12/18/2025
We learned a lot at this fire. Chief Tvedten was a firefighters Chief
Fire in Paper Warehouse Claims Life of Battalion Chief - Kansas City, Missouri - December 18, 1999 - NIOSH Firefighter Fatality Report F99-48
On December 18, 1999, Kansas City Battalion Chief John Tvedten was fatally injured when he became disoriented during a paper warehouse fire. Firefighters were dispatched to the fire and upon arrival they immediately ordered all employees to evacuate the approximately 300,000-square-foot warehouse. The fire was located in the paper-bale section and was causing the structure to fill with a haze of white smoke. The incident commander assumed overall Command and ordered an interior fire attack. He also ordered Battalion Chief Tvedten to take command of interior operations. Firefighters battled the fire for 52 minutes before Command and Tvedten decided conditions were deteriorating and they should go to a defensive attack. Command ordered all firefighters to evacuate the structure, however, several firefighters’ radios malfunctioned and they did not receive the evacuation order. Some of the firefighters with the malfunctioning radios eventually ran out of air, became disoriented, and needed assistance to exit. Battalion Chief Tvedten also became disoriented and did not exit. After learning that all the firefighters except for Tvedten had exited, Command ordered the two initial Rapid Intervention Teams (RIT #1 and #2) to enter and search for the missing officer. Both teams entered but eventually ran low on air and were forced to exit without Tvedten. Additional RITs were formed and found Tvedten approximately 1 ½ hours after the initial dispatch. He was transported to a nearby hospital where he was pronounced dead. Battalion Chief John Tvedten was the first Kansas City firefighter to be killed in the line of duty in 11 years.
The structure involved in this incident was a large area one-story Type II Non-Combustible construction metal-pole building constructed on a concrete slab foundation located at 4231 Clary Boulevard in the East Side section of the city. The interior roof system contained metal roof trusses, and the exterior was constructed of metal, rubber, and stone particulate. The structure was originally used as a grocery warehouse; at the time of the incident, the structure housed Aspen Products, a firm that manufactured paper food containers. It measured approximately 25 feet in height, 500 feet in width, and 600 feet in length with a floor space of about 300,000 square feet. The origin of the fire was determined to be in the paper bale section of the building. This section of the building had no windows. There were six exterior vents in this section, all located at the ceiling level. There were 13 overhead doors on a loading dock located in this section, and one standard door was located on the south side. The ventilation system was not in operation when the fire occurred. The structure was equipped with a sprinkler system.
At the time of this incident, the Kansas City Fire Department served a population of 448,000 in a geographical area of 316 square miles. The department was comprised of 779 career firefighters and required all new firefighters to complete recruit training including Fire Fighter Level I and II, Driver Operator, and Emergency Medical Technician. Refresher training was provided on a monthly basis and covered all areas of standard training. Battalion Chief John Tvedten had 26 years of experience as a firefighter. His training records were reviewed and appeared to be sufficient and complete.
Area weather condition on the evening of the fire included an air temperature of 29 degrees F and a relative humidity of 85 % with southeast winds at 14 mph under cloudy skies (Weather Underground). Note: Research by the National Institute of Standards and Technology (NIST) has shown wind speeds on the order of 10 to 20 mph are sufficient to create wind-driven fire conditions in a structure with an uncontrolled flow path (Madrzykowski and Kerber 2009). The windy and high humidity conditions likely had a significant impact on the outcome of the incident.
On Saturday, December 18, 1999, at 1813 hours, Central Dispatch received a call reporting a fire at the Aspen Products warehouse at 4231 Clary Boulevard. Note: The employees of the warehouse attempted to combat the fire with extinguishers for approximately 15 minutes before notifying the fire department. Pumpers 18, 24, & 35, Trucks 5 & 2, Rescues 9 & 11, Air 1, Battalion Chiefs 105 & 106 and the District Safety Officer responded on a first-alarm assignment.
Pumpers 18 and 24 arrived on the scene at 1820 hours and reported light smoke showing from the rear. At 1822 hours, all companies responding to the first alarm were on the scene. Battalion Chief 105 assumed Command and requested a second alarm due to the size of the structure. Pumpers 17 & 32, Trucks 11 & 13, Rescue 31, HazMat 71, the Incident Safety Officer and Battalion 104 were assigned to respond on the second alarm. Command ordered Battalion Chief 106 John Tvedten to enter the structure and assume interior command. Command then positioned his car in the southeast corner where the fire attack would take place and gave a size-up report indicating a large warehouse, approximately 200 feet by 300 feet, with light smoke at the south end.
The District Safety Officer (DSO) entered the warehouse and reported that employees were still inside. Command ordered an employee evacuation and ordered Battalion Chief 104 to meet with the plant supervisor to make sure all employees were accounted for when he arrived on the scene. At 1825 hours, Command reported to Dispatch that they had paper burning. At approximately the same time, Battalion Chief 104 arrived on the scene and Command was informed that all the employees were accounted for. Battalion Chief Tvedten reported to Command that paper bales were on fire and that he thought that they could suppress the fires with several hoselines.
At 1825 hours, Pumper 18 advanced a 1 ¾-inch hoseline through the south end door. A second 1 ¾-inch hoseline was advanced by Pumper 35 through the same door. Pumper 24 advanced a third hoseline through one of the dock doors. Rescue 11 and Pumper 17 (only part of their crew) entered with Pumper 18 and Pumper 24 to assist them with stretching their hoselines. The second alarm companies arrived on the scene and Command ordered all firefighters on the fireground to switch their radios from channel 5A to the talk-around channel. Note: While in route to the scene, Battalion Chief Tvedten had advised Command that they might have radio problems, due to past experiences with their radios in this type of structure. The fire department was equipped with an 800 MHz trunked radio system. Recognizing that communication problems might occur; operations were assigned to the talk-around channel.
Rescue 31, a second alarm company, was assigned as the Rapid Intervention Team (RIT), but as they approached the scene Command ordered them to advance a 2 ½-inch master stream to the interior. Command ordered Hazmat 71 to take over as the RIT (RIT 1). The remaining firefighters from Pumper 17, who did not enter with Pumper 18 and Pumper 24, assisted Rescue 31 with the 2½-inch line. Members from Truck 5 and Truck 2 also entered the structure to assist with the hoselines as other members from Truck 5 raised the aerial ladder to the roof to check conditions. Truck 5’s radio would not switch to the talk-around channel, requiring Command to monitor two channels at all times.
Truck 11 arrived and assisted the crews advancing the hoselines to the interior and also strung lights to the interior to improve visibility. Firefighters in the interior reported varying smoke conditions, ranging from heavy, white smoke banking down from the ceiling to the mid-part of the structure on the south side, to light haze at other locations inside the structure. Other firefighters in the interior reported that approximately 20-foot flames were extending from the paper bales to the ceiling on the opposite side of the initial fire attack. Battalion Chief Tvedten and the DSO radioed Command and told him that the fire was in the bales and not in the structure and that the visibility was fair. Note: The electrical power was still on in the warehouse. Firefighters stated that at various times throughout the attack, they were able to remove their SCBA facepieces because the smoke was shifting around. Battalion Chef Tvedten was seen without his facepiece donned by several firefighters during the attack.
As the fire attack progressed, firefighters stated that as they hit the fire it would move in and out of bales, from one area to another. Some of the firefighters then moved from the south side of the paper bales to the east side of the bales to get a better angle on the fire attack. Battalion Chief Tvedten, who was assessing the fire from the south end of the paper bales, went around to the north end to evaluate the conditions. The DSO told Tvedten that he would remain on the south side and monitor conditions. Tvedten radioed Command and requested a forklift to move some of the plant equipment to get a better position on the fire. Tvedten positioned himself approximately 15 feet away from the paper bales, near a chain-link fence. At 1841 hours, Dispatch notified Command that the 15-minute clock had just expired. Note: Dispatch starts a running clock when the crews first enter a structure. The clock provides Command with information on how long crews have been in a structure. Concerned about the time the firefighters had been inside, Command radioed Tvedten to get a report on the interior conditions. Tvedten stated that conditions were about the same and there was not much heat, just smoke. Based on the time-of-fire activity, Command requested a third alarm at 1842 hours.
Heavy Rescue 1 responded as a part of the third alarm and was ordered by Command as the second RIT (RIT 2) when they arrived on the scene. Command also requested that Battalion Chief 102 respond and replace Battalion Chief Tvedten in the interior when he arrived. At 1853 hours, Command requested a staff recall, which required all staff officers to report to the scene. Dispatch had also dispatched Pumper 8, Pumper 29, Pumper 43, Rescue 12, Truck 6, and Car 107 as a fourth alarm.
At this point, members from Truck 5, Truck 2, and Truck 10 were on the roof attempting to ventilate. The truck companies reported that the roof had several layers of materials and that they had difficulty getting through it with the saw blades they were using. Tvedten requested a 2 ½-inch master stream device be brought into the structure on the north end where the paper bales were located. Rescue 31 took their 2 ½-inch line and connected it to the master stream device which was located near the front of the paper bales. Pumper 23, with the assistance of Rescue 9, stretched a second 2 ½-inch line through a dock door. The firefighters met up with the Captain from Pumper 17 and also connected their 2 ½-inch line into the master stream device.
Shortly after the master stream was opened, heavy smoke banked down, causing poor visibility. A firefighter from Rescue 9 stated that he saw Tvedten don his facepiece at this time. Command then requested the power to the warehouse be shut off in fear of a firefighter possibly being electrocuted. The power was shut off and the lights went out, which decreased visibility. Battalion Chief 102, who was to replace Tvedten, arrived on the scene and requested Tvedten’s current location. Tvedten told him to follow Pumper 23’s hoseline, as he was close by it. At 1856 hours, Dispatch notified Command that the second 15-minute clock had expired and they would be starting a third. Command felt they were not making much progress against the fire with the hoselines and requested Dispatch to order foam to the scene. Pumper 39 arrived on the scene and was directed to hook into the sprinkler system standpipe connection. Pumper 39’s crew stated that water was flowing into the system, but crews in the interior could not recall if the sprinklers were activated.
Firefighters who were battling the fire had exited and reentered several times to refill their air bottles. Since visibility was poor, Tvedten radioed Command and requested lights be placed at the loading dock doors so firefighters could see their way out. He also requested a second RIT be placed in staging (not knowing that Heavy Rescue 1 had already been assigned as the second RIT). Command informed him they were already in place. Battalion 104, who had entered to check conditions, reported to Command that smoke conditions inside were untenable, and all firefighters should be evacuated from the building. Command radioed Battalion Chief Tvedten and relayed the message from Battalion 104, requesting his opinion. Tvedten reported that conditions had worsened and agreed they should evacuate the structure. Firefighters stated that at this point there was still little heat, but poor visibility at the floor level.
Command was also concerned that the fire would compromise the integrity of the roof, since he had firefighters on the roof. At 1912 hours, Command requested that Dispatch sound an emergency evacuation signal. The dispatch transmissions could only reach the tactical channel (channel 5A) so Command keyed the talk-around channel mike and placed it in front of the channel 5A speaker to transmit the emergency evacuation signal over the talk-around channel. Command then ordered all companies to return to their apparatus and conduct a roll call. He also ordered all fire apparatus operators to blow their air horns as another evacuation signal to firefighters inside.
After making an L-shaped cut in the roof, firefighters on the roof reported that they heard the emergency evacuation signal and immediately exited the roof. Note: Roof ventilation had not been completed when they exited the roof. Several firefighters in the interior reported that they did not receive the emergency evacuation signal over their radio or hear the air horns. Several radios became wet during the operation and were not functioning properly, while other radios apparently did not receive the signal. As the emergency evacuation took place, firefighters started to exit because their low-air alarms sounded. A firefighter from Rescue 9, still near the master stream device, who did not receive the emergency evacuation call, recalled seeing the Captain and two firefighters from Rescue 31 attempting to exit. The Captain and both firefighters were out of air and had pulled off their facepieces. The firefighter grabbed the Captain and two firefighters and started buddy-breathing with them. The firefighter from Rescue 9 found a 2 ½-inch line and started to lead them out, stopping every 10 feet to buddy breathe.
Following the line, they ran into an entanglement of hoselines and became disoriented. He heard the Captain of Rescue 31 radio Command telling him that they were out of air and needed someone to get them out. Command ordered the fire apparatus operators to shine their spotlights into the loading dock doors to assist the disoriented firefighters. The disoriented firefighters became separated and the firefighter from Rescue 9 ran out of air. Another firefighter from Rescue 9, who was exiting with them, ran into the crew from Rescue 31. He noticed the Captain moving slowly so he grabbed him and started moving toward what he thought was an exit. He too ran out of air and pulled off his facepiece. All five disoriented firefighters eventually made it out through a loading dock door near the south end. Both firefighters from Rescue 9 stated that they felt very tired and confused. Note: Several firefighters in the interior either were not equipped with or did not turn on their Personal Alert Safety System (PASS) device.
Command had a report that Pumper 24’s radio was transmitting an emergency signal, but shortly after Pumper 24 reported to Command that they were all accounted for. Then, over the talk-around channel, Command received a call for help from someone still inside. Command asked who needed help and Battalion Chief Tvedten responded by saying “106.” Tvedten was unable to tell Command his location inside the structure. Command told him they were sending in the initial RITs, Hazmat 71 (RIT 1) and Heavy Rescue 1 (RIT 2) to find him. The DSO also reentered the structure to search for Tvedten. The DSO stated he did not have a PASS device on when he entered (his PASS device was broken, and he did not have a replacement). The DSO made two attempts to enter and locate Tvedten, then briefed the RITs preparing to enter. Command ordered that all radio traffic be at a minimum and for all companies to switch back to channel 5A. The Chief arrived at 1921 hours and was given an update of the situation, including concerns about the structure. The Chief and Command concurred that the search activities would remain the priority and ordered both RITs to enter the warehouse and search for Battalion Chief Tvedten.
At approximately 1921 hours, the Heavy Rescue 1 (RIT 2) entered the structure with a rope through one of the loading dock doors on the south end. After donning their equipment, Hazmat 71 (RIT 1) entered with a rope, behind Heavy Rescue 1. Heavy Rescue 1 went toward the area where Tvedten was last seen and searched until three of the firefighters’ low-air alarms sounded, and they exited the structure. The Captain and his FAO continued the search until their low-air alarms sounded and they exited the building. The Hazmat 71 crew searched an area in the front of the structure, until their low-air alarms sounded and they exited the structure. Note: Hazmat 71 was equipped with one-hour air bottles. At least seventeen additional firefighters reported that they entered the structure to search for Tvedten at various times during this interval.
Seven of the additional seventeen firefighters formed two additional RITs (RIT 3 and 4); however, several other firefighters reportedly entered the structure alone and without Command’s direction. Both RITs (3 and 4) entered the warehouse with additional ropes to search for the missing officer. Five additional officers and the DSO from Car 105 were assigned to assist Command with accountability by staying at the doors the RITs were using, since the RITs and firefighters who completed the search and rescue attempts entered and exited at different locations.
Throughout the search, Tvedten radioed that he thought he was in the same location where he was when the smoke banked down (near the chain-link fence). At approximately 1928 hours, he said that he was out of air and was breathing off the floor and asked if all other personnel were accounted for. Command noticed that his voice was labored and garbled. Command asked Tvedten if he could manually activate his PASS device but received no response. No further communications with Tvedten were received. At 1932 hours, Dispatch advised Command that the fourth 15-minute clock had expired, and they would be starting a fifth. Command then ordered dispatch to notify a mutual-aid department to respond with a thermal imaging camera.
At 1937 hours, Command requested the electrical power to the building be turned on to restore lighting. The power was restored, and Heavy Rescue 1 (RIT 2) reported to Command that they were changing their air bottles and would be ready to go back inside. Command told RIT #2 to brief one of the other RITs (RIT 3 or 4) about the locations they had searched and then send one of them inside. Heavy Rescue 1 radioed Command that they had a good idea of the area that they had searched, and they were going to reenter. Heavy Rescue 1 (Captain and 3 firefighters) along with a Captain and a firefighter from Pumper 35, the FAO from Rescue 9, and a firefighter from a mutual-aid department with a thermal imaging camera (all forming RIT 5), entered the structure to continue the search. Following the ropes back to the area they had just searched, the Captain from Heavy Rescue 1 veered off to his right and found Tvedten at approximately 1945 hours. He was unconscious, with no helmet, radio, or SCBA. The Captain immediately yelled to the other firefighters for assistance in removing the unresponsive officer from the building. Unable to locate Tvedten’s pulse, the Captain began cardiopulmonary resuscitation (CPR) until the other firefighters arrived. Command was informed that they had located the missing officer and were removing him. After the radio call, additional firefighters entered the structure to assist. Firefighters later stated that the smoke was clearing and the visibility was improved.
Battalion Chief Tvedten’s helmet was found on the floor in an area where he was operating throughout the fire attack. His SCBA was found approximately 10 feet away from him. He was found equipped with a PASS device, but it was not turned on. Note: Tvedten’s SCBA cylinder was sent to NIOSH for further testing. The test concluded that the cylinder was empty of breathing air but contained a substantial amount of water. Firefighters continued CPR as they loaded Battalion Chief Tvedten into the ambulance where he was transported to Truman Medical Center and pronounced dead. The medical examiner listed the cause of death as asphyxia with carbon monoxide inhalation. His CO level was listed at 51%.
Several days after the fire other firefighters received medical attention for sore throats and breathing difficulties.
The NIOSH report made several recommendations including:
• ensure that proper ventilation equipment is available, and ventilation takes place when firefighters are operating inside smoke-filled structures.
• ensure that one of the first arriving engines be assigned to pump water into the building’s fire department sprinkler connection to reinforce the automatic sprinkler system.
• ensure that when entering or exiting a smoke-filled structure, firefighters follow a hoseline, rope, or some other type of guide.
Following the incident, a group of Kansas City firefighters developed a new training evolution and procedure called Large Area Search Technique (L.A.S.T.) that firefighters can use while performing a search for a downed, trapped, or lost firefighter in large area buildings such as warehouses, big box stores, manufacturing plants, large office buildings, arenas, theaters, etc.
Battalion Chief John O. H. Tvedten, age 47, was a 26-year veteran of the Kansas City Fire Department. A leader in the department, he had received two Distinguished Service Awards. He held a master’s degree in public administration from Harvard University. John was a founding member and president of the International Association of Fire Fighters Local #3808. He also served for over 20 years in various offices of IAFF Local #42, including general vice-president and was chairman of the Firefighters Pension Board, Welfare Board and Deferred Compensation Board. He was predeceased by his father, John H. Tvedten, who had also been a battalion chief with the department. He is survived by his wife, Susan, his son, Tyler, and his mother, Margaret Tvedten.
On December 21, 1999, a memorial service for Battalion Chief John O. H. Tvedten was held at the Kemper Arena with more than 2,000 people including 1,200 firefighters from around the Midwest attending to honor their fallen comrade. The more than two-hour service concluded with the traditional ringing of a fire bell to call the fallen firefighter home. A half-mile long procession of fire apparatus from around the region then escorted the casket of Battalion Chief Tvedten past Fire Station 32. The following day Tvedten was buried at Mount Moriah Cemetery in Kansas City.
The name of Kansas City Battalion Chief John O. H. Tvedten has been inscribed at the site of the Kansas City Firefighters Fountain and Memorial located at the south end of Penn Valley Park in downtown Kansas City. Originally built in 1991 to honor six firefighters who were killed in an explosion at a highway construction site in 1988, it features two bronze figures surrounded by 48 streams of water falling into an 80-foot-wide basin. A larger-than-life bronze sculpture of a firefighter with his head bowed is located directly to the north of the fountain. In 2015, the memorial was updated with an entirely new section that rests between the fountain and the old memorial. Two curved walls made of perforated aluminum are set on top of stone walls. Aluminum plaques that list the names of all Kansas City firefighters who have lost their lives in the line of duty are mounted on the north sides of these walls. As part of this update, the granite pedestals of the old memorial were topped with metal plaques that detail significant moments in the history of the Kansas City Fire Department. Members of the Kansas City Fire Department gather at the site each year to remember the loss of their members.
The name of Battalion Chief John O. H. Tvedten has been inscribed on the 1999 plaque displayed at the National Fallen Firefighters Memorial on the campus of the National Fire Academy in Emmitsburg, Maryland.
Commentary:
Fire operations in large area buildings pose a unique set of challenges for firefighters. The sheer size of such structures makes for difficult fire control and search and rescue operations. Many areas are experiencing rapid development of large area buildings, especially mega-sized warehouses of more than one million square feet. Firefighting in such occupancies calls for different tactics and methods than in the bread-and-butter single-family home fires that we are called to most often. Firefighters, while searching for the seat of a fire or unaccounted for occupants, may be drawn deep into the interior where they can be as much as 200 to 400 feet from the nearest exit. Many of these occupancies also feature tall ceilings that may allow smoke and heat to accumulate above the heads of entering firefighters, masking the seriousness of the fire. New methods are called for when operating at fires and emergencies in these massive occupancies.
We have attached photos and diagrams from the incident. The link to the NIOSH report is here: https://stacks.cdc.gov/view/cdc/163784
We have also attached the link to an article on the Kansas City L.A.S.T. program published in Fire Engineering magazine by Todd Ackerson: https://www.fireengineering.com/firefighting/kansas-city-last/
Thanks to multiple media sources for additional information for this article.
Honor the service of Kansas City Battalion Chief John Tvedten by reviewing your department’s procedures for fire and rescue operations in large area buildings and by touring a large area occupancy in your local response district with your crew members today.
Remember Fallen Brothers.
Get Out There And Know Your Local!!!
On December 18, 1999, Kansas City Fire Department Battalion Chief John Tvedten died during a fire rescue. His death led to the development of the Kansas City L.A.S.T. technique for…
