NIST Modeling Study Reveals the Lethal Dynamics of a San Francisco House Fire

Report Date: November 2014

In 2011, a lieutenant and a firefighter with the San Francisco Fire Department lost their lives in a multi-level hillside residential structure fire while searching for the fire. The fire was on the floor below the firefighters. The National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program determined that when horizontal ventilation occurred on the fire floor, both from windows failing and from crews forcing entry from the exterior, the fire intensified and heat traveled up the interior stairway, exposing the two firefighter victims to a high thermal condition. The NIOSH report is available here.

At the request of the San Francisco Fire Department and NIOSH, the National Institute for Standards and Technology (NIST) Fire Research Division performed a physics-based investigation of the incident to better understand the fire dynamics. As part of the investigation, NIST performed computer simulations of the event using their Fire Dynamics Simulator (FDS) and created a visualization of the event using their Smokeview software. The NIST study determined that a ventilation limited fire in the basement was intensified when basement windows failed. The interior stairway acted as a chimney for the hot gases to flow from the basement to the vent openings on the first floor. The two firefighters were caught in the flow path and exposed to extreme temperatures, succumbing to their thermal injuries.

As a tool to explain and share their findings, NIST has created a summary of the events and a narrated video detailing the fire behavior and interior conditions during the incident. The summary and video can be found here. These investigations should be used to learn from tragedy in an effort to avoid similar losses in the future.

The full NIST report is available to download below.


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  • National Institute of Standards and Technology

    The NIST Fire Research Division develops, verifies, and utilizes measurements and predictive methods to quantify the behavior of fire and means to reduce the impact of fire on people, property, and the environment. This work involves integration of laboratory measurements, verified methods of prediction, and large-scale fire experiments to demonstrate the use and value of the research products.

    Through its programs in measurement, prediction, systems integration, and the dynamics of fire and its interactions with the built and natural environment, the division provides leadership for advancing the theory and practice of fire safety engineering, fire fighting, fire investigation, fire testing, fire data management, and intentional burning.

Overholt, Kristopher J., Craig G. Weinschenk, and Daniel Madrzykowski. Simulation of a Fire in a Hillside Residential Structure - San Francisco, CA. Gaithersburg, MD: National Institute for Standards and Technology, Technical Note 1856, 2014. Retrieved from:

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