Fatality Assessment and Control Evaluation (FACE) Report: Volunteer Deputy Fire Chief Dies When Struck By Motorized Water Monitor that 'Launched' Off Aerial Ladder in Pennsylvania

摘要

On April 8, 2008, a 24-year old male volunteer Deputy Fire Chief (the victim, serving as the Incident Commander), was killed when struck by a motorized water monitor and 30 feet of aluminum pipe that was 'launched' from an elevated aerial ladder at an industrial fire in Pennsylvania. The ladder was normally transported in the rescue mode with the monitor pinned to the second section of ladder so that the waterway would not be in the way if the ladder was set up for rescue operations. At the incident scene, when the waterway was pressurized, the monitor and its support bracket, along with the last 30-foot section of pipe was launched off the aerial ladder by the force of the water in the pipe. The monitor flew approximately 75 feet and fell, striking the Incident Commander on the head, killing him instantly. Another fire fighter standing next to the victim was knocked down but not seriously injured. After the incident, the waterway anchor pin was found on the ground, in front of the trucks cab. The waterway did not include secondary mechanical stops to prevent the separation of the water monitor in the event the anchoring pin was not properly seated. Key contributing factors identified in this investigation include the original equipment design (lack of secondary mechanical stops to prevent separation in the event the anchoring pin was not properly installed), inadequate staffing, the involvement of multiple individuals in setting up and operating the apparatus, and inexperience in setting up the ladder.