Fire Fighter Fatality Investigation and Prevention Program

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fire fighter in front of truckEach year an average of 105 fire fighters die in the line of duty. The National Institute for Occupational Safety and Health (NIOSH) is committed to preventing future fire fighter fatalities through research and prevention. In 1998 the NIOSH Fire Fighter Fatality Investigation and Prevention Program (“Fire Fighter Program”) was created to conduct independent investigations of fire fighter line of duty deaths and to formulate recommendations for preventing future deaths and injuries. As NIOSH enters the 10th year of the Fire Fighter Program we are working to better reach small and rural fire departments with the results of our fatality investigation reports and prevention recommendations. We request your assistance in helping us achieve this goal. Please see the questions at the end of this blog and provide your input in the comment section below.

The Fire Fighter Program

The NIOSH Fire Fighter Fatality Investigation and Prevention Program conducts independent investigations of fire fighter line-of-duty-deaths to formulate recommendations for preventing future deaths and injuries. The program does not seek to determine fault or place blame on fire departments or individual fire fighters, but to learn from these tragic events and prevent future similar events. Investigations are prioritized using a decision flow chart. Investigation priorities will change depending on fatality data. NIOSH also conducts investigations of selected non-fatal injury events.

A NIOSH representative will contact the fire department to initiate an investigation. NIOSH investigators will review all applicable documents (e.g., department standard operating procedures, dispatch records, training records for the victim, Incident Commander and officers training records, the victim’s medical records (where applicable), coroner/medical examiner’s reports, death certificates, blueprints of the structure, police reports, photographs, video and other pertinent records and information. Additionally, investigators will interview fire department personnel and fire fighters who were on the scene at the time of the incident. NIOSH may work closely with other investigating agencies. When needed, NIOSH will enlist the assistance of external experts, such as experts in motor vehicle incident reconstruction or fire growth modeling.

Each investigation results in a report summarizing the incident, outlining the sequence of events that led to the fatality or injury, and includes recommendations for preventing future similar events. NIOSH disseminates these reports to the fire service in a number of ways including posting to the program website, mailings, and other methods detailed in the Communication section below.

NIOSH has worked closely with fire fighters, fire departments and external stakeholders in the fire service to prevent the national tragedy of fire fighter line-of-duty deaths. Since the inception of the Fire Fighter Program through November 2008, NIOSH has finalized 371 investigations of fire fighter fatalities in 48 states.


NIOSH has repeatedly sought input in various forms to ensure that the Fire Fighter Program is meeting the needs of its stakeholders and to identify ways in which the program can be improved to increase its impact on the safety and health of fire fighters across the United States. A series of stakeholder meetings including one during the program’s inception in 1998, another in 2006 and the 2008 stakeholder meeting this week in Rosemont, Illinois, have provided useful input. For more information on the 2008 stakeholder meeting, visit the 2008 stakeholder meeting section of the NIOSH fire fighter web pages, or visit the Federal Register notice to submit formal comments through the docket.


Based on comments from the stakeholder meetings and other independent evaluations, NIOSH has increased our Fire Fighter Program communication efforts. The fire fighter pages on the NIOSH website continue to be some of the most visited pages on the site with over 277,000 visits during 2007 alone. These web pages contain program information, links to all reports and publications, and the option of subscribing for notification when new products become available. Partnerships with fire service trade journals have increased the reach of the fatality investigation reports with the journals publishing summaries of fire fighter fatality reports. NIOSH also mails packets of reports to the more than 35,000 fire departments in the U.S. and presents the report findings at meetings and conferences across the country. In addition, NIOSH is utilizing new “social media” outlets to reach a larger audience with our prevention messages. We have created a MySpace page to get new and updated information to fire fighters, authored two blog posts on the NIOSH Science Blog to create a dialog about fire fighter issues (see also Preventing Fire Fighter Fatalities from Cardiovascular Events), and utilized NIOSH e-News to increase awareness about a specific safety advisory.

Reaching Small and Rural Fire Departments

We will continue to use these and other communication tools as we increase our efforts to reach small and rural fire departments. A recent evaluation by RTI International found that the majority of fire departments routinely reviewing and acting upon the Fire Fighter Program investigations are located in larger cities. We would like to hear your ideas about how to better reach and engage smaller fire departments. Are there ways in which we can provide the information to make it more useful? Do fire service personnel in small and rural fire departments have unique needs? How can we work to better meet them?

Thank you in advance for you assistance.

—Timothy R. Merinar, MS, Paul H. Moore, BSME, Tanya Headley, MS

Mr. Merinar is a safety engineer in the NIOSH Division of Safety Research and the project officer of the Fire Fighter Fatality Investigation and Prevention Program. Mr. Moore is chief of the Fatality Investigations Team in the NIOSH Division of Safety Research. Ms. Headley is a health communication specialist in the NIOSH Office of Health Communication and Global Collaborations.

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9 comments on “Fire Fighter Fatality Investigation and Prevention Program”

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    I would suggest mailing the report packets to the local elected officials in the municipalities where the smaller departments are located. The municipality is usually the workers compensation holder for the fire departments. Smaller rural fire departments may have a no liaison between the local elected officials and the fire department. That might be a be a good way to open the discussion regarding this issue. Also, sometimes the mail may be picked up by an administrator for the fire department and the report may not reach the Chief directly.

    The reports that I have read are very good but they all seem to relate the same cause effect relationships. An attention to providing at least three proactive steps that can be applied, “not a lessons learned” format but a guide to “better battleground safety” that can be checklisted for the fire department. It then makes it personal. eg. Chief to his officers or vice versa. “Did you read that report?” “Did you see the checklist?” “Can our department check those items on the list?

    A commendable program (not lose the lessons), if investigatons are not occurring at the moment, ‘as a matter of course’. I would have thought that it would be the norm to investigate incidents and certainly fatalities.

    For someone to lose their life and in the line-of-duty, in a country with so much and then give people the option NOT to investigate, on the basis of personnel and resource issues, is incomprehensible to me.

    From another angle, it is like asking the Q, “How committed are you to your people?” It’s even worse when you know this particular group of individuals, paid or volunteers, put their lives at risk to do the job!

    It is good to see the Federal Government adapt their communication methods to the changing cyber-environment. Well Done!

    The process used to develop the traditional “Lessons Learned” documents need to also evolve to a product that provides more in-depth review by an interagency team. The analysis should be able to produce a comprehensive report that determines the cause of human, organizational, or system issues. As a fire service, we accept that emergency response is performed in a stressful environment with time-critical decisions, and these decisions often have to be made without the benefit of a careful risk-benefit analysis. Given these situations, it is expected that as individuals, personnel will occasionally make mistakes. We cannot grow as an industry without looking deeper into the psychological aspects of decision making and the impact on fire ground operations. I get frustrated at the same causal factors (communications, ICS, staffing…etc) occurring on every report. Culture and psychology plays into developing the existing system in most of these incidents; and it would benefit us to explore what new analysis tools are out there in the Safety profession that we could adapt in our situation.

    The Fire Service seems unable to adjust their operations, tactics and hold our members accountable to increasing safety for our collective membership. Just as the “Close Calls” program the formal, scientific investigation without a goal of placing blame or sheilding responsibility is necessary and prudent. Now the Fire Service must take your investigative reports and turn them into action, improve officers abilities, improve the tactics and acceptable practices and obviously improve our personal health to try to reduce that annual average of 105 firefighters!

    As we investigate,research,read,review or otherwise attempt to evalulate what we should be doing on the fire ground,training fields, roadways and the gym. We as a culture still have not gotten past the simple idea that is not a good idea to die on duty. If we are going to win this battle we need to help each and be our brother’s keeper and stop the senseless deaths. No drivng like a NASCAR driver with no seatbelt. Learn the science of fire behavior, learn building construction and what one does to the other. Communicate on the fire ground for a safe outcome. Save each other before we are in a Mayday situation.

    I am a safety student in Kerala, India. I want to bring my suggestion before fire admimistration. That is, we want to ensure that every employees in a building must be aware on how to cope with emergency time. Development of robots will help to save lifes of our fire personnel

    NIOSH should consider recommendation #13 from the RTI report and create videos from several LODD reports with common themes: lightweight truss, flashover, tanker rollover, etc. The Chemical Safety Board did a great job with the Little General Store propane explosion video.

    I use the NIOSH reports in my Firefighter I & II classes, by requiring students to give a presentation with an overview of the incident, recommendations, and page references from the IFSTA Essentials of Firefighting manual.

    Reaching small fire departments with NIOSH’s important messages requires a multi-modal approach. Use of social networking is important (as I received notice of this effort via Twitter), but many fire service agencies are not tuned into this type of communication. Small volunteer and combination fire departments might best be reached through state training agencies (but this will vary by jurisdiction), as well as by direct contact (US mail is likely the lowest common denominator). However, continue to push the envelope with alternative communications strategies!



    How much property and how many lives could be saved with a little more attention to detail and prevention.

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Page last reviewed: February 15, 2017
Page last updated: February 15, 2017