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The public depends entirely on fire safety personnel in fire incidents. The United States relies upon approximately one million fire personnel to offer protection to citizens and their property from fire-related losses. In the United States, almost 100 fire personnel die annually while on duty, and there is a common belief that the major causes of these deaths are sudden cardiac attacks and traumas (Department of Health and Human Services, 2008, p. iii). U.S. fire fighting specialists have been collaborating on inventing a new mechanism to lessen shocking therapeutic issues, traumatic injuries, and consequent deaths of fire fighters. This necessitated the establishment of the National Institute for Occupational Safety and Health (NIOSH) to ensure fire personnel safety.

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The NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) is the most significant improvement over what previously existed in the fire fighting sector, and the initiative led to great advances in saving the lives of fire fighters (International Association of Fire Chiefs, 2007, p. 5). NIOSH personnel have safety and fire service expertise, which support an extensive program to curb fires, conduct thorough investigations on the possible cause of fire, and make logical recommendations. The FFFIPP program assigned to NIOSH investigates and reports on the causes of death with a view to reducing deaths and injuries. This body has two integral subdivisions to perform its duties: one explores cardiovascular and medically-related fatalities and the other explores traumatic fatalities. The FFFIPP cardiovascular casualty team has the necessary expertise and qualifications to scrutinize deaths resulting from heart attacks and other therapeutic conditions (International Association of Fire Chiefs, 2007, p. 8). In spite of this initiative by the U.S. government to reduce deaths and injuries among fire fighters, there is an inefficiency in fire service and deaths still occur.

This paper explores a report by the NIOSH on the death of one of the fire fighters in my department, and gives recommendations to improve safety in the department. To achieve this, the paper presents the Illinois incident as the case study, based on the report, released by NIOSH, in relation to the death of two fire fighters and injuries to nineteen other fire fighters in the city. The paper is built around several parts: the first part presents the case; the second part outlines some of the effects of this incident on the fire service department; the third part explores some of factors the report revealed as contributing to the incident; the fourth part discusses significant aspects of fire fighting such as standard operating procedures (SOPs) and the incident command system (ICS), highlighting their significance in fire fighting; the fifth part outlines changes made in the department after the incident, and cited recommendations to improve fire fighting services. It then culminates with a conclusion, bringing together the central points in this thesis.

The Illinois Fire

Whenever there is a fire, property may be lost, injuries may occur, and people may lose their lives. This situation is disturbing, since no one wishes to lose their life in such a shocking manner. Nevertheless, it is a reality we have to face no matter how much we would like to avoid it. A most serious and malignant experience was the recent Illinois fire incident. On December 22nd of last year, a fire broke out in an abandoned business premise in Illinois and caused the death of two fire fighters, and severe injuries to 19 other fire fighters. Due to this, the U.S. Fire Administration Department instructed the NIOSH to investigate the incident and make appropriate recommendations. The victims were a 47-year-old man and his 34-year-old colleague. The structure was old and was abandoned almost a half a decade ago. It is reported that the local authority commissioned the owner to renovate or demolish the building. The structure formerly was used for laundry and believed to have been approximately 84 years old. The fire was under control for a few minutes after the incident, as reported by the Incident manager. The NIOSH investigators visited the site to take photographs and measurements. The NIOSH investigators also visited the fire department’s Breathing Apparatus Service Unit to scrutinize and evaluate the two victims’ self-contained breathing apparatus (SCBA) and personal protective clothing. The NIOSH investigators visited the city’s Office of Emergency Management and Communications (OEMC), which also hosts the fire department’s Fire Alarm Office. The investigators reexamined the fire department’s standard operating procedures, training records, dispatch channel records, witness statements, and DOB records on inspections and citations for the incident structure, including photographs documenting the condition of the structure prior to the incident.

Effects on the Fire Service

Though there was no official legal charges pressed against the company, it was traumatic. After the tragic event, there was some dislocation. The personnel who died were well-trained and resourceful persons, who dedicated their time and energy to the department for the protection of many lives in the city. The death of these persons had an overall effect on fire service operations, despite the fact that they were from the Alarm Office. It took some time for the fire service to recover from this ordeal, since losing two resourceful persons at once and having 19 other fire fighters injured was traumatic. However, with time, the colleagues came to terms with the reality and moved on with the service of protecting citizens from fire-related losses.

Factors that Contributed to Death and Mass Injuries

After interviewing the Superintendent Fire Official and representatives of the fire unit, and the city’s Buildings Inspector, they proceeded to the scene of the fire. NIOSH examiners concluded that a number of factors may have contributed to the deaths of two career fire fighters and the injuries of 19 other fire fighters. These include the absence of abandoned or risky building marking, for example, the placards or posters to inform the fire fighters of the possible dangers of the building. There was no unoccupied or hazardous house information as part of the routine dispatch system. This information is vital in alerting firefighters about hazardous situations. The city authority also did not provide efficient and substantial information about the building. Another factor that prompted the collapse was the dilapidated condition of the structure and a redeployment that occurred during modification, which resulted in fragmented crews. Weather conditions, including snow accretion on the roof and a frozen water hydrant, contributed to the tragedy. Some fire fighters were also not equipped with radios (NIOSH fire fighter fatality investigation, 2011), which are vital for communication between the parties.

Standard Operating Procedures (SOPs)

SOPs direct the actions of fire personnel in virtually all types of incidents. Standard operating procedures must be put in writing (Cook, 2008, p. 3). The SOPs document the performance of the operations to ensure consistent conformity to procedural and system requirements and to support quality maintenance statistics (United States Environmental Protection Agency, 2007, p. 1). They stipulate expectations and responsibilities of team members. The progress, intervallic review, evaluation, and updating of SOPs are imperative to an efficient and secure unit response. All fire unit staff, both career and volunteer, must be conscious of, trained in, and compliant with the department’s SOPs. SOPs are indispensable to all people engaged in fire fighting.

For a comprehensive study, we have to define who a fire fighter is. The term fire fighter covers all members of organized fire departments, including career and volunteer firefighters; full-time public safety officers acting as firefighters; regional and federal bodies fire service personnel, including natural land firefighters and; privately-employed firefighters, including employees of contract fire units and trained individuals of fire brigade manufacturers (IOCAD Emergency Services Group, 2000, p. 3). This incident had some impact on SOPs and this necessitated their review. The analysis of NIOSH pointed out that the department involved in this incident had no SOPs. To reduce the risk of grave injury to fire fighters, written SOPs would be developed, followed, and included in the whole risk management strategy for the fire unit. If there is any alteration in SOPs, then there is a need for further training. Due to the gravity of the case and the effects, recommendations were made for the fire department to ensure enforcement of the SOPs. They included ensuring that the department’s SOPs are developed and followed, and the provision of refresher training, development, and enforcement of SOPs for the safe and prudent operation of emergency vehicles. The last recommendation in this department is the establishment and implementation of an incident command system with written SOPs for all fire fighters.

Incident Command System (ICS)

ICS provides a flexible core mechanism for coordinated and collaborative incident management. It applies to incidents where additional resources are required, or are provided from different organizations within a single jurisdiction, or outside the jurisdiction (National Incident Management System, 2008, p. 46). Although this incident had an Incident Commander in place, other personnel directed some operations and some operations were not in line with the tactics of the Incident Commander. An efficient ground fire operation revolves around one incident command. The Incident Commander reported that the fire was under control, but after a few minutes the roof fell. The Incident Command was in charge of the general management of the incident. Its main concerns are life safety, incident stabilization, and property protection. The incident command group oversaw execution, assessment, determination of risk versus gain, and had the responsibility for fire fighters. In this case, there were some recommendations made to avoid a repeat. The Incident Commander should be designated as the only individual charged with the responsibility for the overall harmonization and directing of all activities at the scene. The second recommendation was that the Incident Commander should communicate tactical decisions to all suppression groups on the ground and frequently reexamine the fire conditions.

Changes Made and Recommendations

Together with other fire service organizations, the management set up a consultative panel to work directly with NIOSH and the FFFIPP. Communication within the fire department is now improved. The department established a method of ground fire communication that permits coordination between the Incident Commander and the fire fighters. In addition to this, the fire fighters are equipped with radios that do not bleed over, cause intrusion, or lose communication under field conditions, and also all the fire fighters now have portable radios to facilitate easier communication. Another achievement for the department is the introduction of fire service subject matter experts, SEMs, to assist the NIOSH in their investigation.

The first recommendation is the marking of hazardous structures. Either the fire service department, or the city authorities, in order to enable the public and the fire fighters to identify the dangerous buildings and take necessary precautions, can carry out this initiative. This is significant due to there being some structures that are risky to people’s health and safety. One could argue that the death of the fire fighters was attributed to the absence of the marks on the building. This recommendation is implemented by fixing posters or placards at the entrance, or other openings, to alert fire fighters of any possible dangers. The second recommendation is the training of the fire fighters to communicate with the Incident Commander about the interior conditions and provide routine updates. This should be one of the initiatives of the fire department to reduce such cases. Frequent communication between fire fighters and the Incident Commander ensures that the IC has adequate information, including the capricious conditions on the ground. On the other hand, the Incident Commander has operationalized a system that captures relevant incident information to allow a continuous situational assessment, efficient decision-making, and progress of incident management arrangements. Adequate information about the reality on the ground is imperative to the Incident Commander since, on the basis of this information, they will be able to make a decision. The third recommendation is for the fire department to give all the fire fighters radios and offer training on their appropriate application. The purpose of this is to enable the fire fighters to communicate even with other colleagues outside the incident site. Radios are intended to put the firefighter in a better position to scrutinize and broadcast a comprehensible message. These radios should be well taken care of and examined by qualified staff on a routine basis (Mitchell, 2002, p.32).

In this incident, we realized there was poor observance of the SOPs. To curb this, the fire department must further develop and implement the use of SOPs to purposefully address activities in abandoned and unoccupied buildings. These buildings sometimes contain dangerous materials, some of which are combustible and endanger the lives of fire fighters. The last recommendation was the wearing of personal protective equipment. This equipment is critical in preventing fire fighter fatalities and injuries. The personal protective equipment recommendations address the proper use of the personal alert safety system (PASS) and the self-contained breathing apparatus (SCBA). In this regard, the person in charge of the fire department should routinely inspect, use, and maintain SCBAs to ensure they function properly when required and, finally, ensure that fire fighters wear their SCBAs equipped with integrated PASS whenever they may be exposed to toxic gases. In addition, there is a need for the training of incident commanders, incident safety officers, and fire fighters in the fire department’s plans and SOPs; development and implementation of the fire department policies and SOPs for emergency response; and fire fighting activities in and around unoccupied structures (NIOSH ALERT, 2009, p. 2).


The damage the analyzed incident caused was traumatic and in fact the mistake partially lies with the city authorities and fire service company. It is evident that though fire may be accidental, human negligence many a time aggravates the situation, hence special care is taken to reduce the incidence of fires. Despite the difficulties and challenges facing the NIOSH, it is a most appropriate mechanism and a significant achievement of this 21st century in reducing the deaths of fire fighters. NIOSH can take praise for several successes and the creation of awareness within different groups of people, particularly by the use of FACE (Fatality Assessment and Control Evaluation), as an investigative method in workplace fatalities.

The basis of current analysis of operational fatalities is entirely on attentiveness to accessible, set, and recommended practices. This advancement normally identifies repetitive underlying factors that can be correlated with failure to pursue the existing standards and recommended practices. It does not build up new information, or offer extra insight into areas where different strategies are thought about or developed. The program has been expanded to assess the existing approaches in comparison to authentic foreign occurrences and outcomes, and to reflect on a broad variety of strategies to avert fire fighter deaths, injuries, and work-related illnesses. The presence of the fire service SME in the NIOSH investigative effort has improved relations between professional NIOSH investigators and local fire department staff, provides background information for NIOSH investigators, and lends extra reliability to the NIOSH team. The FFFIPP effort is in improving information flow from main investigations, bringing together and examining that information, and making that information accessible to the public.

The recommendations discussed above are significant not only to this particular fire service business, but also to every individual who wishes to reduce the number of fire-related deaths or trauma. Take for instance the wearing of protective clothing on the fire site. The marking of abandoned structures plays an integral part in ensuring the safety of the fire fighter. The marked buildings or structure sensitizes the crew to the potential dangers associated with the building. Normally, this is possible by the use of placards or posters at the entrance, or any other opening, to warn the crew. Moreover, to ensure the efficient functioning of the incident command system, there must be regular communication between the Incident Commander and the fire fighters. This is to provide adequate information concerning the fire site, to the Incident Commander for proper coordination. Nevertheless, this can only be possible if proper communicative mechanisms are taken into consideration, such as the use of portable radios that are clear and free from any mechanical defect. This paper also takes into consideration the health of the fire fighters, more specifically, cardiac-related disease. This includes also the significance of the physical fitness of the fire fighters, an initiative that addresses the health of an individual in the workplace (Kuchel, 2007, p. 4).


Agarwal, Arun. (2007). Standard Operating Procedures for Hospitals in India. New Delhi: Atlantic publishers and distributors Ltd.

Cook, John. (2008). Standard Operating Procedures and Guidelines. Park 80 west, United States: Fire engineering books and video.

Department of Health and Human Services. (2008). National Institute for Occupational Safety and Health Washington, DC: NIOSH fire fighter investigation and prevention program.

Department of Health and Human Services (2009). Preventing Deaths and Injuries of Fires Fighters When Fighting Fires in Unoccupied Structures. Washington, DC: NIOSH ALERT.

Greenwood South Carolina Police Department. (2002). Personal Communication. Chicago: Mitchell, Captain.

Fire Fighter Fatality Investigation and Prevention Program. (2011). Two Career Fire Fighters Die and 19 Injured in Roof Collapse During Rubbish Fire at an Abandoned Commercial StructureIllinois. Illinois: NIOSH.

International Association of Fire Chiefs. (2007). Fire Fighter Fatality Investigation and Prevention Program Task Force.

Kuchel K. (2007). Presentation at the 2007 John P. Redmond Symposium in Chicago, IL on October 23, 2007. Economic Impact of the Wellness Fitness Initiative. Chicago.

Office of Environmental Information. (2007). Guidance for Preparing Standard Operating Procedures. Washington, DC:  United States Environmental Protection Agency.

U.S Department of Homeland security. (2008). National Incident Management System. Washington, DC.


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