NIOSH: Fatal Boston fire truck crash shows need for air brake training

Apparatus maintenance and safety deficiencies contributed to the fatal Boston Fire Department ladder truck crash, investigators found

By Ken Robinson
FireRescue1 Associate Editor

BOSTON — NIOSH is calling for fire departments to adopt comprehensive fire apparatus maintenance and safety measures after investigators found deficiencies led to the death of a Boston firefighter.

Lt. Kevin Kelley was killed in January last year and three other firefighters were injured when the ladder truck they were riding slammed into a building after the brakes failed.

Aside from braking system deficiencies, NIOSH investigators also found flaws in the maintenance program, insufficient training and failure to wear seat belts all contributed to the incident, according to a report released Tuesday.

The report is the latest in a series of official reports on the crash, released by various agencies.

NIOSH suggests fire departments work with local, state, and federal authorities having jurisdiction to adopt proficiency requirements for individuals operating fire apparatus equipped with air brakes.

The driver of the ladder truck indicated he had repeatedly pressed the brake pedal in an attempt to slow the apparatus.

"Repeatedly pressing the brake pedal, or 'pumping the brakes,' can drastically deplete air pressure within the air brake system, thus lowering the ability of the brakes to slow or stop a vehicle," the report said.

"Knowing how to interpret an air pressure gauge reading, ensuring that the system is operating correctly, and understanding how the system should work is paramount."

The ladder truck also underwent multiple brake adjustments without finding the underlying problem that led to the failure, according to investigators.

Fire departments should also carefully monitor apparatus services performed by vendors, investigators warned after finding several vendors were used to do routine work on the ladder truck and may have contributed to the brake failure.

"According to the NIOSH expert consultant, the front brake pads were the wrong friction rating for that type of apparatus," the report said. "The department did not document service requests to vendors."

The report suggests fire departments use a check sheet system for inspection procedures and track fleet records to further improve vehicle upkeep, citing NFPA 1911 as a resource for example check sheets and forms.

NIOSH is also stressing the need for departments to have preventive maintenance programs according to manufacturer guidelines and national standards, along with qualified personnel to oversee them.

"Prior to this incident, the fire department did not employ a fleet service manager or qualified personnel to oversee daily operations of their fleet service department," the report said.

Other recommendations in the report include adopting comprehensive driver training programs, seat belt enforcement, and policies for new apparatus specifications and replacement cycles.

The report says fire departments can find useful information on securing grant funding by visiting and, to help maintain vehicles.

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