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NIOSH: Uncoordinated ventilation caused flashover killing Ill. firefighter

Investigators say crews failed to recognize signs of an imminent flashover; firefighters were between the fire and ventilation points

By Ken Robinson
FireRescue1 Associate Editor

HOMEWOOD, Ill. — Uncoordinated ventilation caused a flashover that killed one firefighter and injured another when both failed to recognize signs of rapidly deteriorating conditions, investigators found.

Insufficient staffing was also cited as a key contributing factor in the incident, as crews on scene were stretched thin according to a NIOSH report released Tuesday.

Rookie Homewood Fire Department Firefighter-Paramedic Brian Carey was killed of smoke inhalation on March 30 while assisting in search and rescue of a reported victim trapped in a house fire, the report said.

Responding to reports of a downed brother, firefighters conducting a search discovered Firefighter-Paramedic Carey entangled in a hoseline and not wearing his helmet or facepiece, and without a hood.

Firefighter-Paramedic Karra Kopas, who had entered the structure along with him, was injured in the fire and had to be rescued four feet from the front door where she said her gear melted to the living room carpet.

At the time of the flashover, firefighters performing ventilation were not coordinating with hoseline and search and rescue crews inside the house, according to the investigation.

Both Firefighters Carey and Kopas were between the fire and the ventilation source.

"One firefighter accounts heavy, turbulent, black smoke pushing from a window on the B-side after it was broken," the report said.

"Shortly after, the house sustained an apparent ventilation-induced flashover."

NISOH says the thick, black and heavily pressurized smoke that exited through ventilation should have been acted upon as a warning sign.

"The IC, and individuals working on the exterior, need to recognize this as a potential for extreme fire behavior and evacuate interior crews," the report said.

In addition, investigators recommend training firefighters under realistic conditions to indentify the signs of an imminent flashover.

"Obtaining proper training and hands-on experience through the use of a flashover simulator may assist interior firefighters in making sound decisions on when to evacuate a structure fire," the report said.

The inability to appropriately coordinate fireground operations may have been directly tied to inadequate staffing.

"Due to short staffing, the ambulance personnel were tasked with fire suppression activities, thus taking them out-of-service as a medical unit," the report said.

The incident commander, a Lieutenant, was also required to ride and operate as the officer of an Engine Crew due to short staffing.

"This removed him from his command response vehicle which would have allowed him to command at a tactical level versus having to potentially perform tasks," the report said.

Investigators also found an accountability system was never put in place and a personnel accountability report was never conducted following the incident.

As a result of the incident, NIOSH made the following key recommendations for fire departments to follow:

  • Ensure that a complete 360-degree situational size-up is conducted on dwelling fires and others where it is physically possible and ensure that a risk-versus-gain analysis and a survivability profile for trapped occupants is conducted prior to committing to interior firefighting operations
  • Ensure that interior fire suppression crews attack the fire effectively to include appropriate fire flow for the given fire load and structure, use of fire streams, appropriate hose and nozzle selection, and adequate personnel to operate the hose line
  • Ensure that firefighters maintain crew integrity when operating on the fireground, especially when performing interior fire suppression activities
  • Ensure that firefighters and officers have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior
  • Ensure that incident commanders and firefighters understand the influence of ventilation on fire behavior and effectively coordinate ventilation with suppression techniques to release smoke and heat
  • Ensure that firefighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures.



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