FIRE DEPARTMENT CITY OF NEW YORK

SAFETY AND INSPECTION SERVICES COMMAND

INVESTIGATIVE REPORT
BRONX BOX 3-3 2997
236 E 17STH STREET
JANUARY 23, 2005
CASE NUMBER 03-05
FATAL INJURY
LIEUTENANT CURTIS W. MEYRAN
LADDER COMPANY 27 (COVERING)
FIREFIGHTER JOHN G. BELLEW
LADDER COMPANY 27
VOLUME I
THE INVESTIGATION
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I. SlTMMARY
On Sunday, January 23, 2005, at approximately 0758 hours, the New York City
Fire Department's Bronx Borough Communications Office received a telephone alarm of
fire. T h ~ caller reported a fire in apartment 3A at 226 East 178
th
Street.
Units were dispatched at approximately 0759 hours. The initial response included
three Engine Companies (Engine Company 42, Engine Company 46, and Engine
Company 75), two Ladder Company companies (Ladder Company 27 and Ladder
Company 33), and one Battalion (Battalion 19). The dispatcher then received a call for
the corrected address of 236 East 178
th
Street and notified responding units. Engine
Company 42 arrived first on the scene at 0803 hours, investigated and found fire in
apartment 31, the third floor rear apartment. Standard firefighting procedures were
initiated.
The fire building was a four story, class 3, non-fireproof multiple dwelling with 3
apartments per floor. The building dimensions were approximately 40 feet wide by 90
feet deep. The fire apartment (31) and the apartment directly above (4L) were both
illegally altered into a layout commonly referred to as a single room occupancy (SRO).
An illegal partition wall was constructed in each of these apartments and hindered access
to the secondary means of egress, the rear fire escape.
Engine Company 42 stretched a 1 % inch hose line via the interior stairs to the
third floor rear apartment. Ladder Company 33 arrived and assumed operations on the
fire floor as the first due Ladder Company. Engine Company 46 assisted Engine
Company 42 in stretching the first hoseline. Ladder Company 27 assumed the position of
the second due Ladder Company and operated on the fourth floor. Engine Company 42
was positioned at a hydrant that was frozen. Due to the frozen hydrant, Engine Company
75 relayed water to Engine Company 42 from a serviceable hydrant.
Battalion 19 transmitted a 10-75 signal at 0806 hours and assumed command.
Engine Company 75, assisted by Engine Company 43, stretched a second 1 % inch
.boseline to the fourth floor. Rescue Company 3 arrived and was ordered to assist on the
floor above with searches. A short time later, Engine Company 42 experienced a loss of
water in their hoseline and backed out of the fire apartment. Battalion 19 repositioned
Page 1 of 86
Engine Company 75's hoseline from the fourth floor to the fire apartment on the third
floor.
The fire extended to the apartment directly above, cutting off the means of egress
for six members operating in this apartment. These members were forced to evacuate
their positions via the fourth floor rear windows.
Members were initially treated on scene and transported by FDNY Emergency
Medical Service to area hospitals. Lieutenant Curtis Meyran, Ladder Company 27
(covering), and Firefighter John Bellew, the Chauffeur of Ladder Company 27,
succumbed to their injuries. The Forcible Entry and Hook Firefighters of Rescue
Company 3, and the Forcible Entry ~ d Can Firefighters of Ladder Company 27 were
admitted in critical condition.
As a result of the Safety and Inspection Service Command's investigation, the
following is a synopsis of the recommendations in Section VIII that are made to improve
fireground safety:
\
1. Provide, as quickly as possible, the equipment and training for a Department
approved method of self-evacuation.
2. Reinforce the policy of not allowing members to enter, operate in, or leave an
Immediately Dangerous to Life and Health (IDLH) atmosphere alone.
3. Emphasize the importance of performing proper and complete searches and
communicating the results to the Incident Commander in a timely manner.
4. Reinforce to all members the importance of maintaining operational discipline.
5. Reinforce to all Officers the importance of maintaining unit integrity during
operations and to operate as ordered.
6. Review All Unit Circular 275 (Rescue Company Policy), Addendum 1 (Rescue
Company Operations), and Addendum 2 (Squad Company Operations) pertaining
to specialized unit assignments at fire operations.
Page 2 of 86
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7. Reinforce the importance of determining the location of the main body of fire
when operating. This is important to all units, especially those operating on the
floor above.
8. Reinforce the importance of operating with the protection of a charged hoseline
when in a fire area, the floor above, or any exposed area.
9. Emphasize to all members the importance of having a back-up hoseline available
as a precautionary measure,#other than those already in operation.
10. Establish procedures to recalibrate flow meters in a timely and effective manner.
11. Re-evaluate the specifications regarding the minimum idle setting for pumper
apparatus.
12. Update all documents and procedures, including the Chauffeur Training School
Engine Reference Manual, pertaining to current Engine Company apparatus and
pumping operations.
13. Revise the appropriate documents to include actions necessary to address a loss
of water in a hoseline.
14. Incorporate an emergency alert button on the remote microphone of the handie
talkie as soon as possible.
15. Emphasize the use of the handie-talkie emergency alert button for any
MAYDA Y or URGENT transmission.
16. Emphasize the critical need to employ proper handie-talkie MAYDA Y ~
procedures. This investigation, along with previous Firefighter fatality/serious
injury investigations, indicate that this continues to be a problem.
Page 3 of 86
17. Implement a structured training program for all members emphasizing proper
fire ground communications.
18. Implement the handie-talkie recorder technology in all Battalion vehicles.
19. Emphasize the importance ofpropedy performing hydrant inspection duty.
20. Examine the current procedures for identifying, prioritizing and thawing frozen
hydrants to make these procedures more effective.
21. Establish a program to coordinate the notification of violations and defects found
I
by other city agencies that are relevant to the Department.
22. Include weather forecasts on the daily Fire Department Chief Officers Schedule.
It should also be included on the daily safety message.
23. Emphasize the need to use the correct method for anchoring the Life Saving Rope
during Life Saving Rope operations, and explore alternatives.
24. Emphasize proper procedures for off duty members offering services for
voluntary duty.
25. Member assignments should be predicated on the Officer's evaluation of a
member's capabilities and experience.
Page 4 of 86
v. F.D.N.Y. OPERATIONS
The following account of operations generally follows sequentially, however, at
any given time, many actions are in fact occurring simultaneously and at different areas
of the fire scene. \ Also, it is strongly recommended that the reader refer to the provided
fold out diagrams of the third and fourth floor apartment layouts located in the front and
rear of this report to aid in understanding the sequence of events.
Initial Response
At 0759 hours on Sunday, January 23, 2005, the Bronx Fire Communications
Office transmitted box 2997 for a fire at 226 East 178
th
Street. The fire was reported to
be in apartment 3A on the third floor. Bronx box 2997 is located'at the intersection of
Anthony A venue and East 178
th
Street. The address is on the south side of East 178
th
Street between Anthony A venue and the Grand Concourse. Engine Companies 42, 46,
75, Ladder Companies 27, 33, and Battalion 19 were assigned and responded to that
location. There was an overnight storm that left approximately 12 inches of snow on the
ground. The wind and driving snow created near whiteout conditions at the time of the
initial r e s ~ o n s e . The temperature was 17 degrees Fahrenheit: and there were northwest
winds gusting in excess of 45 mph. Due to the adverse weather conditions, all Engine
Companies were staffed with five Firefighters, and all Rescue Companies were staffed
with six Firefighters.
Engine Company 42 arrived at the reported address first and transmitted the signal
10-84 at 0803 hours. At 0804 hours, the dispatcher corrected the address to 236 East
178
th
Street apartment E on the third floor. Battalion 19 acknowled.ged the change of
address on the department radio. Engine Company 42 continued east on East 178
th
Street
to the correct address, and positioned the apparatus at a hydrant located at 239 East 178
th
Street.
Ladder Company 27 was assigned as the first due Ladder Company, but arrived as
the second ladder behind Ladder Company 33. Ladder Company 27's response was
delayed when a commercial delivery truck blocked entry to Anthony A venue from East
Tremont A venue. Ladder Company 27 was forced to utilize a different route via the
Grand Concourse.
Page 16 of86
Ladder Company 33, the second due Ladder Company, arrived in front
correct address at 0805 hours and transmitted a signal 10-84. Ladder Lompany
followed Ladder Company 33 into East 178
1h
Street and positioned their apparatus at
northwest comer of 234 East 178
1h
Street, which was exposure #4.
Engine Company 46, assigned as the second due Engine Company,
behind Ladder Company 27. Engine Company 46 stopped at a hydrant on the north
of East 178
1h
Street, neafthe Grand Concourse. Engine Company 75 arrived
Engine Company 46 on the northbound service road of the Grand Concourse. B
19 arrived behind Engine Company 75 and parked on the Grand Concourse at
southeast comer of East 178
1h
Street. Engine Companies 46 and 75, and Battalion
transmitted the signal 10-84 at 0805 hours.
Fire Building
The fire building is a 4 story, class 3, non-fireproof multiple
approximately 40 feet wide by 90 feet deep. There are three apartments per floor,
the numerals designating the floor and the letters designating the apartment. The
building is attached to exposure #4, which is a similar building. There is an
shaft between the two buildings. The windows of the interior staits are on the
landings and open onto the enclosed shaft. The exposures are as follows:
Exposure 1 - East 178
1h
Street
Exposure 2 - Parking lot by a 6 foot alley
Exposure 3 Rear yard
Exposure 4 Similar attached
Apartment 31, the fire apartment, and apartment 4L, the apartment directly
were both illegally altered into a layout commonly referred to as a single room f">f"'l11"\<lnl'1
(SRO). The rooms were converted into individually padlocked living units within
two apartments. In both apartments bedroom 3 was converted to a living unit by
construction of an illegal partition wall. This wall created a hallway, which led from
kitchen to the fire escape and bedroom 4 in both apartments. In apartment 4L, this
was framed with 2 inch x 4 inch lumber with gypsum board on both sides. This
partition concealed the extension of fire into that apartment and also isolated bedrooms
2, and 3 from the fire escape. The illegal partition in apartment 31 was also constructed
Page 17 of86
with 2 inch x 4 inch lumber but was finished with a thin combustible material that
quickly burned through in the fire.
Initial Operations
As the Captain of Engine Company 42 entered 236 East 178
th
Street, several
civilians in front of the address casually indicated there was a fire in the building. On the
way up the interior stairs, the Jtngine Company 42 Captain encountered other civilians
who told him that the fire was on the third floor. The Engine Company 42 Captain
transmitted this information via the handie-talkie to the Engine Company 42 Firefighters.
He also told them that there was no well hole in the stairway. The Engine Company 42
Firefighters began to stretch six lengths of 1 % inch hose into the building. When the
Engine Company 42 Captain reached the third floor, he saw smoke pushing from around
the closed door of apartment 31.
As the Engine Company 42 Captain was transmitting the 10-75 via the handie
talkie, Battalion 19 arrived on the scene and transmitted the signal 10-75 to the Bronx
Borough Communications Office. The Engine Company 42 Chauffeur reported via the
handie-talkie that the fire hydrant where he had positioned his apparatus was frozen .

The Ladder Company 33 Lieutenant, Forcible Entry and Can Firefighters (Inside
Team) ascended to the third floor. The Forcible Entry and Can Firefighters (Forcible
Entry Team) forced open the door to the fire apartment. While waiting for Engine
Company 42 to bring their hoseline to the .apartment, Ladder Company 33 maintained
control of the door allowing civilians from the upper floor to evacuate down the stairs.
The Engine Company 42 Captain asked Ladder Company.33 to force open the door to the
opposite apartment, to enable Engine Company 42 to flake out their hoseline. The
Ladder Company 33 Forcible Entry Team forced open the door to apartment 30.
The Ladder Company 27 Officer (Lieutenant Meyran), Forcible Entry and Can
Firefighters entered the building and started up the stairs. Upon reaching the third floor,
Lieutenant Meyran informed the Ladder Company 33 Lieutenant that Ladder Company
27 was going above. Ladder Company 33 kept the door to the fire apartment closed until
Ladder Company 27 was in position on the fourth floor. Lieutenant Meyran and the
Ladder Company 27 Forcible Entry and Can Firefighters, forced entry into apartment 4L
and began to search this apartment directly above the fire.
Page 18 of 86
...
The Engine Company 46 Lieutenant and Firefighters went to the fire building and
assisted Engine Company 42 with the hose stretch. The Engine Company 46 Chauffeur
reported via the handie-talkie that his fire hydrant was also frozen.
The Battalion 19 Firefighter transmitted a preliminary report and size-up of the
fire building to the Bronx Dispatcher. He also included that there were frozen hydrants
and that the incoming units should be notified.
The dispatcher notified the Battalion 19 Firefighter that the fourth engine would
be Engine Company 43. The dispatcher also notified the Battalion 19 Firefighter that
..
Squad Company 41, Rescue Company 3 and Division 7 were responding. He added that
Ladder Company 59 was the Firefighter Assist and Search Team (FAST Unit) and
Battalion 17 was the All Hands Chief.
The Ladder Company 33 Roof Firefighter and the Ladder Company 27 Roof
Firefighter went to the roof by way of the interior stairs of the adjoining building
(exposure #4). They arrived on the roof at approximately the same time and began roof
operations.
I ninal Operations in the Rear
The Ladder Company 33 Outside Vent Firefighter and the Ladder Company 27
Outside Vent Firefighter went to the rear of the fire building via an alley on the exposure
#2 side of the building (see diagram, pg. 15). There were two windows to the fire escape
on each floor in the rear. They ascended to the third floor balcony and observed fire
venting from the left fire escape window on that floor. The Ladder Company 33 Outside
Vent Firefighter vented the first window off of the fire escape, to his right. Noticing that
the remaining window on the fire escape was about to self-vent, the Ladder Company 33
Outside Vent Firefighter vented this window and descended to a position between the
second and third floor landings. Fire was now venting out both fire escape windows.
The Ladder Company 33 Chauffeur followed the Ladder Company 33 and the
Ladder Company 27 Outside Vent Firefighters to the rear yard. He transmitted a report
of the fire conditions in the rear over the handie-talkie. He then returned to the front of
the fire building and verbally told Battalion 19 that there was fire showing out two
windows in the rear on the third floor.
Page 19 of 86
Initial Operations in the Front
The Ladder Company 27 Chauffeur, Firefighter Bellew, set up Ladder Company
27's apparatus for operations and raised the aerial ladder to the roof of exposure #4. He
then entered the fire building.
Engine Company 75 arrived at the comer of the Grand Concourse and East 178
th
Street. The Engine Company 75 Chauffeur heard reports of frozen fire hydrants and
circled the block after dropping off the Officer and four Firefighters. These members
proceeded to Engine Company 42's apparatus. The Engine Company 75 Chauffeur
arrived at the opposite erd of East 178
th
Street at Anthony Avenue and located a
serviceable hydrant. The Chauffeur backed his apparatus into East 178
th
Street to the
front of Engine Company 42's apparatus. The Engine Company 75 Chauffeur and the
Engine Company 75 Control Firefighter connected a 3 V2 inch supply hoseline to the
Officer's side gated inlet of Engine Company 42's apparatus. The Engine Company 75
Chauffeur then utilized the apparatus to backstretch the supply hoseline to the serviceable
fire hydrant. The Chauffeur and the Control Firefighter then made the necessary
connections to relay water to Engine Company 42's apparatus. The remaining members
of Engine Company 75 started stretching a second 1 34 inch hoseline into the fire
building.
Initial Operations Fire Floor
As the Engine Company 42 Nozzle and Back-Up Firefighters reached the half
landing between the second and third floors, the Engine Company 42 Captain told them
to bring their hose up to the third floor. I:Ie directed them to flake out the hoseline into
apartment 3G, the apartment opposite the fire apartment. This resulted in 1 V2 to 2 lengths
of hoseline flaked out in that apartment. He told his Control Firefighter to make sure that
the door did not close over the hose. Engine Company 46 members assisted in this
stretch. They found excess hose on the first floor, moved it up to the second floor, and
then flaked out approximately one length of hose in the middle apartment on that floor.
The Engine Company 42 Chauffeur informed his Officer that he was ready to
supply booster water when they were ready to operate. The Engine Company 42 Captain
directed his Chauffeur to charge the hoseline. When the Engine Company 42 Nozzle
Firefighter opened the nozzle to bleed the air from the hoseline, there was insufficient
Page 20 of 86
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( water pressure. The Captain relayed this information to his Chauffeur. As the Engine
Company 42 Chauffeur charged the hoseline, he noticed that the preset pressure went to
45 psi.
l
He then manually raised the pressure to 150 psi.
The Ladder Company 33 Inside Team opened the door to the fire apartment,
entered, and began to search. The Engine Company 42 Captain then momentarily closed
the fire apartment door to allow civilians to continue down the stairs from above. After
the civilians descended, the Engine Company 42 Captain, Nozzle and Back-up
Firefighters entered the fire apartment with their hoseline to begin extinguishment
operations.
There was heavy smoke and heat in the fire apartment. Engine Company 42
initially advanced their hoseline straight down the apartment hall, past the kitchen,
toward the rear bedrooms. The Ladder Company 33 Forcible Entry Firefighter entered
the kitchen area and located the fire. He returned to the apartment hall and verbally
directed Engine Company 42 back to the kitchen doorway. Engine Company 42 pulled
the hoseline back, entered the kitchen and began their attack on the fire. While Engine
Company 42 members operated their hoseline, the Ladder Company 33 Inside Team
searched bedroom 1 and the bathroom.
Initially, a Probationary Firefighter had the nozzle position on Engine Company
42's hoseline. While supplied with booster water, the Nozzle Firefighter operated the
hoseline in the kitchen and began to extinguish fire extending into the kitchen.
Water Relay
The Engine Company 75 Chauffeur notified the Engine Company 42 Chauffeur
via handie-talkie that he was ready to relay hydrant water. At 0813 hours, the Engine
Company 42 Chauffeur told the Engine Company 75 Chauffeur, "Send it up." Engine
Company 75 supplied Engine Company 42 with water at approximately 180 psi. The
Engine Company 42 Chauffeur fully opened the gated inlet on the Officer's side of
Engine Company 42's apparatus. The Engine Company 42 Chauffeur transmitted to his
Officer, via the handie-talkie, that he was on hydrant water. The incoming pressure,
1 The default pressure of the PRO Pressure Governor is 45 psi. It is field adjustable and programmable
according to unit needs. The LED display that indicates the psi setting on the PRO Pressure Governor
does not always indicate the actual discharge pressure (see Finding 21).
Page 21 of 86
coupled with the pressure added by Engine Company 42's apparatus, resulted in
approximately 290 psi being supplied to Engine Company 42's hoseline at the discharge
gate.
2
The Engine Company 42 Nozzle Firefighter had difficulty operating the hoseline
due to a nozzle pressure of approximately 160 psi.
3
He was forced to shut the hoseline
down several times to maintain stability and to prevent losing control of the hoseline.
The Captain of Engine Company 42 did not fully understand what was happening to his
Nozzle Firefighter. At this point, the Captain of Engine Company 42 wanted a more
experienced Firefighter on the nozzle. He ordered the Back-up Firefighter and the
Nozzle Firefighter to switch positions .
..
Initial Operations Floor Above
Rescue Company 3 arrived and Battalion 19 ordered them to search the floor
above the fire. As Engine Company 75 stretched their hoseline up the stairs, the Rescue
Company 3 Captain, Forcible Entry, Hook, and Outside Vent Firefighters, and Firefighter
Bellew, the Ladder Company 27 Chauffeur, were seen on the stairs to the third floor
landing. The Rescue Company 3 Captain, Forcible Entry, and Hook Firefighters
ascended the stairs to the fourth floor. It is believed that Firefighter Bellew followed the
Rescue Company 3 Inside Team to the fourth floor to assist with searches. The Rescue
Company 3 Outside Vent Firefighter then went to the fourth floor. As soon as the Rescue
Company 3 Captain arrived on the top floor, he confirmed that the Ladder Compapy 27
Inside Team was in the apartment over the fire (4L). The Rescue Company 3 Captain
then initiated a primary search of the adjoining apartment (4K) with the Rescue Company
3 Forcible Entry and Hook Firefighters. The Rescue Company 3 Outside Vent
Firefighter, on arrival at the top floor, entered the apartment directly above the fire (4L).
On the third floor, the Lieutenant of Engine Company 75 had consulted with the
Captain of Engine Company 42 about fire conditions. Engine Company 75's hoseline
was taken, as per Standard Op.erating Procedure (SOP), to the floor above. The
Lieutenant of Engine Company 75 entered the apartment directly above (4L) and
2 Current engine apparatus in pressure position adds approximately 110 psi at idle to incoming pressure.
The static hydrant pressure was 70 psi. Engine Company 75's apparatus added 110 psi, supplying Engine
Company 42 with 180 psi. Engine Company 42's apparatus added approximately 110 psi to this incoming
pressure. This resulted in approximately 290 psi being supplied to Engine Company 42's hoseline.
The recommended nozzle pressure is 50 psi.
Page 22 of 86
proceeded toward bedroom 1. He was redirected by Rescue Company 3' s Outside Vent
Firefighter back toward bedroom 3. The Lieutenant of Engine Company 75 conferred
with Lieutenant Meyran at the door to bedroom 3. Lieutenant Meyran, Ladder Company
27, was using the thermal imaging camera. Lieutenant Meyran told the Lieutenant of
Engine Company 75 that there was heat behind the apartment hall entrance door to
bedroom 3. The Lieutenant of Engine Company 75 called for water in his hoseline and
his unit prepared to operate. Lieutenant Meyran then ordered the padlocked door to
bedroom 3 to be forced open.
Operations in Fire Apartment
The Rescue Company 3 Chauffeur went into the third floor fire apartment (31) to
search. He went stnught down the apartment hall toward the rear. At the door to
bedroom 3, he noted significant heat. He opened that door to bedroom 3 and saw that the
..
room was involved in fire. He also noted that a hoseline (Engine Company 42's) was
operating adjacent to this area in the kitchen. He then closed the apartment hall door to
bedroom 3 to prevent extension.
During Engine Company 42's advance and operations on the fire floor, the
members of Engine Company 46 assisted on the hoseline. While Engine Company 42
was operating, Engine Company 46 members were on the fire floor landing, at the fire
door, and in the fire apartment with Engine Company 42. This resulted in eight
Firefighters and two Officers crowded in a relatively small area operating with the 1 %
inch hoseline.
Division 7 Arrives on Scene
Battalion 19 instructed the Battalion Firefighter to transmit the All-Hands signal
and to request an additional Engine and Ladder Company. At 0812 hours, Division 7
arrived. He proceeded to the front of the fire building and assumed command. Division
7 was updated by Battalion 19 regarding fire conditions and the location of the operating
units. Division 7 then ordered Battalion 19 to supervise operations on the fire floor.
Ladder Company 59, the FAST unit, arrived and reported to the Command Post in front
of the fire building with the appropriate equipment. Engine Company 43, the fourth
engine, was assigned to keep the stairs clear and assist on tht? second hoseline.
Page 23 of86
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After performing initial roof duties, the Roof Firefighter of Ladder Company 33
removed a vent on the roof to check for heat in the cocklofL He observed no indications
of heat or fire in the cockloft.
At approximately 0814 hours, Battalion 17, the All-Hands Chief, arrived at Grand
Concourse and East 178
th
Street. The Battalion 17 vehicle was equipped with a handie
talkie recorder as part of a pilot program. The handie-talkie recorder began recording
handie-talkie transmissions at approximately 0812 hours prior to Battalion 17's arrival on
the scene.
The Battalion 19 Firefighter transmitted the building CIDS information via the
handie-talkie stating, "Stairway is in bad condition, just relay it to all members." The
Battalion 19 Firefighter informed Battalion 19 via the handie-talkie that the additional
engine was Engine Company 48 and the additional ladder was Ladder Company 56.
The Division 7 Firefighter directed the dispatcher to instruct Engine Company 48
to take a position at the ~ y d r a n t on the west side of Anthony Avenue and to have Ladder
Company 56 report to the front of the fire building.
Engine Company 43 reached their position between the second and third floors to
assist Engine Company 75 with the second hoseline.
The Rescue Company 3 Captain reported via the handie-talkie that the search of
the adjoining apartment on the fourth floor was negative, and the examination of the
dumbwaiter shaft, which serves both apartments, was also negative.
Water Problems in Fire Apartment
In the fire apartment, Engine Company 42 advanced their hoseline from the
kitchen into the hallway formed by the illegal partition wall. This illegal partition wall,
which isolated bedroom 3 from the fire escape, had burned through. These areas were
heavily involved with fire. The sound of the stream gave the member operating the
nozzle the sense that he was operating into a large room. Actually, with the wall gone, he
was hitting both the hallway and bedroom 3. As the member operating the nozzle
advanced into this area, he lost water in the hoseline. When the nozzle was shut, the
hoseline became firm. When the nozzle was opened there was a very weak water stream.
This scenario occurred two or three times. As the heat increased, the Engine Company
42 Captain ordered the hose line with\frawn from the fire apartment.
Page 24 of86
The Rescue Company 3 Saw Firefighter looked over the rear parapet and noticed
a repeated fluctuation in the water stream from the third floor windows. The stream
appeared to strengthen and weaken several times, and then stopped. He transmitted via
the handie-talkie that fire was still showing out one window in the rear at 0814:58 hours.
Squad Company 41 transmitted a lO-84 at 0815:21 hours on the MDT. Squad
Company 41 then reported to the Division and was ordered to stand fast. The Squad
Company 41 Lieutenant directed his outside team to go to the roof.
Loss of Water
At 0817:25 hours, there were three unidentified and unacknowledged calls over
the handie-talkie pertaining to the loss of water. There were verbal reports of a burst
length among members on the hoseline. Engine Company 42 and Engine Company 46
members backed the hoseline out of the' fire apartment and into the front apartment (30).
The Ladder Company 33 Lieutenant, Can and Forcible Entry Firefighters also exited the
-'
fire apartment.
Battalion 19 called the units on the floor above via the handie-talkie and
Lieutenant Meyran responded. Battalion 19 informed these units that there was a loss of
water on the fire floor. Due to the water loss, Battalion 19 asked the Engine Company 75
Lieutenant if he could bring his hoseline down to the third floor. The Engine Company
75 Lieutenant responded, "We got the line charged and ready to go. They're forcing the
door in the apartment on the floor above. We'll get water on it as soon as they ge! that
door open." Division 7 attempted to contact Battalion 19. Battalion 19 again asked
Engine Company 75 if they could bring their hoseline downstairs. The Engine Company
75 Lieutenant said, "10-4 Chief... do you want the line back downstairs on the third
floor?" Battalion 19 responded, "Yeah, bring it down, we have a burst length here." The
Engine Company 75 Lieutenant verbally notified Lieutenant Meyran that he was bringing
the hoseline downstairs.
Lieutenant Meyran verbally acknowledged that the hoseline was b ~ i n g removed.
The Ladder Company 27 Inside Team continued to search bedrooms 1, 2, and 3.
Lieutenant Meyran and the Ladder Company 27 Forcible Entry Team began to look for
the fire escape. There was a heavy smoke condition, no discernible heat, and no visible
fire extension observed in the apartment directly above the fire at this time. No report of
Page 25 of 86
conditions from the apartment directly above the fire was transmitted via the handie
talkie. The Ladder Company 27 Inside Team was unaware of the existence of bedrooms
4 and 5 or of the hallway formed by the illegal partition wall.
Battalion 19 reported to Division 7 that they had lost water in the first hoseline
and were bringing the second hoseline from the floor above to the fire floor. Division 7
acknowledged this message and told Battalion 19 that Squad Company 41 was standing
fast in front of the fire building. Division 7 asked Battalion 19 what he wanted to do with
Squad Company 41. At 0818:48 hours Battalion 19 responded, "Stretch a third line,
stand fast in front of the building, and have enough lengths to cover the fourth floor."
Division 7 ordered Squad Company 41's Lieutenant to stretch a hoseline to the front of
the building.
Battalion 17 reported to Division 7 in front of the fire building and was assigned
to the floor above. Battalion 17 contacted his Battalion Firefighter via the handie-talkie
and told him to come to the front of the fire building. The Battalion 17 Firefighter
brought him his SCBA.
Division 7 attempted to contact Battalion \9 via the handie-talkie for the progress
of the searches. This transmission was not acknowledged. The Rescue Company 3
Captain directed his Hook Firefighter to move from the fourth floor adjoining apartment
(4K) into the apartment directly over the fire (4L) to evaluate conditions.
The Engine Company 42 Chauffeur had heard a report of a burst length via the
handie-talkie. He called his Captain via the hand ie-talkie and asked him if he had a burst
length. Battalion 19 answered at 0819:46 hours, "42 has a burst length. 75 is coming
down to the fire floor. " The Engine Company 42 Chauffeur was puzzled by this message
since the readings on his pump panel did not indicate a burst length. However, based on
the confirmation of a burst length, the Engine Company 42 Chauffeur shut down the first
hoseline. He then directed an off duty Firefighter from Engine Company 42 to follow the
first hoseline into the fire building to check the hoseline and to report back to him. No
one was notified that the hose line was shut down.
The off duty member of Engine Company 42 had his fire fighting gear with him,
but did not have a hand ie-talkie. He obtained a SCBA from Engine 75's apparatus and
followed the hoseline to the second floor. On his way to the second floor, he noticed two
small kinks in Engine Company 42's hoseline at the base of the stairs on the first floor
Page 26 of 86
and removed them. Other than the two kinks at the base of the stairs, the off duty
member did not see anything else wrong with the hoseline. Since he did not have a
handie-talkie, he was unable to transmit a report back to the Engine Company 42
Chauffeur, and continued up the stairs to the second floor.
The Squad Company 41 Nozzle and Backup Firefighters started to stretch a 2 Y2
inch hoseline from Engine Company 42's apparatus. The Engine Company 42 Chauffeur
stated that the first hose line was not in use and he had plenty of water for another
hoseline. Squad Company 41 stood fast with the hoseline in the street. The Squad
Company 41 Roof and Saw Firefighters were on the roof of the fire building. When they
heard via the handie-talkie that Squad Company 41 was assigned to stretch a hoseline,
they started to descend from the roof through exposure #4.
Backing Out ofthe Fire Apartment
After backing out of the fire apartment, 'Engine Company 42's Captain and
Ladder Company 33' s Lieutenant conferred and agreed that all Fire Department members
were out of the fire apartment. They then closed the door to the fire apartment, unaware
that the Chauffeur of Rescue Company 3 was in the fire apartment. Engine Company
42's hoseline was withdrawn into apartment 3G. The Officers supervising this hoseline
did not issue orders to investigate or correct the problem with this hose line. The
Firefighters operating on this hoseline took no meaningful action to correct the water
problem.
After withdrawing the hoseline, the Engine Company 42 Captain went to the
second floor rear apartment to determine the layout of that line of apartments. He was
unable to gain entry so he utilized members from Engine Company 43, assisting in
Engine Company 75's hoseline, to force open the door. The off duty Engine Company
42 Firefighter, ascending the stairs while checking Engine Company 42's hoseline as
directed by his Chauffeur, met up with the Captain and was directed to accompany him
into the rear apartment.
Vibralert Activates - Floor Above
The Ladder Company 27 Inside Team continued to search bedrooms 2 and 3 in
apartment 4L. The Ladder Company 27 Forcible Entry Firefighter's vibralert sounded
Page 27 of 86
and Lieutenant Meyran ordered him to leave. The Rescue Company 3 Outside Vent and
Hook Firefighters each continued to separately search apartment 4L. There was a heavy
smoke condition but no discernible heat; members were able to walk upright.
The Ladder Company 33 Chauffeur was on the roof and saw the top floor rear
windows being vented from the inside. He feared auto exposure from the fire apartment
into the apartment on the floor above. He advised via handie-talkie at 0820:00 hours to
not vent those windows, but ventilation was already completed. The fourth floor rear fire
escape windows were not vented from the interior.
The members of Engine Companies 42 and 46 continued to standby with the first
hoseline in apartment 3G. The Ladder Company 33 Inside Team waited at the door of
apartment 31 for Engine Company 75 to reposition their hoseline. Members of Engine
Company 75 descended to the third floor fire apartment door with their hoseline.
Battalion 19 monitored conditions w.hile on the third floor landing. The Rescue
Company 3 Chauffeur notified his Captain via handie-talkie from inside the fire
apartment, "Just so you know they had a burst length. They don't have it yet." The
Rescue Company 3 Captain acknowledged the transmission at 0820:14 hours. This was
followed by a handie-talkie transmission 'by the Ladder Company 59 (FAST Unit)
Forcible Entry Firefighter reporting to his Lieutenant from the fourth floor of exposure
#4, "4J checks out clear." Engine Company 48 transmitted their 10-84 at 0820 hours.
Water Relay
The Engine Company 42 Chauffeur asked the Engine Company 75 Chauffeur if
his apparatus was in pumps. The Engine Company 75 Chauffeur responded that he was
in pumps, but only at idle. The Engine Company 42 Chauffeur told the Engine Company
75 Chauffeur to take his rig out of pumps because he had too much intake pressure. The
Engine Company 75 Chauffeur complied and took his apparatus out of pumps. This
action reduced the incoming pressure to Engine Company 42's apparatus from
approximately 180 psi to approximately 70 psi, the static hydrant pressure.
Fire Extinguishment Operations - Fire Floor
As Engine Company 75 arrived at the third floor fire apartment door with their
hoseline, the Rescue Company 3 Chauffeur' exited the fire apartment. Members were
Page 28 of 86
unaware that he was in the apartment. Engine Company 75 then advanced their hoseline
into the fire apartment on the third floor. The Ladder Company 33 Lieutenant, Forcible
Entry and Can Firefighters re-entered the fire apartment to search. The Rescue Company
3 Chauffeur also re-entered this apartment. Engine Company 75 entered the kitchen area
and started to extinguish the fire in apartment 31. Engine Company 43 was positioned on
the stairway between the second and third floors and assisted with the hoseline
advancement. The Ladder Company 33 Lieutenant and Forcible Entry Firefighter
searched bedrooms 1 and 2 in the fire apartment. The Ladder Company 33 Can
Firefighter stayed behind the hoseline as it advanced.
Members of Engine Company 42, while standing by with their hoseline in
apartment 3G, believed that the earlier water problems had been resolved. They believed
they had water back in their hoseline, although no corrective actions had been taken.
Battalion 19 verbally ordered this hoseline to the fourth floor. At approximately this
time, Engine Company 42's Chauffeur was shutting down the hoseline in response to the
handie-talkie confirmation of a burst length. These members were unaware that this
hoseline was being shut down. Since the Captain of Engine Company 42 was on the
second floor, the Lieutenant of Engine Company 46 led Engine Company 42's members
with their hoseline to the floor above. Division 7 was not informed of any of these
actions.
Fire Operations -Floor Above
The Rescue Company 3 Captain and the Rescue Company 3 Forcible Entry
Firefighter left the adjoining apartment 4K, and entered the apartment directly over the
fire, apartment 4L. While searching the kitchen area with the thermal imaging camera,
the Rescue Company 3 Forcible Entry Firefighter found fire in a wall in the area of
bedroom 4 or bedroom 5. There was no handie-talkie transmission of this fire condition
by any member. The Rescue Company 3 Captain asked the Rescue Company 3 Hook
Firefighter for his location via the hand ie-talkie at 0822:25 hours. The Rescue Company
3 Hook Firefighter answered, "I'm in the apartment over the fire."
The Engine Company 46 Lieutenant arrived on the top floor. The members of
Engine Company 42 and 46 followed him with the hoseline. The hoseline reached the
top floor and was flaked out into the opposite apartment on the fourth floor, apartment 41.
Page 29 of86
Civilians from apartment 41 started to self evacuate down the front fire escape. As the
Engine Company 46 Lieutenant entered apartment 4L, he was told that the fire was to the
right. He saw a 'glow' in the kitchen area.
In apartment 4L, the Engine Company 46 Lieutenant ordered the hoseline brought
into the kitchen. The Engine Company 42 Nozzle Firefighter saw fire in the kitchen area
and opened the nozzle. The uncharged hoseline, having been shut down at the pump
panel, immediately went limp. At 0823:07 hours, an unidentified member transmitted
"We have no pressure in 42's line." This message was merely broadcast via the handie
talkie and not directed to any specific member. There was no handie-talkie response to
this transmission. At this time, the following members were operating in apartment 4L:
The Ladder Company 27 Inside Team
The Ladder Company 27 Chauffeur
The Rescue Company 3 Inside Team
The R e s ~ u e Company 3 Outside Vent Firefighter
The Engine Company 46 Lieutenant and Engine Company 42 members on
the hoseline
There were no handie-talkie transmissions regarding the developing fire condition.
Civilians - Top Floor
Civilians that had self-evacuated onto the front fire escape were shouting to
members in the street that someone with a baby was still in the fourth floor apartment. At
0823:14 hours, an unidentified member transmitted, "We got people on the fire escapes
and it's getting pretty charged on the top floor." At 0823:18 hours, Battalion 19 asked
Division 7 to start the third hoseline up and stated that Engine Company 42's hoseline
kept losing pressure. This message was not acknowledged. Battalion 19 then asked
Division 7, "Do you read me?" at 0823:27 hours. Again, he did not receive a reply.
At 0823:50 hours, Division 7 notified Battalion 17 of "a report of somebody in
apartment 4 George on the fourth floor with a baby." Squad Company 41 was standing
fast with the hoseline at the front of the building. Division 7 verbally ordered them to
drop the hoseline to assist with the civilians reported on the fourth floor. The Squad
Company 41 Lieutenant, Hook and Forcible Entry Firefighters ascended the interior stairs
of the fire building in an attempt to get t ~ the fourth floor. The Squad Company 41
Page 30 of 86
Chauffeur took the front fire escape to reach the top floor. The Ladder Company 33
Chauffeur left the roof through exposure #4 to return to his apparatus to raise the Tower
Ladder basket in response to the report of civilians on the top floor.
Battalion 19 noticed Battalion 17 attempting to ascend to the top floor. Numerous
members crowding the stairway prevented Battalion 17 from reaching the top floor at this
time.
The Rescue Company 3 Captain directed his Roof Firefighter to, "Drop down,
start pulling ceilings on that top floor, let me know what you got." The Rescue Company
3 Roof and Saw Firefighters saw fire exposing the rear fire escape and attempted to
descend to the top floor via the bulkhead stairs of the fire building.
No Water on the Floor Above
Battalion 17 called Ladder Company 27 via the handie-talkie and there was no
response. Another unidentified and unanswered transmission stated, "We got no water in
42's line. We need water in 42's line." This message was not directed to any specific
member. The Engine Company 46 Lieutenant and the members on Engine Company
42' s hoseline retreated out of the apartment and into the opposite apartment (4J).
Conditions on the top floor started to deteriorate quickly. The smoke condition became
heavier and thicker.
Battalion 17 then transmitted via the handie-talkie at 0824:43 "Battalion 17 to any
units, to any truck on the top floor." He did not receive an acknowledgement. Division 7
and Battalion 17 then conversed via regarding the status of the people
evacuating from the fourth floor and the fire escape. Battalion 17 attempted to go above
using the front fire escape from apartment 3G, but was unable to. He then returned to the
interior stair.
The Squad Company 41 Saw and Roof Firefighters heard that Squad Company 41
had been reassigned to assist civilians on the fourth floor. They stopped descending to
the street and evaluated conditions on the top floor of exposure #4. Engine Company 48
arrived at the Command Post at approximately 0824 hours and was ordered by Division 7
to stand fast with the 2 1h inch hoseline previously stretched by Squad Company 41. The
Captain of Engine Company 42 returned to the third floor to rejoin his company but they
had been repositioned to the fourth floor.
Page 31 of86
On the third floor landing, the Ladder Company 33 Lieutenant verbally reported
to Battalion 19 that the primary search in the apartment, other than the immediate fire
area, was negative.
Division 7 informed Battalion 17 that the reported trapped civilians were self
evacuating down the front fire escape. Battalion 17 informed Division 7 of the continued
loss of pressure in the hoseline on the top floor. Division 7 asked, "You need another
line, ah, we got a line standing in front of the fire building K." Battalion 17 responded
affirmatively. Division 7 ordered Engine Company 48 to bring their hoseline to the top
floor and notified Battalion 17 of this at 0825 :46 hours.
There was another unidentified, undirected and unanswered hand ie-talkie
transmission at 0825:56 hours stating "42 has no pressure on the floor above, with the
line." Engine Company 42 and Engine Company 46 continued to stand by with the
uncharged hoseline in apartment 4J. The Squad Company 41 Lieutenant, Hook, and
Forcible Entry Firefighters reached the top floor and attempted to enter apartment 4L.
Member Out ofAir - Floor Above
In bedroom 3, Lieutenant Meyran and the Ladder Company 27 Can Firefighter
discontinued their search for the fire escape because their vibralerts began to sound.
They could see the fire escape from window D, but were unable to reach it because of the
illegal partition wall in that room. As they were leaving bedroom 3 through the French
doors into bedroom 2, they met the Ladder Company 27 Forcible Entry Firefighter. This
member had removed his helmet and facepiece and was yelling that he was out of air.
..
The interior door from bedroom 2 to the apartment hall was closed and window C was
approximately 5 feet to their right. Lieutenant Meyran steered the Ladder Company 27
Forcible Entry and Can Firefighters to window C.
Having heard the several handie-talkie transmissions regarding pressure problems
in Engine Company 42's hoseline, the Engine Company 43 Chauffeur and an off duty
Firefighter from Engine Company 43 attempted to correct the water problem. Since there
were several Chauffeurs at Engine Company 42's apparatus attempting to address the
problem, they went to Engine Company 75's apparatus. The Chauffeur of Engine
Company 75 was not there; he was assisting at Engine Company 42's apparatus. The two
Page 32 of86
members from Engine Company 43 noticed that Engine Company 75's apparatus was not
in pumps. They put the apparatus back into pumps. No one was notified.
Ladder Company 56, the additional Ladder Company, was standing fast in front
of the fire bUilding. On direction of his Lieutenant, the Ladder Company 56 Outside
Vent Firefighter went to the rear of the fire building via exposure #2 alley to check
conditions. He noticed smoke coming from all the rear windows on the top floor. He
returned to the front of the fire building to inform his Lieutenant. Windows A, B, C, and
D had already been vented by Ladder Company 27 from the interior. The fourth floor
fire escape windows had self vented.
From their position on the rear fire escape, the Ladder Company 33 and Ladder
Company 27 Outside Vent Firefighters saw the Ladder Company 27 Forcible Entry
Firefighter at window C on the fourth floor. He appeared to be in distress. They asked
him if he was okay. He responded that he was okay and just needed some air. The
Ladder Company 27 Can Firefighter ran out of air at this time. Lieutenant Meyran still
had air in his cylinder but had removed his facepiece.
Report of Slight Extension on the Floor Above
Division 7 called Battalion 17 via the handie-talkie and asked if there was
extension on the floor above. Battalion 17 called Ladder Company 27 via the handie
talkie and asked, "Do we have extension on the top floor? Are you in the apartment
now?" Lieutenant Meyran responded, "We're in the apartment on the floor above K.
Slight extension, we had a line up here and ah, that was 75's line earlier. What's the
status of the fire?" Battalion 17 respondedt "So we had (cleared throat), so that's a pos,
we did have extension?" Lieutenant Meyran answered, "Slight extension, slight
extension." It was now 0826:43 hours. Battalion 17 then asked, "is the line hitting it?
I'm in the hallway."
The Rescue Company 3 Outside Vent Firefighter was searching in the vicinity of
bedroom 3 when another member informed him that there was high heat on the exposure
4 side of the apartment. He believes that this member was Firefighter Bellew.
Page 33 of 86
seBA Lowered From the Roof
The Ladder Company 27, the Ladder Company 33, and the Rescue Company 3
Roof Firefighters heard the conversation between the Ladder Company 27 Forcible Entry
Firefighter at window C and the Outside Vent Firefighters on the rear fire escape. The
Rescue Company 3 Hook Firefighter, at window A in bedroom 1, also heard this
conversation. He dislodged the child gate in window A and hinged it out toward
exposure #2. He saw the Ladder Company 27 Forcible Entry Firefighter at window C.
The Ladder Company 27 and Rescue Company 3 Roof Firefighters lowered a SCBA
from the roof to the Ladder Company 27 Forcible Entry Firefighter with a utility rope.
This operation went unreported to the Incident Commander.
The Ladder Company 56 Outside Vent Firefighter returned to the rear yard and
observed members lowering a SCBA from the roof to window C. He also saw other
members at windows but they did not appear to be in distress. The Ladder Company 56
Outside Vent Firefighter noticed the smoke condition from the fourth floor windows was
getting worse. He returned to the street to inform his Officer.
While taking civilians down the front fire escape, the Squad Company 41
Chauffeur found security gates on the second floor fire escape windows. He asked, via
the handie-talkie, for a portable ladder to remove the civilians to the street.
Engine Company 48 continued to stretch tite third hoseline up the interior stairs.
The hoseline was broken in the street and was in the process of being connected to
Engine Company 42's apparatus when it was discovered that more hose was needed. A
length of hose was added and the hoseline was connected to the pumper.
MAYDAY Transmissions
The Engine Company 42 Captain contacted Division 7 via handie-talkie and
stated "Chief, We have ... " when he was interrupted at 0828:20 hours by Lieutenant
Meyran transmitting "MAYDAY, MAYDAY, MAYDAY." The Engine Company 42
Captain continued his message at 0828:21 " ... we hive fire into the hallway on the floor
above. You need a line upstairs." At 0828:27, "MAYDAY, MAYDAY, MAYDAY" was
transmitted. The Engine Company 42 Captain concluded his transmission at 0828:29
" ... Forty two has no water." This message was immediately followed at 0828:30 hours
by Lieutenant Meyran clearly transmitting, "MAYDAY, MAYDAY, MAYDAY, Ladder 27
Page 35 of 86
MAYDAY." The Investigative Team believes that the three separate MAYDAY
transmissions were in response to the fire and heat conditions now extending into
bedroom 2.
Division 7, coordinating the removal of civilians from the front fire escape, did
not hear the MAYDAY transmissions. As the Ladder Company 56 Chauffeur verbally
informed Division 7 of the MA YDA Y transmissions, the Rescue Company 3 Hook
Firefighter transmitted from bedroom 1, "You gotta get a hole in the roof before the
ceiling blows down on everybody." Division 7 transmitted, "Division 7 to the, ah,
MAYDAY message. Go ahead, who's the MAYDAY?" At 0828:46 hours, the Rescue
Company 3 Hook Firefighter answered Division 7' s message from his position in
window A, "The member from 27 Truck, he's outta air, a mask has been lowered to him
and there's a member with him. But we need to get a hole in the roo}:" The Rescue
Company 3 Hook Firefighter then left the window in an attempt to exit bedroom 1. He
was met with heavy fire in the apartment hall and was forced to close the bedroom door,
and return to the window. At this time, the Rescue Company 3 Saw and the Ladder
Company 33 Roof Firefighters continued clearing snow and cutting a hole in the roof
over bedroom 4.
The Rescue Company 3 Forcible Entry Firefighter, who was now just inside
bedroom 2, was knocked over by another member. The Rescue Company 3 Forcible
Entry Firefighter got up and scrambled to window B.
The Investigative Team believes that the member who knocked over the Rescue
Company 3 Forcible Entry Firefighter was Firefighter Bellew. Firefighter Bellew reacted
to the sudden increase in heat and collided with the Rescue Company 3 Forcible Entry
Firefighter. Firefighter Bellew subsequently entered bedroom 3 where he continued to be
subjected to the severe conditions.
Division 7 verbally ordered Ladder Company 59, the FAST unit, to the roof on
the report of the distressed member at the rear window and the need for roof ventilation.
They proceeded to the roof via exposure #l. Division 7 then verbally ordered Ladder
Company 56 to the top floor of the fire building. The Ladder Company 56 Lieutenant
split his team with the approval of Division 7. He sent his Chauffeur, Roof and Outside
Vent Firefighters to cover the roof, while he led his Forcible Entry and Can Firefighters
to the rear for a quick exterior survey prior to ascending to the top floor.
Page 36 of86
All units assigned on the alann were on scene and operating. No other units were
assigned to the fire at this time.
Members in Distress at Rear Windows
Lieutenant Meyran, the Forcible Entry and Can Firefighters were now crowded
together at window C. The child guard gate was still in place and was approximately 25
inches in height from the sill, covering the lower section of the window opening. An
attempt to remove the child guard gate was discontinued because of the rapidly
deteriorating conditions. The Forcible Entry Firefighter was breathing from the SCBA
which had been lowered from the roof to the window. Lieutenant Meyran was positioned
to the left of the Forcible Entry Firefighter. The Ladder Company 27 Can Firefighter was
positioned slightly behind and to the left of Lieutenant Meyran when he ran out of air.
When Lieutenant Meyran realized that the Can Firefighter was out of air, he pulled him
into the window, which was approximately 32 inches wide. The Can Firefighter, who
was facing to the left outside the window, saw Jmember at the adjoining window
(window B).
Lieutenant Meyran directed the Can Firefighter, positioned to his immediate left,
to remove his SCBA to make more room at the window. The Can Firefighter slightly
backed away from the window into the room and removed the right shoulder strap of his
SCBA. He felt intense heat and was forced to quickly move back to the window.
Lieutenant Meyran was now climbing out over the child guard gate in window C: The
Ladder Company 27 Forcible Entry and Can Firefighters grabbed onto him as he climbed
over the child guard gate. The Ladder Company 27 Can Firefighter believed that
Lieutenant Meyran was either making room at the window or showing the way out by
using what looked like a self-rescue maneuver.
From the landing between the third and fourth floors, Battalion 17 saw fire
blowing out of the shaft windows on the top floor. At 0829:'13 hours, he transmitted a
handie-talkie message for all units to back out to the stairway.
The Rescue Company 3 Hook Firefighter was now straddling window A, facing
window B. At 0829:30 hours, he called for a rope to be deployed from the roof.
At 0829:41 hours, there was an unidentified and unanswered call via the handie
talkie for the 2 Y2 inch hoseline (Engine Company 48's hoseline) to be broken and
Page 37 of86
charged with water. Simultaneously, the Division 7 Firefighter transmitted a second
alarm on the Department radio stating, "We got three handlines stretched. We have
extension to the floor above and into the cockloft. At this time we got a MAYDAY K,
FAST truck is in operation. Doubtful at this time, K."
"We're Bailing Out ofHere"
The Rescue Company 3 Hook Firefighter noticed the Rescue Company 3 Forcible
Entry Firefighter scrambling out the top half of window B onto the air conditioner
mounted in the window. The transom above the bedroom 1 door failed and fire started
entering this room. At 0829:52 hours the Rescue Company 3 Hook Firefighter
transmitted a MAYDAY. Approximately ten seconds later he transmitted, "We're
bailing out of here, hurry up."
On arrival at the rear, the Ladder Company 56 Lieutenant looked up and saw a
member (Lieutenant Meyran) hanging trom a window with other Firefighters holding
onto him. At 0830: 13 hours, the Ladder Company 56 Lieutenant transmitted, "MAYDAY,
get a rope to the roof Rope to the roof! Get a thirty-five in the rear. Thirty-five to the
rear. Rope on the roof, thirty jive to the rear." Division 7 acknowledged this message
and notified Ladder Company 59, the FAST Unit, of the need for a rope on the roof. This
handie-talkie transmission was recorded at 0830:33 hours.
The Rescue Company 3 Forcible Entry Firefighter was lying on top of the air
conditioner in window B with his legs still in the room. From this position, he asked the
Rescue Company 3 Hook Firefighter in window A for help because he was burning. He
stated that he had a rope but could not tie it off.4 The Rescue Company 3 Forcible Entry
Firefighter threw the carabiner attached to the end of the rope to the Rescue Company 3
Hook Firefighter. The Rescue Company 3 Hook Firefighter stepped on the end of the
rope, took several turns around his forearm, and braced himself against the window
frame.
Lieutenant Meyran hung from the child guard gate in window C before he fell to
the ground. The Ladder Company 27 Can Firefighter then climbed out this window. As
he hung from the child guard gate, he saw heavy smoke and fire above the Ladder
4 This rope was 3/8 inch flat woven Kevlar rope - 50 feet in length with a carabiner on each end. When
found it had a descender and carabiner located 6 feet, 8 inches from the leading end.
Page 38 of 86
Company 27 Forcible Entry Firefighter. He realized he was blocking the only escape
route for the Ladder Company 27 Forcible Entry Firefighter. He released his grip on the
\
child guard gate and fell to the ground. The Investigative Team believes that at
approximately this time, Firefighter Bellew was forced to jump from window D as fire
rapidly extended into bedroom 3.
At 0830:43 hours, the Ladder Company 56 Lieutenant transmitted, "MAYDAY,
MAYDAY, 56, man down, fell out the window ... MAYDAY, MAYDAY, ... fireman down in
the rear, two firemen down in the rear."
The Rescue Company 3 Forcible Entry Firefighter attempted to belayS down the
rope being held by the Rescue Company 3 Hook Firefighter. He swung like a pendulum
from his position on the air conditioner in window B, toward exposure #2. He was
unable to control his descent and fell to the ground, landing near the top of the rear yard
stairs. The Rescue Company 3 Hook Firefighter then hooked the carabiner of the rope to
the partially removed child guard gate in window A. The Rescue Company 3 Hook
Firefighter then attempted to belay down the rope. He was also unable to control his
descent and fell to the ground, landing at the base of the rear yard stairs.
After the Ladder Company 27 Can Firefighter dropped from window C, the
Ladder Company 27 Forcible Entry Firefighter felt the heat intensifying through his
hood. He then rolled over the child guard gate in an attempt to exit but a strap of his
SCBA became caught on the gate. As he hung there in an upright position, he looked up
and saw a member corning over the parapet wall from the roof. The SCBA strap
suddenly freed itself and he fell to the ground.
Life Saving Rope Rescue Attempt
Just prior to this, the Squad Company 41 Saw Firefighter looked over the rear
parapet and saw a member falling in mid air and other members lying on the ground. He
also saw a member (Ladder Company 27 Forcible Entry Firefighter) climbing out over a
child guard gate in window C. He immediately picked up a Life Saving Rope, hooked
the loops of the bowline onto his personal harness, and threw the rope bag to the Rescue
Company 3 Roof Firefighter. The Rescue Company 3 Roof Firefighter took turns with
5 Belay is understood to mean the use of a rope wrapped around the back and held with both hands at the
front of the body. The friction created by the body allows for enough control to lower oneself.
Page 39 of86
the rope on the hook of his personal harness, dropped on his back and braced his feet
against the rear parapet wall. The Squad Company 41 Saw Firefighter climbed over the
rear parapeq As the Squad Company 41 Saw Firefighter began to be lowered, the Ladder
Company 27 Forcible Entry Firefighter in window C dropped to the ground. The Roof
Firefighters from Ladder Company 27 and Ladder Company 33 assisted in the Life
Saving Rope operation. The Squad Company 41 Saw Firefighter was lowered
completely to the ground.
Operations After Forced Evacuation
Handie-talkie recordings indicate that the first member was on the ground at
0830:43 hours, and all six members were on the ground by 0831 :23 hours, a span of 40
seconds.
The Engine Company 48 Lieutenant called for radio silence and requested water
In Engine Company 48's hoseline at 0830:06 hours. Just prior to this, the Engine
Company 48 Nozzle Firefighter had reached the top floor. Due to the crowded stairway
and fire venting from the apartment door onto the landing, he had no place to flake out
his length of hose. Several members informed him of the urgent need for a hoseline in
the rear apartment. The Engine Company 48 Nozzle Firefighter dropped his folds of
hose down the stairs behind him.
The members of Engine Companies 42 and 46 made their way down the interior
stairs from the fourth floor. The Engine Company 42 Captain went to the second floor
rear apartment with the Engine Company 42 Door Firefighter. The remainder of Engine
Company 42 members went to the street. The Squad Company 41 Forcible Entry and
Hook Firefighters became separated from their Lieutenant and also went into the second
floor rear apartment. Engine Company 46 briefly assisted in advancing Engine Company
48' s hoseline, and then descended to the street to replace their cylinders.
Engine Company 75 had knocked down all visible fire in apartment 3I. The
Engine Company 43 members moved into apartment 31 to take over Engine Company
75's hoseline. The Engine Company 75 members exited the third floor via the rear fire
escape and re-entered the building on the second floor. They subsequently assisted in
moving the 2 Y2 inch hoseline up the stairs.
Page 40 of 86
A ventilation hole was opened in the roof above bedrooms 4 and 5 and heavy
smoke followed by fire forcibly vented from the hole. Ladder Company 59 members
arrived on the roof and began looking for a substantial object to which a Life Saving
Rope could be tied . .-They then assisted with roof cutting operations.
The Division 7 Firefighter transmitted a third alarm at 0832 hours.
At 0833:38 hours, Battalion 17 notified Division 7 that "48 is gonna make it's
push into the apartment." The Engine Company 48 Nozzle Firefighter initially operated
from the public hall into apartment 4L. As the hose in the stairway was straightened out,
the hoseline advanced into the apartment and knocked down fire in the apartment hall.
The hoseline was then directed into the kitchen. The Engine Company 48 Lieutenant
heard a PASS Alarm going off in the rear of the apartment. He advanced to bedroom 2
and found a SCBA and a helmet. He then went to bedroom 1 and found fire still in that
room. He returned to the hose line and redirected it to bedroom 1. The Engine Company
48 members subsequently moved their hoseline to bedrooms 4 and 5 and knocked down
all visible fire in apartment 4L.
Numerous members assisted in the treatment and removal of the six injured
members. None of the six injured members had removed their SCBAs prior to exiting
the windows. Members providing first aid either cut off or removed the SCBAs. The six
injured members were removed from the rear yard. Multiple EMS units arrived on the
scene and the six injured members were transported to area hospitals. The 3/8 inch
Kevlar rope that the Rescue Company 3 Hook and Forcible Entry Firefighters attempted
to use was later cut by a member retrieving equipment in the rear yard. This rope did not
break: during the self-rescue attempts.
Page 41 of 86
VI. FINDINGS
1. The illegal wall on the fourth floor impeded the discovery of the growing fire on
that floor and also channeled the fire's path through the apartment. The fire
,
began in bedroom 4 on the third floor. The window in that room self-vented,
intensifying the fire. The fire extended to the fourth floor in bedroom 4 and then
to bedroom 5. When the fire escape windows on the fourth floor self vented, the
wind suddenly drove the fire through the kitchen. The fire raced through the
apartment hall toward bedrooms 1, 2 and 3. This forced members to the windows
in these rooms, where eventually, they were forced to evacuate their positions.
2. The construction of the illegal partition wall in bedroom 3 on the fourth floor
hindered completion of searches and prevented direct access to the secondary
means of egress. It also delayed the discovery of the fire extending to that floor.
3. The wind had a profound negative effect on this fire. Wind changed fire
conditions rapidly. The thermo-pane windows on the fourth floor fire escape self
vented and allowed the fire to be driven with surprising speed.
4. Five of the six injured members were wearing Department issued personal
harnesses. Personal harnesses without personal ropes are ineffective for self
rescue. The Department discontinued the use of and recalled all personal ropes in
the year 2000 after having them in service for over ten years. This eliminated the
possibility and/or the probability that any of the trapped members could have
exited their positions using an approved, tested, self-rescue means in time to
prevent tragedy. Some members had enough time to deploy and use the former
personal harness and rope system. Due to the lack of alternatives, two members
were forced to improvise using unsanctioned equipment. No consideration should
be given to the use, or potential use, of unsanctioned equipment.
5. At this fire, a junior Engine Company Firefighter was assigned to the roof
position. The Investigative Team found that the duties of the assignment were
completed and had no deleterious effects at this operation.
Page 42 of 86
VI. FINDINGS
1. The illegal wall on the fourth floor impeded the discovery of the growing fire on
that floor and also channeled the fire's path through the apartment. The fire
,
began in bedroom 4 on the third floor. The window in that room self-vented,
intensifying the fire. The fire extended to the fourth floor in bedroom 4 and then
to bedroom 5. When the fire escape windows on the fourth floor self vented, the
wind suddenly drove the fire through the kitchen. The fire raced through the
apartment hall toward bedrooms 1,2 and 3. This forced members to the windows
in these rooms, where eventually, they were forced to evacuate their positions.
2. The construction of the illegal partition wall in bedroom 3 on the fourth floor
hindered completion of searches and prevented direct access to the secondary
means of egress. It also delayed the discovery of the fire extending to that floor.
3. The wind had a profound negative effect on this fire. Wind changed fire
conditions rapidly. The thermo-pane windows on the fourth floor fire escape self
vented and allowed the fire to be driven with surprising speed.
4. Five of the six injured members were wearing Department issued personal
harnesses. Personal harnesses without personal ropes are ineffective for self
rescue. The Department discontinued the use of and recalled all personal ropes in
the year 2000 after having them in service for over ten years. This eliminated the
possibility and/or the probability that any of the trapped members could have
exited their positions using an approved, tested, self-rescue means in time to
prevent tragedy. Some members had enough time to deploy and use the former
personal harness and rope system. Due to the lack of alternatives, two members
were forced to improvise using un sanctioned equipment. No consideration should
be given to the use, or potential use, of unsanctioned equipment.
s. At this fire, a junior Engine Company Firefighter was assigned to the roof
position. The Investigative 'Team found that the duties of the assignment were
completed and had no deleterious effects at this operation.
Page 42 of86
6. A Life Saving Rope operation was initiated at this fire. Due to the urgency of the
situation, it was not deployed according to Department procedures.
7. No definite sequence can be developed regarding the order in which the six
members were forced out of the windows. What is known is that the six members
used four separate windowi to evacuate.
Lieutenant Meyran was the first to fall from window C. He was followed
by the Ladder Company 27 Can Firefighter and then the Ladder Company
27 Forcible Entry Firefighter from the same window.
The Rescue Company 3 Forcible Entry Firefighter fell off a rope after
exiting from window B. Then the Rescue Company 3 Hook Firefighter
fell from the same rope after exiting from window A.
Firefighter Bellew fell from window D.
COMMUNICATIONS
Proper Communications are essential to the safe and efficient management of any
emergency operation. Proper fire ground communications are well described in our
current procedural manuals. At this fire, there were many failures of these procedures.
8. After a MAYDAY transmission was given by Lieutenant Meyran, the Incident
Commander asked who gave the MAYDAY. Another member answered and
gave what he thought was the critical information. This may have prevented the
identity of the MAYDAY member (Lieutenant Meyran) and the information he
wanted to give from reaching the Incident Commander. As a result of his answer,
the immediacy of the situation was not conveyed.
9. In many instances, members aware of important, even life threatening
information, did not transmit the information properly, did not get an
acknowledgement, or simply never transmitted the information to anyone. It is
important to give accurate reports and to use correct terminology in all fire
communications (Le.: handie-talkie, department radio, verbaL .. ). Even one
erroneous report can have very serious consequences.
Page 43 of 86
a. Several members did not notify the Incident Commander that conditions on
the floor above were not improving and in fact, were getting worse over an
extended period.
b. A report on the progress of searches was not given in a timely manner.
c. The Incident Commander did not receive or pursue reports on searches and
extension in a timbly manner, though he did request this information.
d. An erroneous, misleading report of fire extension on the floor above was
given by a member operating in the apartment directly above the fire
apartment.
e. A mistaken report that the first hoseline in the building had burst, led to the
Chauffeur shutting the first hoseline down at the discharge.
f. Notification was not made that the first hoseline had been shut down at the
discharge gate.
g. A number of handie-talkie messages about the failure of Engine Company
42's hoseline were not specifically directed, went unanswered, and were not
questioned.
h. Two Firefighters put Engine Company 75's apparatus back into pumps
without the knowledge of the Engine Company 75 Chauffeur, and failed to
notify anyone.
1. When Officers on the floor above realized that there were members trapped,
they failed to notify the Incident Commander.
J. Important handie-talkie messages were sent without identifying the sender or
the intended receiver. Unidentified handie-talkie messages are simply "noise"
on the radio.
k. Several Firefighters witnessed or participated in the lowering of a SCBA from
the roof level to a Firefighter in distress and did not communicate this
information to the Incident Commander.
OPERATIONS
10. Members did not thoroughly search the apartment directly above the fire. The
illegal partition wall contributed to the difficulty in completing this search.
Page 44 of86
11. Some members went to locations contrary to their orders or assignments:
a. Members operating individually, searched the fire floor or floor above.
b. A unit Officer, after being ordered to stand fast, sent two members to the
roof.
c. A member of the FAST Unit, while his unit was standing fast, searched
apartment 4J in exposure #4.
I
12. Members' actions or inactions created dangerous conditions:
a. Engine Company Officers did not issue orders to ensure restoration of
water in a hoseline that was reported to have burst. When the hose line
appeared to have restored pressure, the Officer in Charge of this line did
not question or verify how this occurred.
b. In lieu of addressing the water problem, a Company Officer left his
hoseline on the fire floor to examine the apartment below.
c. Engine Company members took no significant action to check the hoseline
for kinks, burst lengths, or other defects after it had experienced water
problems.
d. The Incident Commander was not notified of the repositioning of Engine
Company 42's hoseline to the floor above.
e. Members finding fire extension to the apartment directly above the fire did
not notify the Incident Commander and did not alert members in that
apartment.
f. Two members attempted to descend from the roof via the roof bulkhead
stairway prior to the fire being declared under control.
g. A senior company officer was on the floor above throughout this
operation. He either knew or should have known about the fire extension
to that floor at some point earlier in the operation and transmitted this
information to the Incident Commander.
Page 45 of86
13. There was a delay in deploying the third hoseline to the fourth floor.
a. The Battalion Chief on the fire floor believed that the first hoseline had
regained its water supply and ordered that hoseline repositioned to the
fourth floor.
b. Approximately three to four minutes later, the Battalion Chief on the fire
floor became aware that the repositioned hoseline on the fourth floor
continued to Have water problems. He requested via handie-talkie that the
third hoseline be deployed from the street to the top floor. Neither this
message, nor an attempt to confirm this message, were acknowledged.
c. At the time of the request to stretch the third hoseline to the fourth floor,
the Incident Commander was receiving verbal reports of civilians trapped
on the fourth floor.
d. Approximately two minutes later the All Hands Chief requested the third
hoseline to be stretched to the top floor. The Incident Commander then
ordered the third hoseline to be stretched from the street to the top floor.
e. The first two hoselines were stretched via the interior stairway. The third
hoseline was stretched to the fourth floor via the same interior stairway
rather than via the exterior of the building as per Firefighting Procedures,
Engine Operations Chapter 8, section 8.16.1, and Firefighting Procedures,
Multiple Dwelling Fires Section 3.3.20 and 3.3.29 C.
f. Members stretching this 2 Yz inch hoseline were initially unaware ?f the
urgency of the situation and were unassisted by other members.
Note: The third hoseline was supplied with water approximately five
minutes after members commenced stretching to the fourth floor.
14. The Engine Companies that teamed to operate the first hoseline did not ensure
efficient operations. They were not properly spaced and not in the correct
positions on the first hoseline.
15. Officers, while descending from the top floor, did not issue orders to assist with
the 2 Y2 inch hoseline being stretched to the top floor.
Page 46 of 86
16. Members on the floor above continued to operate in a fire area after their
protective hose line was removed. It is extremely dangerous to be operating in any
fire area without the protection of a charged hoseline. The floor(s) above a fire
must be considered potentially life-threatening areas to work in until the fire on
floor(s) below is controlled.
17. At this fire the 3 Y2 inch relay hoseline was hooked up on the Officer's side of
Engine Company 42' s apparatus, as is commonly done for several valid reasons.
This required the Chauffeur of Engine Company 42 to be on that side to open the
gated inlet when relay water was started. Hooking up on this side of the apparatus
brought the Chauffeur away from the pump panel. In this position, he was
unaware of the incoming pressure and the total pressure which is instantly
delivered to any open discharge gate.
18. The All Hands Chief was delayed in reaching his assigned position.
. :-".
19. Violations of All Unit Circular (AUC) 329 FDNY Policy/OSHA Respiratory
Standards (Two-in-Two out Policy) and AUC 220, SCBA Policy, and Training
Bulletin Mask:
a. The Rescue Company 3 Hook, Forcible Entry and Outside Vent
Firefighters operated independently in apartment 4L.
b. The Rescue Company 3 Chauffeur Firefighter operated independently in
apartment 31.
c. The Ladder Company 27 Chauffeur Firefighter operated independently in
apartment 4L.
d. The Department's SCBA policy was not followed when the Ladder
Company 27 Forcible Entry Firefighter's vibralert began to sound.
Department procedures require that a member in this situation exit the
IDLH area immediately with another member. Since there were three
members of the Inside Team, all three members should have exited at that
time.
Page 47 of 86
WATER
20. The first hoseline failed at this fire. This developed into a critical event, which
led to many problems. There were no mechanical problems found in Engine
Company 42's apparatus. There were no defects found in the 1 % inch hose used
in the first two hoselines. During the interview process, a number of members
indicated that they believed the loss of water in Engine Company 42' s hoseline
was a result of ice in the hose. The Investigative Team researched this possibility
and discounts rit as a possible explanation. After an extensive investigation
conducted by this team, it is believed that this loss was caused by one or a
combination of the following circumstances: (See Addendum 1 at the end of the
Findings section for detailed explanations)
a. Kinks in the hoseline
b. Over-compensation for excessive pressure
c. A loss of prime due to air entering the pumps
21. While this had no bearing on operations, the preset on the pump of Engine
Company 42 was not reprogrammed from its default setting of 45 psi. The day
after the fire, the pressure governor's manufacturer (FRC) and the pumper
manufacturer (Seagrave) thoroughly tested the apparatus at Fleet Maintenance.
The representative from FRC noted that the preset was not "set" above its default
setting. No defects were found.
22. Department publications do not address pumping operations for our current fleet
of first line pumpers.
23. Many Chauffeurs report that they do not rely on their apparatus flow meters as
accurate. The flow meter manufacturer (FRC) recommends periodic calibration
of the flow meters. The Investigative Team has found that flow meters are not
calibrated on a regularly scheduled basis. Training Bulletin Apparatus P-2 Flow
Meters describes the procedure for calibrating flow meters. The tools and training
necessary to calibrate the flow meters were never made available to units.
Page 48 of86
24. The standard for relaying water, Evolution 8, is not current. It does not apply to
the pumpers currently in service and does not warn Chauffeurs of the excessive
pressures that may develop in a relay operation. It is in conflict with more recent
written documents on the size of hose to use.
MISCELLANEOUS
25. The 3/8 inch Kevlar rope that was used by the members exiting from windows A
and B did not break. This rope was cut by a member retrieving tools from the rear
yard after the injured members were removed.
,
26. There are no specific written instructions in Departmental publications on what to
do if a hoseline bursts in a regular stretch. Evolution 3 addresses a burst length in
a stretch via the exterior of a building only. There is currently no curriculum
addressing burst length scenarios at the Department Training Academy.
( 27. Members were SUbjected to heat levels ranging from 480 degrees to 930 degrees
Grenheit for approximately two to three minutes. Members were exposed to
heat levels consistent with flashover temperatures. In such conditions, the
function of Firefighters clothing and equipment is simply to provide protection
during the short time needed for an escape without serious [bum] injury as noted
in the Intertek Testing Services report.
28. Two out of the first three hydrants used at this fire were frozen. Department
procedures for identifying, reporting, and thawing hydrants that are subject to
freezing are inefficient.
29. Apartments 31 and 4L were illegally subdivided apartments with single room
occupancy (SRO) conditions. Legal SROs in tenement buildings would have had
to comply with Section 248 of the New York State Multiple Dwelling Law.
Section 248(5) requires SRO apartments in non-fireproof buildings to have
automatic fire sprinklers in every hall or passage within the apartment and at least
Page 49 of 86
one sprinkler head in every roOID. No such system was installed in these two
apartments.
30. Housing and Preservation Department (HPD) inspectors had access to apartment
4L when they issued numerous NOV's for minor maintenance issues, in June 0 '
2004. Single Room Occupancy (SRO) conditions existed in the apartment at th
time of inspection. HPD failed to address or remedy the SRO conditions. 1
31. Several off duty members reported to the fire scene and operated in contradiction
to Departmentpolicy.
Page 50 of 86
Addendum
PLAUSIBLE REASONS FOR LOSS OF WATER
1. Kinks in the Hoseline
The Investigative Team reenacted Engine Company 42's hoseline stretch,
with three possible hose layout configurations on the third floor. There were one
to two lengths of hose flaked into the apartment (3G) opposite the fire apartment.
There was also approximately one length flaked into the middle apartment (2E)
on the second floor. This configuration indicated that the hose line stretched at the
,
actual fire could have been subjected to kinking in the apartment hall in apartment
3G after being flaked out. The re-creation of this hoseline stretch resulted in
several kinks forming in the hoseline in this very narrow apartment hallway (3
feet 3 inches wide by 29 feet long). The description of the failure of Engine
Company 42's hoseline made by the Firefighter operating the nozzle is consistent
with kinks in the hoseline as found during the re-creation. As the member
operating the nozzle advanced into the area of the illegal hallway, he lost water in
the hoseline. When the member shut the nozzle, the hoseline became firm. When
the nozzle was re-opened there was a very weak water stream. This scenario
occurred two or three times. The position of members on the hoseline and their
reported actions after the loss of water also indicate the likelihood of undetected
kinks being the cause of the loss of water.
2. Relay Operations and the Pressure Governor
During the course of this investigation, the hose stretch, water pressures,
and pump operations were simulated as described by the members who operated
at the fire. This was done to try to understand what might have caused the
problems in Engine Company 42's hoseline. The pumper and equipment were
tested on several occasions. There were no defects found.
When the Investigative Team conducted the relay operation tests, they
discovered that the pressure governor performs in ways that may be
misunderstood by members in the field. It was discovered that current pumpers,
while in pumps and in pressurt? position, will produce approximately 110 psi at
Page 51 of 86
now took an additional corrective action. He called the Engine Company 75
Chauffeur and told him to take his pumper out of pumps. This reduced pressure
in the supply line to a manageable leveL
The second hand line stretched and supplied from Engine Company 42
(Engine Company 75's hoseline) did not experience any of the same pressure
problems. This hose line never operated until they were called down from the
fourth floor to the third floor. With the nozzle closed, any excess pressure in the
line was undetectable. By the time they relocated the line to the third floor and
-began to operate, the Chauffeur of Engine Company 42 had detected the problem
at the pump panel and properly adjusted the operating pressures.
The Investigative Team spoke to a number of Chauffeurs in various units
not involved in this operation to get a sense of the level of understanding of this
overpressure situation. In most cases, the Chauffeurs had an incorrect concept
about the capabilities of the pressure governor.
3. Loss of Prime in Engine Company 42's Pump
The first call regarding the loss of water in Engine Company 42's hoseline
occurred at 0817:25 hours. This was four minutes after the start of water in the
relay operation and one minute twenty seconds after the charging of Engine 75's
hoseline. The Engine Company 42 Nozzle Firefighter reported that he lost water
several times before the hoseline went completely soft. Immediately after the
hoseline was withdrawn from the fire apartment, it appeared that pressure in the
line was restored. This description of the loss of water is consistent with what
might occur if a loss of prime developed in the pump. While the Investigative
Team was unable to reproduce a loss of prime during tests at the Chauffeur
Training School, it is possible that it may have occurred at the time of the fire.
Instructors at Chauffeur Training School reported that, while training new
Chauffeurs, it has occurred at random times without explanation. In order to
correct the problem, the discharge gates must be closed and the pump must be re
primed.
Page 53 of 86
VII. CAUSES
Direct Causes
1. Blunt force trauma to the six members.
Indirect Causes
1. Electrical wiring overload in close proximity to a mattress in the fire apartment.
2. The construction and location of the illegal partition wall hindered the discovery
of fire extension and the secondary means of egress in the apartment directly
above the fire.
3. The fire separated members from a safe means of egress.
4. Forced self-evacuation from fourth floor windows without a Department issued
personal escape system.
5. Seeking refuge at a window when a member's air supply was depleted instead of
exiting the IDLH.
6. Search operations on the floor above the fire:
a. Members operating on the floor above did not ascertain the location or
extent of the fire in the fire apartment below.
h. Units above fire did not conduct a complete search in the apartment
directly above the fire.
c. Members searched a limited area of the apartment for a prolonged period
of time.
d. Members continued to operate in a dangerous area without the protection
of a charged hoseline.
e. Members continued operations in an IDLH after vibralert activation.
f. Members did not report conditions in the apartment directly above the fire,
especially worsening conditions, over a period of time.
7. Water loss in first hoseline:
a. The second Engine Company Officer did not properly act as the Water
Resource Officer.
Page 54 01'86
b. Failure of Officers ,and members on the hoseline to take any proper,
meaningful action to find or correct the loss of water.
c. Failure of Officers to properly communicate with the Engine Company
Chauffeur about subsequent pressure or water problems after the first
hoseline was taken to the floor above.
d. Members assumed and announced that the cause of a serious problem with
the hoseline was a burst length without any verification.
e. An Engine Company Chauffeur did not report to his Officer that he had
shut down the water supply to the first hoseline.
,
f. An Engine Company Chauffeur did not properly act on, question, or
clarify numerous unidentified reports of pressure problems with a hoseline
supplied by his pumper.
S. Communications:
a. Neither exposed operating members nor the Incident Commander were
warned or notified of a known, developing, and dangerous fire condition
on the floor above.
b. Chief Officers did not properly solicit and ensure receipt of necessary
information on status of searches and fire extension in a timely fashion.
c. MAYDA Y and URGENT Procedural Failures.
d. Handie-talkie procedural failures. Many critical and important handie
talkie transmissions were not directed to specific members and were not
acknow ledged.
Basic Causes
1. Failure of the Department to provide an approved means for self-evacuation.
2. Failure of the Department to update documents pertaining to pump and water
supply operations.
3. Inadequate training of Engine Company Chauffeurs regarding pump operations
for current apparatus.
4. A lack of experience was reflected in the inability of some members to perceive
and communicate an imminently dangerous environment.
S. Failure to identify, report, and thaw two frozen hydrants.
Page 55 of 86
6. Gusting wind conditions caused fire to spread on the floor above at unusual speed
trapping members.
Page 56 of 86
VIII. RECOMMENDATIONS
1. Provide, as quickly as possible, the equipment and training for a Department
approved method of self-evacuation.
2. Reinforce the policy of not allowing members to enter, operate in, or leave an
Immediately Dangerous to Life and Health (lOLH) atmosphere alone. If a
member leaves a contaminated area, another member using a SCBA must
accompany this member to a safe area. Applying this concept to the three
members of a Ladder Company's Inside Team, if one member's vibralert sounds,
all three members must immediately exit the lOLH.
3. Emphasize the importance of performing proper and complete searches and
communicating the results to the Incident Commander in a timely manner. Size
up, including risk/reward analysis, should be a continuous process until the fire is
declared under controL An Incident Commander's strategy is based on
information received, which must be updated as necessary.
4. Reinforce to all members the importance of maintaining operational discipline.
Units and members must abide by Standard Operating Procedures (SOP) and
must complete their assigned tasks.
5. Reinforce to all Officers the importance of maintaining unit integrity during
operations and to operate as ordered. All companies, including Specialized Units
such as Rescues, Squads, and FAST Units, must report in to the Incident
Commander and operate as directed.
6. Review All Unit Circular 275 (Rescue Company Policy), Addendum 1 (Rescue
Company Operations), and Addendum 2 (Squad Company Operations)
pertaining to specialized unit assignments at fire operations. There is a need to
specify and standardize operations and procedures to ensure that Chief Officers
Page 57 of 86
and units are aware of the duties and locations of Special Operations Command
members.
7. Reinforce the importance of determining the location of the main body of fire
when operating. This is important to all units, especially those operating on the
floor above. Communicate this critical information as early as possible.
8. Reinforce the importance of operating with the protection of a charged hoseline
when in a fire area, the floor above, or any exposed area.
9. Emphasize to all members the importance of having a back-up hoseline available
as a precautionary measure, other than those already in operation. A hoseline
that becomes defective for any reason may have to be quickly replaced.
10. Establish procedures to recalibrate flow meters in a timely and effective manner.
11. Re-evaluate the specifications regarding the minimum idle setting for pumper
apparatus.
12. Update all documents and procedures, including the Chauffeur Training School
Engine Reference Manual, pertaining to current Engine Company apparatu.s and
pumping operations. New, updated procedures should be developed in at least
the following areas:
A. Pressure versus volume operations
B. Inline pumping
C. Relaying water
D. Operation of the pressure governor
E. The preset function on the pressure governor
The Department should also provide, as soon as possible, refresher classes for
Engine Company Chauffeurs emphasizing new procedures as they relate to the
above.
Page 58 of 86
13. Revise the appropriate documents to include actions necessary to address a loss of
water in a hoseline. These procedures should include actions to locate and correct
a burst length. Currently, the only infonnation regarding a burst length of hose is
contained in Evolution 3 which only pertains to a hoseline stretched to the roof or
upper floors via the outside of a building.
14. Incorporate an emergency alert button on the remote microphone of the handie
talkie as soon as possible. At the present time, access to the emergency alert
button is difficult when all Personal Protective Equipment is worn properly.
.}
15. Emphasize the use of the han die-talkie emergency alert button for any MAYDAY
or URGENT transmission. The increased transmitting power (five watts
compared to two watts) provides more transmitting power to overcome other
handie-talkie transmissions occurring at the same time and will alert more
members on the fire ground to the MAYDAY or URGENT situation. The use of
the emergency alert button with the associated MAYDAY transmission will also
cause the emergency alert tone to sound via the handie-talkies of all members on
the scene, alerting members to the fact that a MA YDA Y or URGENT situation is
in progress. If a member transmitting the MAYDAY or URGENT does not use
the emergency alert button, then the Incident Commander must use the emergency
alert button to boost the transmission wattage to alert all members on the scene of
the emergency transmission.
1\
16. Emphasize the critical need to employ proper handie-talkie MAYDAY
I
procedures. This investigation, along with previous Firefighter fatality/serious
I
injury investigations, indicate that this continues to be a problem. When a
MA YDA Y is transmitted, all handie-talkie communications shall cease except
those between the member initiating the emergency transmission and the Incident
Commander. Nonnal handie-talkie communications should only be resumed
\
\
when authorized by the Incident Commander.
~
Page 59 of 86
17. Implement a structured training program for all members emphasizing proper fire
ground communications. This program should stress the following:
A. The recognition of conditions that require a MAYDAY or URGENT
transmission.
B. The need to properly transmit important information to the appropriate
person.
C. The importance of properly identifying the sender and the intended
receiver of all handie-talkie transmissions.
D. The importance of getting an acknowledgement for all transmissions.
Unacknowledged handie-talkie transmissions are just "noise" on the radio.
18. Implement the handie-talkie recorder technology in all Battalion vehicles. This
technology should include the identification of all transmitters and activations of
the emergency alert button. These recordings are extremely valuable for
investigations and can be a valuable training tool for teaching proper
communications.
19. Emphasize the importance of properl y performing hydrant inspection duty.
20. Examine the current procedures for identifying, prioritizing and thawing frozen
hydrants to make these procedures more effective.
21. Establish a program to coordinate the notification of violations and defects found
by other city agencies that are relevant to the Department.
22. Include weather forecasts on the daily Fire Department Chief Officers Schedule.
It should also be included on the daily safety message. Wind and weather
conditions can have an overwhelming effect on operations.
23. Emphasize the need to use the correct method for anchoring the Life Saving Rope
during Life Saving Rope operations, and explore alternatives.
Page 60 of 86
24. Emphasize proper procedures for off duty members offering services for
voluntary duty.
25. Member assignments should be predicated on the Officer's evaluation of a
member's capabilities and experience. Assignments to the more hazardous
unsupervised positions on any given tour should be decided according to the
members' experience, determination, and observation skills.
Page 61 of 86