NIOSH Death in the Line of Duty Report F2007-28

The deaths of Captain Matthew Burton and Engineer Scott Desmond in a residential fire on July 27, 2001 were the result of a complex web of circumstances, actions, and events. The Contra Costa County Fire Protection District and National Institute for Occupational Safety and Health (NIOSH) both investigated this incident and have published reports that outline the sequence of events, contributing factors, lessons learned, and recommendations. Readers are encouraged to read the Contra Costa County Fire Protection District Report and National Institute for Occupational Safety and Health (NIOSH) Death in the Line of Duty Report F2007-28. Also have a look at Tim Sendelbach’s post In Their Honor at Firefighter Nation.

Incident Overview

Early on the morning of July 21, 2007, Captain Matthew Burton and Engineer Scott Desmond were performing primary search of a small, one-story, single family dwelling in San Pablo, California. During their search, they were trapped by rapidly deteriorating conditions and died as a result of thermal injuries and smoke inhalation. Two civilian occupants also perished in the fire.

The crews of the first arriving companies (two engines arrived almost simultaneously) faced significant challenges with a report of civilian occupants trapped in the building, flames from the door and a large window on Side Alpha and smoke throughout the structure. The two engines rapidly initiated fire attack, primary search, and placed a blower for positive pressure ventilation. During interior firefighting operations, Captain Burton and Engineer Desmond were trapped extremely rapid fire development in the hallway and bedrooms while conducting search without a hoseline.

Contributing Factors

NIOSH Report F2007-28 identifies eight factors that contributed to the tragic outcome of this incident.

  • Failure by the alarm company to report a confirmed fire
  • Inadequate staffing to effectively and safely respond to a structure fire
  • The failure to conduct a size-up and transfer incident command
  • Conducting a search without protection from a hoseline
  • Failure to deploy a back-up hoseline
  • Improper/inadequate ventilation
  • Lack of comprehensive training on fire behavior
  • Failure to initiate/deploy a Rapid Intervention Crew

NIOSH identified these factors as contributing, not causal factors. This reflects the complex and interrelated relationship between the factors that resulted in the occurrence of extreme fire behavior during primary search operations and inability of the search crew to escape from the building.

As you read the reports on this incident consider the contributing factors identified by NIOSH. Do you agree that these factors were contributory; if so, in what way; if not, why not?

NIOSH Recommendations

Based on analysis of this incident and the contributing factors, NIOSH made nine recommendations [emphasis added]:

  • Ensure that fire and emergency alarm notification is enhanced to prevent delays in the alarm and response of emergency units
  • Ensure that adequate numbers of staff are available to immediately respond to emergency incidents
  • Ensure that interior search crews are protected by a staffed hose line
  • Ensure that firefighters understand the influence of positive pressure ventilation on fire behavior and can effectively apply ventilation tactics
  • Develop and implement standard operating procedures (S.O.P.’s) regarding the use of backup hose lines to protect the primary attack crew from the hazards of deteriorating fire conditions
  • Develop and implement (S.O.P.’s) to ensure that incident command is properly established, transferred and maintained
  • Ensure that a Rapid Intervention Crew is established to respond to fire fighters in emergency situations
  • Implement joint training on response protocols with mutual aid departments

Additionally standard setting agencies, states, municipalities, and authorities having jurisdiction should:

  • Consider developing more comprehensive training requirements for fire behavior to be required in NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA102 1 Standard for Fire Officer Professional Qualifications and states, municipalities, and authorities having jurisdiction should ensure that fire fighters within their district are trained to these requirements

This final recommendation is extremely significant in that this is the first time that NIOSH has indicated that lack of effective fire behavior training in the US fire service is a systems problem. Fire training is often driven by the need to meet (rather than exceed) minimum standards. This is understandable, given the wide range of competencies required of today’s firefighters and fire officers. However, the need to develop a sound understanding of fire behavior and practical fire dynamics is critical. While this issue needs to be addressed in the professional qualification standards, we should not wait until this is accomplished. Firefighters and fire officers must become (or continue to be) students of fire behavior and develop proficiency in reading the fire and mitigation of the hazards presented by extreme fire behavior phenomena such as flashover, backdraft, smoke explosion, and flash fire.

Ed Hartin, MS, EFO, MIFireE, CFO

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