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38-Year-Old Volunteer Recruit Firefighter Dies During SCBA Confidence Training at Fire Academy—California
Death in the Line of Duty…A summary of a NIOSH fire fighter fatality investigation
F2023-02 Date Released: January, 2024
Executive Summary
On February 19, 2023, a 38-year-old recruit volunteer firefighter (Recruit) suffered a fatal medical event while participating in the county’s joint firefighter academy (JFA). The Recruit was in week seven of the 19-week academy participating in the firefighter safety and survival training.
The firefighter safety and survival training was a 24-hour course based on state fire marshal curriculum and included one day of classroom instruction and two days of hands-on skills training. One of the skills taught included having recruits become familiar with their self-contained breathing apparatus (SCBA) in a confidence maze. The maze was designed to simulate obstacles a firefighter might encounter during a fire or building collapse.
The training was being taught at a three-story training tower made of six shipping containers. The training tower had three containers on the first story, two containers on the second story, one container on the third story, and an observation deck on top.
The maze was located on the third story of the training tower which included a walk-in door, two windows, a roof vent, and the maze. The maze was built by academy staff and was three levels within the third-story container, made of plywood and dimensional lumber. Obstacles in the maze include diminishing clearances, small openings, wire, and mattress spring entanglements, collapsed walls/floors, and confined spaces.
The incident occurred on the morning of the second day of skills training, which began at 0700 with physical training (PT), stretching, a safety briefing, instructor roles, and a video. At 0900 hours the recruits were divided into four groups that rotated through five types of self-rescue exercises.
The Recruit had completed the first four exercises, and he was working his way through the maze when he became unresponsive. The maze was designed to allow an instructor to stay in verbal communication and observe the recruits as they navigated through the obstacles. The Recruit was approximately six feet from completing the maze when he had difficulty finding the exit, which was an opening between the middle and bottom levels of the maze. The Recruit told the instructors he was “freaking” because he was having difficulty finding the way out. The instructors reassured him he was ok and told him to relax and breathe as they helped him find the opening to the bottom level and exit. With the assistance of the instructors, the Recruit was in a sitting position with his legs in the opening to the first level, he lowered his SCBA in front of him and proceeded through the opening towards the maze exit. However, as he transitioned through the opening, he became unresponsive and slumped to the ground on the first level.
The maze instructor immediately told the assistant working with him to open the maze emergency doors and remove the Recruit from the opening. The maze instructor then alerted the lead instructor who was outside of the incident location. The maze instructor and lead instructor both arrived to find the assistant instructor performing cardiopulmonary resuscitation (CPR) after pulling the Recruit from the maze, CPR was initiated at approximately 1058 hours and the Emergency Communication Center (ECC) was advised of a firefighter down and a request was made for both ground and air advanced life support (ALS) transport due to the remote training location. Approximately 20 minutes later, ALS arrived and assisted with resuscitation efforts at the scene. At approximately 1149 hours, medics and nurses stopped resuscitation efforts and requested the coroner to the incident.
Key Recommendations
NIOSH investigators offer the following recommendations to reduce the risk of sudden death among firefighters training at this, and other fire departments across the country.
- Key Recommendation #1: Implement a systematic risk assessment for training programs in accordance with NFPA standards.
- Key Recommendation #2: Implement procedures for safe exit in accordance with NFPA 1500 Standards as the 3rd story maze’s sole access by exterior ladder did not allow for rapid evacuation in a medical emergency situation.
- Key Recommendation #3: Consider implementing physiological monitoring system to protect firefighter health.
- Key Recommendation #4: Fire training facilities shall appoint a safety officer to review the planned exercises and actively observe all training activities in accordance with NFPA Standards.