed it was hot. Also, he felt a mask that was dangling and thought it was the victim’s but it was actually the E123’s pipeman, who was tangled up with the victim. Note: The E123 pipeman was on air and his facepiece became dislodged while assisting the victim. The FF/PM had no radio and he couldn’t locate the victim’s radio so he yelled Mayday as he tried to get the victim and other crew member untangled. The TL39 Lieutenant and SQ5 fire fighters heard the FF/PM’s verbal Mayday and the SQ5 Lieutenant tried to transmit a Mayday over heavy radio traffic (see Diagram 2). Note: The victim’s hoseline in the hallway (see Diagram 2) had burst but it is believed to have occurred during the thermal incident or post incident.

At 1727 hours, the TL39 crew had just completed the first hole in the roof about midway on Sector 4 roof with minimal fire showing, when they heard the Mayday. The IC verified that a fire fighter was down, called a Mayday, and requested a 2-11 Assignment. Dispatch initiated a 2-11 alarm. SQ5 and other members on the 2nd floor grabbed the victim and got him down the stairs. The TL39 crew, with assistance from a T33 and SQ5 fire fighter, had just completed a second hole on Sector 4 of the roof about a third of the way back when conditions worsened. At 1729 hours, the roof ventilation crew was back in the aerial basket when they noticed the victim being brought out to the front yard. The victim was nonresponsive in the front yard and CPR was successfully performed. The IC met the A19 crew and escorted them to the victim. The revived victim was responsive and talking to the paramedics as he was loaded into the ambulance. At 1738 hours, the victim was transported to the local hospital where he had complications during airway management and died.

Fire Behavior

According to the arson investigator’s report, the fire originated in the attic and was accidental in nature. It is unknown how long the fire had burned before it was observed by the residents on the 2nd floor in the enclosed rear porch. Smoke pouring out the attic (indicating the fire was in an advanced stage) was noticed by a person at the street corner west of the structure. He ran up and knocked on the door to let the residents know the structure was on fire. The residents immediately exited the structure.

The developing fire burning in the attic void space was ventilation limited and produced a large volume of unburned products of incomplete combustion and high pressure. The first arriving companies observed optically dark smoke from the 2-1/2 story apartment building coming from the front and rear attic windows. As the engine crew advanced a hoseline to the 2nd floor, BC19 searched the 1st floor and went to the rear of the structure and noticed fire in the enclosed rear porch area. Another engine crew advanced a hoseline down the back alley to the exterior rear of the structure. Once the 2nd floor rear porch door failed, the fire gases from the porch flowed into the hallway.

Indicators of significant fire behavior

  • 911 Dispatch received multiple phone calls reporting a structure fire
  • First arriving crews could see smoke from blocks away prior to arriving on scene
  • BC19 saw smoke pushing out attic window in Sectors 1 and 3
  • The BC went to 2nd floor and noticed glow around rear door to porch
  • The BC went in 1st floor apartment to rear porch and noticed fire raining down in enclosed porch area
  • BC reports working fire and dispatch sends a RIT response
  • TL39 firefighter opened the first floor doors (one exterior and one interior) of Sector 3 to the enclosed porch and notices the fire intensifies up the stairwell (horizontal ventilation)
  • The 2nd floor rear porch door fails
  • BC calls for an engine crew to the outside of Sector 3 with 2 ½-inch hoseline to hit the eaves and attic window
  • Truck company is in process of venting roof on Sector 4 side near Sector 3 with little smoke when they hear the Mayday over the radio
  • The TL39 crew, with assistance from a T33 and SQ5 fire fighter, cut a second hole on Sector 4 mid-way between chimneys, flames and black smoke came out the second hole then precede to the basket to get off roof
  • Within minutes roof totally involved in flames
  • Defensive operations were initiated.

Note: The National Institute of Standards and Technology (NIST) is developing a computerized fire model to aid in reconstructing the events of the fire. When completed, this model will be available at the NIST websiteExternal Web Site Icon:

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 led to the fatality:

  • Modified building construction with multiple ceilings and a multi-story enclosed rear porch
  • Horizontal ventilation contributed to the rapid fire growth
  • Fireground communications
  • Lack of proper personal protective equipment
  • Lack of a sprinkler system in the residential rental building.

Cause of Death

According to the medical examiner, the victim’s cause of death was inhalation injuries received at a structure fire.

thanks Chris

Tags: , , ,

NIOSH report on Christopher Wheatley LODD

The NIOSH report on the August 9, 2010 LODD of Chicago FF/PM Christopher Wheatley has been released. FF/PM Wheatley died from injuries sustained when he fell from a fire escape at commercial fire.

Executive Summary

On August 09, 2010, a 31 year-old male career fire fighter (the victim) died from a fall while climbing a fire escape ladder. Crews were responding to an alarm at a 4 story mixed occupancy structure. When crews arrived at 0031 hours, they noticed sparks emitting from the top of the roof near an external exhaust duct that originated in a street level restaurant. The victim and three other fire fighters were using an exterior fire escape to access the roof. At the fourth floor landing the victim started to ascend the vertical ladder to the roof carrying a 63 pound hand pump in his right hand while being supported by a fire fighter on the landing. When out of reach of the supporting fire fighter, the victim lost his grip on the ladder falling 53 feet to the pavement. The victim was transported to the local medical center where he was pronounced dead.

Contributing Factors

  • Using a fire escape to access the roof rather than a safer means such as an aerial ladder or interior stairway
  • Victim unable to maintain contact with the vertical portion of fire escape due to carrying the hand pump.

Key Recommendations

  • Ensure that standard operating guidelines (SOGs)on the use of fire escapes are developed, implemented, and enforced
  • Ensure that tactical level accountability is implemented and enforced
  • Ensure that companies are rigorously trained in safe procedures for roof operations and climbing ladders of any type
  • Ensure that fire fighters are rigorously trained in safe procedures for carrying and/or hoisting equipment when ascending or descending elevations
  • Evaluate the fire prevention inspection guidelines and process to ensure that they address high hazard occupancies, such as restaurant, and incorporate operational crew participation.


The complete report can be found HERE.

The Chicago Tribune has a related article HERE.

Tags: , ,