Safety & Health

Company Near-Miss Review: The Last Burn

Issue 6 and Volume 15.

Does your department use the last burn of the day to consume the property? (Pixaby)

In many of our training evolutions, we provide a foundation for an event, and direct the training groups through that initial phase. When there are different groups, it begins to seem like the same thing happening over and over. Personnel that present the instruction for each evolution can see a common pattern and may begin to predict how the trainees will perform. When the training progresses as expected, we know the lessons are understood and applied.

We all have different levels in our understanding of how we perceive information. When the material becomes repetitious for the people conducting the training, we begin to predict the next step in the event. That is the way we have learned to observe conditions and react. We must be careful not to project conditions based on expectations, and continue to observe, evaluate, and decide the next step.

The Event

Crew Separated During Training Fire
Published: 10/22/2014

I attended a training burn with my department members. We had been assigned RIT the entire day. Everything was going great; we hadn’t had any problems until the last burn. Some of the instructor staff had asked us if we wanted to get in on the last one since we had spent all day being RIT. We eagerly replied with a yes.

This structure was a split-level foundation house with a wood frame. The garage was our burn room, so it was three feet lower than the actual house. We were standing on the Charlie side of the house, doing our gear checks and making sure everyone was good to go. I was on a four-person crew; my nozzle firefighter was in the first position, then myself as the officer in charge and two other members behind me. We bled the hose line of all air, and we made entry.

To our right, a burn crib had started to re-kindle, so we put it out. We then turned to our left and opened the door to the burn room (garage). I am no veteran to the fire service, but I wouldn’t have sent my crew into the burn room if I didn’t feel like it was a fightable fire. We descended three steps and sat down about five feet away from the door. I looked behind me to make sure my third and fourth members were there, and they weren’t. They were gone.

At first, I thought that the instructors were doing this just to mess with me. I called my firefighter’s name out three times. My nozzle firefighter was getting anxious and kept saying, “What do I do, what do I do.” I told him to stay calm. I was just trying to find our crew. I then told him to open the bail to the hose line. He did and then closed it within seconds. I looked behind me again, this time getting really worried. I still couldn’t find my third and fourth crewmembers. My nozzle firefighter began to yell, “What do I do, what do I do.” That’s when the smoke that was above our heads banked straight to the ground.

It was the blackest smoke I have ever seen in my life. With the smoke, it brought the heat. I knew it was time to leave. The first thing that started to burn was my ears, then my head, neck, throat, chest, arms, and knees. I yelled to my nozzle firefighter, “We need to leave now.” He didn’t move, so I yelled again, “We need to leave now.” Still, he wouldn’t move. I grabbed his SCBA strap with one hand and pulled.

The first thing I said, when my mask was cut off my face was, “Where’s my crew?” I was so worried because my third and fourth man had never made contact with me since we entered the structure.

Points to Consider

Having read the event description, take a moment to discuss with your crew some of the possibilities from this event.

What are some of the reasons the crew may have been separated? What instructions do you have for your crew when you separate?

The officer in charge of this crew states that he is no veteran, but did not consider the fire room to be unmanageable. What are some of the possible contributing factors that prevented them from controlling the environment?

What would your training objectives have been in this scenario? Would you expect the training to have a different objective on the last burn of the day in an acquired structure?

Is there any kind of checklist you could have utilized before entering this evolution?

Does your department use the last burn of the day to consume the property? The author from this report had an important message to share about this event, but also to encourage additional care during any live burn training.

Lessons to Share

What happened was my third man had forgotten to connect his regulator into his face piece before entry. When we went in, he got a mask full of smoke and hot gases. He left, and the fourth man followed him. Neither of them told me. My nozzle firefighter was overcome with fear, which was why he didn’t move when I told him we needed to leave. I sustained first and second degree burns to my face, ears, and arms. I had smoke inhalation and carbon monoxide poisoning. My nozzle firefighter had a nickel-sized burn on his shoulder, from where my hand was when he was being pulled out. This entire incident lasted about 90 seconds.

The instructors left us in the burn room alone. The fire crib was built with too much fire load (couches), and the stoker crew was inexperienced. Communication was not done properly, and crew integrity and accountability was lost. As the officer of that crew, I take full responsibility for those two mistakes.

What happened that day is a firm reminder that written standards are for a reason. We followed NFPA 1403 almost entirely that day, except for that last burn.

How many people have stoked that last fire, and thrown everything and anything into it so that it would burn well? How many people have gone into that last fire of the day, knocked it down, and then pulled out and let the entire house go? That is what was supposed to happen.

No one should have to know what it feels like to burn alive, and no one should have to know what it feels like to search for your best friend (3rd man), or what it feels like to have the thoughts that you’re dying and seeing your family for the last time.

I don’t want sympathy or to be called a hero; I just don’t ever want anyone to have to live through something like that. I want people to be aware of what really can happen, even if you let your guard down for a training burn.

I had started sweeping my way out with the other hand. I was in a low-crouch position, and my nozzle firefighter was lying down. I couldn’t get the needed leverage to pull him if I would have been lying down, so that is why I was crouched. I just kept pulling him, trying to find our way out. The air in my SCBA was so hot that it hurt to breathe. It hurt my lungs, mouth, and nose so much that I didn’t want to take another breath.

Finally, my hand hit the bottom of the steps. As soon as it did, everything flashed over. All I saw was orange and red, and I was in the worst pain I have ever been in in my entire life. Four people then appeared in my head – my mother, father, and two little sisters. I thought to myself that this was the last time I was ever going to see them and how I was going to die in a training burn, literally burning alive. The fight to get out and to stop burning was what pushed me to get out of that house alive.

I pulled my nozzle firefighter up the steps and then fell on the floor. The room I had just entered was now already on fire. The door we had just come out of was fully involved. The nozzle firefighter and I crawled to a window and bailed out on the alpha side of the house. I remember crawling away, trying to stop the burning and pain.

Expanded Discussion

The author from this report mentions several things that changed the dynamic for the last burn. We don’t know if these changes in fire cribbing were announced, or if as the author pointed out an inexperienced stoker crew used unapproved combustibles in the fire set. Having these changes alone could have been the difference for this crew.

The standard for live burn training is specific about the materials used in the fire cribbing. The author mentioned there was a couch on the crib, and anything that would burn well. He also mentioned they were left alone in the fire room. NFPA 1403 requires a safety line, staffed by an extinguishing crew, and provided from a separate water supply during every live burn.

Remembering that this crew had been on the scene as RIT observing each crew perform the same evolution that day could also allow them to predict the stages of the event. Predicting conditions other than those present could have resulted in a loss of situational awareness (SA). Having the distractions of missing crewmembers can also cause that loss in SA.

For the nozzle firefighter, crews before may have been able to use short bursts of water to bring the heat levels down to pre-flashover conditions, this may have been a confusing factor. When the fire load included a couch, the fire load was very different from the earlier sets. Polyurethane foam found in furniture is made from hydrocarbons that can produce flammable vapors. These vapors can move with the superheated smoke, and ignite when the fuel mixes with adequate oxygen. Often we see this as a flashover that seems to begin at the entry doorway behind us. If the fire load were significantly larger than previously experienced, it would have required more than a short burst of water to control the fire.

Any of these conditions could cause distractions for this crew. One or two of these changes begin to add dimensions that were not expected for the officer. When the contributing factors began driving the evolution, leaving the exercise may have been the best choice.

Oftentimes the last burn of the day is used to burn the structure and reduce solid waste clearance for the property owner. The last fire can also be the most dangerous. If you have had a training burn that took a sharp turn, I would like to hear about it. The National Near-Miss reporting system, found at is where your stories are stored and shared. Keeping this information available is our mission, keeping it relevant relies on you. Please take a moment and share your live fire training stories today.

Thank you for reading.

Additional Resources:
Live Fire Training – Conducting NFPA 1403-Compliant Live Burn Training in Acquired Structures. Found at


Greg Lindsay, MPA, CFO, has been a member of the Oklahoma City (OK) Fire Department since 1984. He has worked through each level of the operational fire service and has been a battalion chief for the past 15 years. Lindsay has a master’s degree in public administration from the University of Oklahoma and Chief Fire Officer designation from the Center for Public Safety Excellence. He has been with the Firefighter Near Miss reporting team since March 2005. You can reach him at [email protected]