NIOSH LODD Report: Colorado Firefighter Falls Through Roof

NIOSH Fire Fighter Fatality Investigation and Prevention
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Close-up of translucent corrugated roof panel taken from the roof on the night of the incident. Note how the translucent corrugated roof panel lacks a frame or other indicator of its presence, allowing it to blend with the rest of the roof. (Photo courtesy of the fire department.)

On June 28, 2015, a 46-year-old male career fire fighter/engineer was critically injured after falling through a translucent corrugated roof panel.

Read the Report:
Career Fire Fighter/Engineer Dies After Falling Through Translucent Corrugated Roof Panel While Searching for Fire Extension


The fire fighter was the engineer on Truck 8, the third truck company dispatched to a possible structure fire at a multipurpose commercial structure at 2132 hours. The first arriving companies found an exterior dumpster on fire with flames extending approximately 4 feet up the exterior sheet-metal wall along the edge of an exterior window. District Chief 2 arrived on-scene and assumed incident command (IC) just as the dumpster was being pulled away from the structure. Fire fighters quickly extinguished the fire in the dumpster using a booster hose.

The IC directed crews to force entry into the structure to conduct an interior search for occupants and fire extension. The IC also directed the Truck 8 crew to the roof to check for fire extension. All searches were negative. The IC requested that the Truck 8 crew size up the approximate building dimensions.

While reporting the building dimensions to the incident commander, the Truck 8 engineer stepped onto a translucent corrugated roof panel, which cracked under his weight. The roof was not well illuminated and the translucent panel blended with the rest of the roof. He fell approximately 17 feet onto the concrete floor below. The engineer suffered multiple open bone fractures and vascular damage. He was immediately transported to a trauma hospital (Hospital 1) where multiple surgeries were performed over a 2-week period.

On July 9, 2015, the engineer was discharged from the hospital to continue his recovery at home. On July 15, six days after discharge, the engineer experienced sudden onset of severe shortness of breath. He was transported by ambulance to Hospital 2, but upon arrival in the hospital’s parking lot, he suffered a cardiopulmonary arrest. Efforts to resuscitate the engineer in the hospital’s emergency department were unsuccessful.

An autopsy revealed a massive pulmonary thromboembolism originating from a thrombus in his lower extremity formed as a result of blunt trauma injuries sustained during his fall. The pulmonary thromboembolism occurred despite being on anticoagulation therapy.

Contributing Factors:

  • Unrecognized fall hazard associated with walking on translucent corrugated roof panels.
  • Low light conditions on the roof.
  • Engineer distracted by talking on the radio while walking on the roof.
  • Roof crew did not continuously sound the roof.
  • Previous near-miss incident not effectively reported as a learning tool.
  • Translucent roof panels do not require the same load bearing or fall resistance performances in the International Building Codes as scuttles or skylights.
  • Translucent roof panels, skylights, or scuttles may not be identifiable from roof panels.

 
Key Recommendations:

  • Fire departments should ensure that all fire fighters, company officers, and chief officers are aware of and trained to recognize translucent corrugated roof panels and the fall hazard these panels present.
  • Fire departments should establish policies and procedures to ensure that fire fighters follow safe roof operating practices, including sounding the roof; not walking or standing on translucent corrugated roof panels, scuttles, and skylights; having enough ladders for safe exit in low-light conditions; and always wearing the proper personal protective equipment, including self-contained breathing apparatus.
  • Fire departments should ensure that fire fighters are trained in and recognize the importance of situational awareness at all times, including while working on a roof.
  • Fire departments should conduct pre-incident planning inspections of buildings within their jurisdictions and include this information in computer-aided dispatch systems to facilitate development of safe fireground strategies and tactics.


Additionally:

  • Manufacturers, distributors, and installers of translucent corrugated roof panels should ensure that end users are fully aware of the load-bearing limitations associated with these types of roof panels.

 

 



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