Safety Alert Number 0805142


Improper Set-up of Aerial Ladders with a Locking Waterway May Put Fire Fighters at Risk
NIOSH recommends that all fire departments utilizing aerial ladder trucks with locking (pin-anchored, lever
actuated, clamped) waterways immediately take the following actions to reduce the risk of fire fighters being
struck by unsecured waterways or parts of the waterway:
1 Ensure that Standard Operating
Procedures (SOPs) and/or Guidelines
(SOGs) on setting up multi-position
waterways include steps to properly
position the waterway and to inspect and
verify that the locking mechanism
(anchoring pin(s), lever, clamps, etc. ) are
properly installed and functioning as
designed before pressurizing the
waterway. 2 Properly train and practice the correct
method of securing waterways and
verifying they are secured (per
manufacturer's recommendations). NIOSH is currently investigating an April 8, 2008
fire fighter line-of-duty-death that illustrates that
adhering to manufacturer recommended set-up
procedures for aerial ladder operations is
paramount to ensuring fire fighter safety. Preliminary findings in this investigation suggest that some
equipment designs do not provide secondary stops for the waterway on aerial adders. Thus, failure to
properly secure the waterway in the proper position can lead to catastrophic waterway failure and
possible serious or fatal injury to fire fighters working in the area. The pin-anchored waterway design
involved in this particular investigation is not limited to a single model or apparatus manufacturer. NIOSH is
aware of at least 7 similar incidents that occurred in Delaware, Michigan, New Jersey, Texas, Virginia and
Ontario without serious injury. Newer aerial ladder trucks may incorporate different types of anchoring
mechanisms and/or a more fail-safe design but proper set up still needs to be verified before operation. Photo 1 - A properly seated pin at the fly section for defensive water
stream operations is highlighted in the red circle. The hole behind it
(yellow arrow) shows the location where the pin would be inserted (from
the top) to keep the monitor assembly back at the second ladder section
for rescue mode. NOTE: Various methods are used throughout the fire
apparatus industry to secure the waterway: this picture represents a pinanchored
waterway design. Circumstances of incident under investigation by NIOSH
On April 8, 2008, a volunteer Deputy Fire Chief (the Incident Commander), was killed when struck by a
motorized water monitor and 30 feet of aluminum pipe that was "launched" off an elevated aerial ladder at a
fire at an industrial manufacturing plant in Pennsylvania. The truck 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 were "launched" off the aerial
ladder by the force of the water pressure in the pipe. The monitor flew approximately 75 feet and fell,
striking the Incident Commander on the head, killing him instantly. After the incident, the anchor pin was
found on the ground, in front of the truck's cab. The waterway did not include any secondary mechanical
stops to prevent the separation of the water monitor in the event the anchoring pin was not properly seated. The NIOSH Fire Fighter Fatality Investigation and Prevention Program is currently investigating this incident
and a full report will be available at a later date.

NIOSH would like to bring this information to the attention of all U.S. fire departments and fire fighters who
operate or work around aerial ladder trucks with locking (pin-anchored, lever actuated, clamped) waterways
so that future occurrences of waterway monitor "launches" or the unexpected movement of the waterway
monitor can be prevented. If secondary mechanical stops are present, the unexpected impact of the waterway
monitor against the mechanical stop could cause structural damage to the aerial ladder and jeopardize the
safety of any fire fighter standing on the aerial ladder. While not a contributing factor in the fatal incident,
NIOSH reminds fire departments to comply with relevant federal regulations and NFPA standards for fire
apparatus inspections and certification. Photo 2 – Aerial ladder with monitor at tip Photo 3 – anchoring pin
Photo 4 – Monitor and pipe that "launched" Photo 5 - The receiver assembly where the pin is inserted
The NIOSH Fire Fighter Fatality Investigation and Prevention Program is conducted by the National
Institute for Occupational Safety and Health (NIOSH). The purpose of the program is to investigate fire
fighter line-of-duty-deaths and 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. For more information, visit the
program website at www.cdc.gov/niosh/fire or call 1-800-CDC-INFO.