The National Institute for Occupational Safety and Health (NIOSH) is the agency responsible for investigating firefighter line-of-duty deaths (LODDs). From the investigations, NIOSH publishes reports with findings and contributing factors to make recommendations for the prevention of future incidents. Over the years, a pattern has developed; a group of five causal factors is present in nearly all of the incidents.
The NIOSH 5, as they are commonly referred to in trade journals, texts, and classes, are (1) improper risk assessment; (2) lack of incident command; (3) lack of accountability; (4) inadequate communications; and (5) lack of, or failure to, follow standard operating procedures (SOPs). These are command/strategic and tactical level, “upstream” problems that appear on dysfunctional firegrounds that have been identified as contributing factors to deaths or injuries.
These same five factors lead to other, more common, events like near misses, significant injuries, missed victims, and excessive fire losses.
More information about the NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) can be found at:
https://www.cdc.gov/niosh/fire/
An example of the level of investigation detail conducted by NIOSH for a fire fighter fatality is contained in this NIOSH Report Regarding a Worcester, MA Lieutenant Fatality.