Few assignments carry more weight than a fire in which someone has died. Families want answers, prosecutors may need to decide whether a crime occurred, and prevention professionals want to know how similar deaths can be avoided. Because no single agency holds every responsibility, a fatal fire investigation is almost always a team effort. The 2022 Utah Chapter IAAI conference addressed this in a session titled "Investigating fire fatality with multiple agencies for better results." This article outlines how agencies can work together effectively from the first call to the final report.
Who Is Involved?
Depending on jurisdiction and circumstances, a fatal fire investigation may involve:
- The fire department, which controls the incident, performs suppression and overhaul, and often provides the origin and cause investigator.
- The fire marshal or fire investigation unit, responsible for determining origin and cause.
- Law enforcement, responsible for criminal investigation, scene security and death investigation duties within its authority.
- The medical examiner, who has authority over the decedent and determines the cause and manner of death.
- The prosecutor's office, when criminal charges are possible.
- State and federal partners, who may assist on request with specialized resources.
- Private-sector investigators, who may later represent insurers or other interested parties.
Each agency has legal responsibilities that cannot be delegated. The goal is not to decide who is "in charge" of everything, but to agree early on how responsibilities will be coordinated.
The First Hours: Protecting the Scene and the Victim
Recognize the scene for what it is
Once a victim is found, the scene should be treated as a potential death investigation scene until proven otherwise. Unless life-saving efforts are still possible, avoid moving the victim or disturbing the surrounding debris before documentation. When firefighters must move a victim during rescue or overhaul, their observations about the original location and position become critical data.
Secure and log the scene
Establish a perimeter and an entry log recording every person who enters, when and why. Limit entry to those with a defined role. Early scene security protects evidence and protects every agency's work from later challenge.
Coordinate before examination
A brief meeting of the lead representatives from the fire department, investigators, law enforcement and the medical examiner's office should establish the plan: who will photograph, who will document the victim, how the victim will be removed, how evidence will be handled and how information will be shared.
Documenting the Victim in Context
The victim's location and condition are part of the fire's story. Documentation should include:
- Overall, mid-range and close-up photographs of the victim before removal, and of the area beneath the victim after removal.
- The victim's position relative to the area of origin, exits, windows and smoke alarms.
- Clothing, footwear and items near the victim, such as smoking materials, heaters, oxygen equipment or mobility aids.
- Protected areas on the floor and furnishings that show where the victim was during the fire.
Our fire scene photography guide describes systematic coverage techniques that apply directly here.
Working With the Medical Examiner
The autopsy and toxicology findings often answer key questions for the investigator, and the investigator's scene findings help the medical examiner interpret those results. Questions commonly explored together include whether the victim was alive when the fire started, which may be indicated by findings such as soot in the airways and elevated carboxyhemoglobin levels; whether injuries unrelated to the fire are present; and whether drugs, alcohol or medical conditions may have affected the victim's ability to escape. Share scene information promptly and ask the medical examiner what additional information would be useful.
Origin and Cause Still Come First
A fatality raises the stakes but does not change the method. The origin and cause must be determined through the scientific method described in NFPA 921, testing every reasonable hypothesis. Investigators should be especially alert to expectation bias in high-profile cases, where there may be pressure to reach a conclusion quickly. An honest "undetermined" is better than an unsupported conclusion.
Evidence and Chain of Custody Across Agencies
When several agencies collect evidence, confusion over item numbers and custody can create problems later. Agree on a single evidence numbering system, designate who will package and submit each category of evidence, and ensure every transfer between agencies is recorded. See our guide to evidence collection and preservation.
Interviews and Background Information
Interviews with surviving occupants, neighbors, first responders and the 911 caller often reveal the victim's last known activities, habits such as smoking, and the condition of smoke alarms. Coordinate interview plans so that witnesses are not interviewed repeatedly by different agencies without purpose, and so that legally sensitive interviews are handled by the appropriate agency. Our article on interviews and canvassing covers techniques in depth.
Communicating With Families and the Media
Designate a single point of contact for the family, and use a public information officer for media inquiries. Agencies should agree on what can be released and when, to avoid contradictory statements and to protect the integrity of the investigation. Treat families with compassion and keep them informed as far as the investigation allows.
Prevention Lessons
Fatal fire investigations often reveal prevention opportunities: missing or disabled smoke alarms, blocked exits, unsafe heating practices, smoking while using medical oxygen, or occupants with limited mobility. Documenting these factors carefully allows fire prevention professionals to target education and outreach where it is needed most.
Common Pitfalls to Avoid
- Removing the victim before the scene and the victim's position have been fully documented.
- Assuming the cause early because of the victim's habits or history.
- Allowing several agencies to collect evidence under different numbering systems.
- Failing to share scene findings with the medical examiner, or autopsy findings with the investigator.
After the Scene: Debriefing and Wellness
A joint debrief after the scene work is complete helps agencies identify what worked and what should change next time. Just as important, fatal fire scenes take a personal toll on investigators and firefighters. Peer support and employee assistance resources should be offered as a normal part of the process. Our fire scene safety article discusses investigator health and wellness.
Build Relationships Before You Need Them
The best multi-agency investigations happen when people already know each other. Conferences and chapter meetings are where fire investigators, law enforcement officers, attorneys and laboratory staff build those relationships. Learn more about the Utah IAAI annual conference, check the Training page and consider joining the chapter.