Analysis by FSRI of a Near Miss in a Garden Apartment Fire

Research Report Available: Analysis of a Near Miss in a Garden Apartment Fire 2022

November 1, 2022

Funded by the U.S. Department of Homeland Security (DHS) Federal Emergency Management Agency’s (FEMA) Assistance to Firefighters Grant Program, the Analysis of a Near Miss in a Garden Apartment Fire - Georgia 2022 research report has been released as part of the Fire Safety Research Institute (FSRI)’s Study of Firefighter Line of Duty Injuries and Near Misses.

This report details an incident in which four firefighters suffered burn injuries while fighting a garden apartment fire. It provides a detailed account of the incident, what occurred, why it occurred, and what can be done differently in the future to result in  more favorable outcomes. FSRI’s analysis applies research results and utilizes fire research tools, such as computer fire models and test data, to examine key fire phenomena and tactical outcomes.

Similar to other near miss scenarios, the root cause of the incident cannot be attributed to a single factor. Through FSRI’s investigative study of this fire, conducted with the department involved, six contributing factors were identified:

  1. Size-Up, Communication and Accountability
  2. Delayed Exterior Attack
  3. Lack of Protection of the Entry Hall 
  4. Apartment Arrangement and Construction
  5. Thermal Imager Use
  6. Mayday Procedures and Training 

The last contributing factor of calling the mayday was a positive contribution that helped avoid more serious injuries. 

Based on the contributing factors, five recommendations were made that include:

  1. Improved Size-Up
  2. Exterior Fire Control to Prevent Exterior Spread
  3. Protection of Exit Pathways
  4. Basing Fire Ground Tactics on Known Information
  5. Recognizing When a Change in Tactics is Needed


 “After our incident where a mayday was called and four of our firefighters were burned, Cobb Fire knew we needed the help of an independent agency to assist us in determining the factors contributing to this incident.  We reached out to FSRI for their expertise and resources to help us truly understand what happened inside that structure in the early morning hours. The FSRI team worked diligently with our After Actions Review Team (AART) and our members that were involved with the fire. In the end, FSRI was able to use the data they gathered during their research and first hand accounts from our crews, to put together a detailed report that will benefit Cobb Fire and the entire fire service.” 

— Kevin Gross, deputy fire chief of preparedness, Cobb Fire & Emergency Services

“We are grateful to Fire Chief Gross and Cobb County Fire & Emergency Services for giving us the opportunity to conduct this study, and their willingness to share information from this incident with the fire service. We hope that these recommendations will continue to improve the safety and effectiveness of firefighters.” 

— Daniel Madrzykowski, director of research, FSRI.  

Download the report here.

Sign up for the FSRI Newsletter here for future updates on the upcoming online training course based on the report.  



On February 9, 2022, Cobb County Fire and Emergency Services responded to a fire in a ground floor unit of a garden apartment building. Upon arrival, the fire was in a post-flashover state in a bedroom. Initial fire control was attempted by an interior fire attack team which was unable to quickly locate the fire. Exterior suppression through the bedroom window was started prior to discovery of the fire by the interior team. Shortly after fire discovery by the internal team, a mayday was called. Four firefighters from the interior fire attack team received first and second degree burns. This report analyzes photographic, video, and written documentation from the incident to evaluate the timeline of the incident and to assess the fire conditions present. Computer modeling using the Fire Dynamics Simulator (FDS) was performed to provide further insight into the fire conditions and the impact of decisions and actions on the fireground. Additionally, data from a full-scale fire test of a similar fire in a similar structure was used to provide additional insight.

Four FDS simulations were performed in support of the analysis. These included a simulation of the event as it unfolded and three simulations looking at the impact of alternative tactics which included: initial exterior attack prior to entry, the use of a smoke curtain to protect the building exit path, and interior attack only. FDS simulations provided insight on the heat present in the apartment during the fire and the impact of the interior and exterior suppression on conditions inside the apartment. Full scale test data of a similar fire showed similar behavior to the FDS predictions and gives credence to the FDS results. 

Results of the analysis suggest that injuries sustained resulted from the length of time the interior attack team was present inside the apartment before actions were taken to reduce the severity of the fire. Six contributing factors were identified including size-up, communication and accountability, delayed exterior attack, lack of entry hall protection, the apartment layout and construction, thermal imager use, and mayday procedures and training. This last contributing factor was a positive contribution that helped avoid more serious injuries. 

Based on these contributing factors, five recommendations were made that include improved size up, exterior fire control to prevent exterior spread, protection of exit pathways, basing fire ground tactics on known information, and recognizing when a change in tactics is needed.


Research Project: Study of Firefighter Line of Duty Injuries and Near Misses

Report Title: Analysis of A Near Miss in a Garden Apartment Fire - Georgia 2022

Report Authors: Jason Floyd, Daniel Madrzykowski

Download the Report:

Release Date: October 3, 2022


Study of Firefighter Line of Duty Injuries and Near Misses