Fatality Assessment and Control Evaluation (FACE) Report: A Career Fire Fighter Dies and a Career Engineer is Seriously Injured Investigating Smoke Resulting from a Manhole Fire in California

摘要

On March 26, 2008, a 35-year-old male career fire fighter (victim) died and a 48-year-old male career engineer was seriously injured while investigating smoke in an unmarked utility closet resulting from a manhole fire. Central dispatch received a call at 1357 hours from an employee of an office supply store who reported an explosion and the smell of smoke in the store. At 1358 hours, central dispatch received a second 911 call reporting an underground explosion that shook the entire block, with smoke coming from a manhole. An engine company was dispatched to the scene to investigate the smell of smoke. At 1422 hours, a third call was placed to central dispatch with the report of smoke coming from a locked storage area in a commercial building on the corner of the same block where the manhole incident was being investigated. A full alarm was dispatched for a structure fire and assigned a different incident number and tactical channel. The victim's apparatus arrived on scene to what they believed was a structure fire and attempted to force open the unmarked utility closet door to investigate the cause of smoke. The victim began to cut the door bolt with a rotary saw when the utility closet exploded and the victim was struck by the door. Key contributing factors identified in this investigation include insufficient situational awareness, a lack of hazard identification, and dispatch not recognizing the relationship and severity of the incidents. NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should ensure that members are trained to maintain situational awareness and use extreme caution when operating at sewer and underground vault incidents. Additionally authorities having jurisdiction should: (1) ensure that entrances to electrical rooms, vaults, and similar enclosures are clearly identified and provide proper warning to unauthorized people; (2) ensure that central dispatch has the technical capability to communicate information among multiple incident responses and that dispatchers are trained to recognize when separately reported incidents are related.