fdny report on fatal fire, january 23, 2005

8/4/2019 FDNY report on fatal fire, January 23, 2005

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FIRE DEPARTMENT CITY OF NEW YORK SAFETY AND INSPECTION SERVICES COMMAND

INVESTIGATIVE REPORT BROOKLYN BOX 2-21770

577 JEROME STREET JANUARY 23, 2005

CASE NUMBER 09-05 FATAL INJURY

FIREFIGHTER RICHARD T . SCLAFANI LADDER COMPANY 103

VOLUME I THE INVESTIGATION


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Firefighter Sclafani was transported by FDNY Emergency Medical Service(EMS) to Brookdale Hospital. The results of the autopsy revealed that FirefighterSclafani had a carboxyhemoglobin (COHb) level of 24 percent as well as third degreeburns to his head, torso and upper extremities.

As a result of the investigation into this fatality, Safety and Inspection ServicesCommand makes the following recommendations:

1. Develop a procedural guide to assist Chief Officers in formulating a strategy to" manage a MAYDAY for distressed members.

. Develop and implement training for Chief Officers that will focus on the procedures and the active management of a MAYDAY operation.

3. Re-emphasize the importance of using the proper format when transmitting aMAYDAY as per Communications Manual Chapter 9, Section 9.4.

4. Amend the Communications Manual Chapter 9, section 9.4 to include: Themergency alert button must be used during any MAYDAY or URGENT

transmission.

5. Amend the Communications Manual and other appropriate documents to requirethat every time a MAYDAY is transmitted, the Incident Commander must announce the MAYDAY on the handie-talkie and on the appropriate Department borough radio frequency.

6. Incorporate all pertinent information and procedures pertaining to distressed members into a single guide.

7. Re-evaluate Firefighting Procedures Volume 1, Book 6, Private Dwellings, Chapter 3, section 2 pertaining to fIrst due Engine and Ladder Company operations at cellar fIres in private dwellings having an exterior cellar entrance.

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8. Amend Firefighting Procedures Volume 1, Book 6, Private Dwellings Chapter 5section 1.2.B, by adding the following: "Type and location of interior stairs."

9. Re-emphasize that the first due Ladder Company Outside Team must perform aquick exterior survey and notify their Officer and Incident Commander of theconditions found, coordinate VES with the Inside Team, and vent the firearea/room when ordered.

10. Equip each Ladder, Rescue and Squad Company with an additional SCBA to betaken by the unit assigned or designated as the FAST Unit.

11. Amend AVC 320, FIREFIGHTER ASSIST AND SEARCH TEAM - FASTUNIT, to specify member assignments.

12. Re-emphasize the importance of the FAST Unit bringing the full complement ofFAST tools and equipment to the Command Post or Operations Post.

13. Reinforce to all members the need to maintain building entrances and stairwaysunimpeded.

14. Re-emphasize that handie-talkie transmissions must be concise and directed tospecific members or units.

15. Re-emphasize to all Chief Officers the importance of transmitting preliminary andprogress reports as required by the Communications Manual.

16. Battalion and Division Commanders must ensure that units in their command arestaffed with an appropriate number of Firefighters trained to work as Battalionand Division Firefighters.

17. Re-emphasize the importance of notifying the dispatcher when the FAST Unit isput to work.

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DIAGRAM #2 - CELLAR LAYOUT

Coat Rack

Sub WaterBox Breakers Meter Drawing not to scale

PlayArea

0 Vent Pipe

D - w a S h e r

D-Dryer

o-waterHeater

D-BOilerUmbrellaStroller

I Circuit t

Iron___ r--- GateNote: OverheadAwning, SeePage 8 of 62

Bedroom

Boxes

Half - Landing

CarI_Seat-----,o [ Desk

D I

LivingROOnl

D

DD

D

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The exposures were as follows: Exposure #1 - Front yard

xposure #2 - Similar detached private dwelling separated by a nine foot driveway. The driveway contained four parked cars that impeded access to the rear of the fIre building. Exposure #3 - Rear Yard Exposure #4 - Vacant lot with a chain link fence located approximately fIve feet from the fIre building. The Bureau of Fire Investigation determined that the fIre was started accidentally

y combustible material in close proximity to a portable electrical heater in the rear of thecellar. (See Diagram # 2) There was a delay in the notifIcation to 911. Occupants spentsome time searching the first floor for the source of smoke before realizing that the fIrewas in the cellar.

Initial OperationsEngine Company 290 transmitted a 10-75 for a fIfe in a two-story private

welling at 1340 hours. Engine Company 290 back stretched a P4-inch hose line to thefront of the fIfe building. The Engine Company 290 Officer reached the fIfe buildingfirst and an occupant told him that the fIfe was in the cellar. The Engine Company 290OffIcer opened the interior cellar door, located just inside the front entrance, and heavyblack smoke pushed out. He immediately closed the door and waited for the hose line tobe placed in position and charged.

Ladder Company 103, the fIfst due Ladder Company, arrived at approximately341 hours. The Ladder Company 103 Officer, the Ladder Company 103 Forcible Entry

FirefIghter, and Firefighter Sclafani, the Ladder Company 103 Can Firefighter (the InsideTeam) proceeded to the front stoop and donned their facepieces while waiting for EngineCompany 290's hose line to be charged.

The Ladder Company 103 Chauffeur Firefighter began to remove the cellarwindow bars on the exposure #1 side. The Ladder Company 103 Roof Firefighter placeda portable ladder on the exposure #4 side adjacent to the fIfst floor windows. He thenworked on removing the window bars on two rear cellar windows on the exposure #4side before proceeding to the rear. Neither member completely removed these cellar

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window bars. The Ladder 103 Outside Vent Firefighter went to the rear and beganforcing the exterior rear cellar entrance door.

When Ladder Company 107 arrived, the Officer thought that the fire was on thefirst floor due to heavy smoke venting out the front door. The Ladder Company 107Inside Team went to the second floor and conducted a primary search. There was a lightsmoke condition on the second floor with no fIre extension. The primary search on thesecond floor was negative.

The Ladder Company 107 Chauffeur, Roof and Outside Ventilation Firefightersbegan to remove the cellar and fIrst floor window bars on the exposure #1 side.

Initially, Engine Company 332 assisted Engine Company 290 in stretching theirhose line. Engine Company 332 then stretched a 1%-inch hose line from the apparatus ofEngine Company 290 and charged it in front of the fIre building.

Engine Company 236 arrived as the third due Engine Company and teamed upwith Engine Company 290.

At approximately 1344 hours, the Ladder Company 103 Inside Team encountereda heavy smoke condition as they opened the door leading to the cellar. FirefighterSclafani, the Ladder Company 103 Can Firefighter, began to descend the upper cellarstair followed by the Ladder Company 103 Officer. Both members were able to walkdown the stairs upright; the heat condition was not severe at this time. The LadderCompany 103 Forcible Entry Firefighter descended the upper cellar stair behind theLadder Company 103 Officer. When Firefighter Sclafani reached the half landing hecalled out that there was a door. Firefighter Sclafani was at the wall on the half landingthat was straight ahead from the upper stair. The lower stair leading down to the cellarfrom the half landing was behind Firefighter Sclafani and to his left. Firefighter Sclafanisaid, "It's to the left", and then continued down the lower stair to the cellar followed bythe Ladder Company 103 Officer.

The Ladder Company 103 Forcible Entry Firefighter and the Engine Company290 Officer descended the upper cellar stair followed by the hose line to the half landing.The Ladder Company 103 Forcible Entry Firefighter was unable to descend the lowerstair to the cellar due to the conditions on the half landing.

While the Engine Company 290 Nozzle Firefighter advanced the hose line downthe upper cellar stair to the half landing, the Engine Company 290 Back Up Firefighter

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landing. The Engine Company 290 Officer felt that the heat condition increasedsignificantly and ordered the hose line opened again. There was no visible fire on thecellar stairs. The Ladder Company 103 Officer and Firefighter Sclafani were in the cellarapproximately eight to ten feet from the base of the stairs.

While operating in the cellar, the Ladder Company 103 Officer was unable to seethe screen of the thermal imaging camera due to the unusually heavy smoke condition.The Ladder Company 103 Officer decided to leave the cellar when he heard EngineCompany 290's hose line operating. He told Firefighter Sclafani, "Let's go." FirefighterSclafani replied, "Okay." When they reached the base of the cellar stair, the LadderCompany 103 Officer as well as the other members operating on the stairs then heard theEngine Company 290 Officer call for everyone to get out.

At approximately 1346 hours, Battalion 44 arrived in front of the fire building andnoticed the window bars covering the cellar and fITst floor windows. Battalion 44requested an additional Engine Company and Ladder Company due to the presence ofwindow bars. Battalion 44 observed fITe venting from the exposure #2 side cellarwindow.

Battalion 44 ordered Engine Company 332 to reposition their hose line to the rear.As Engine Company 332 was repositioning their hose line via the alleyway on theexposure #4 side; they observed fITe venting from the two rear cellar windows on theexposure #4 side.

At approximately 1346 hours, the Ladder Company 103 Officer and FirefighterSclafani were craw ling up the lower stair from the cellar. The Ladder Company 103Officer stated that Firefighter Sclafani was right behind him, at his feet, as they craw ledup to the half landing. Engine Company 290's hose line was being directed toward theexposure #2 wall on the half landing. As the Ladder Company 103 Officer reached thehalf landing, there was congestion with other members who were exiting. At that time,the Ladder Company 103 Officer heard Firefighter Sclafani who was behind him state ina muffled tone, "Let's go, Let's go."

There was no visibility due to the heavy black smoke. The Engine Company 290Nozzle Firefighter operated the hose line from the half landing to protect the memberswho were exiting the cellar. The Engine Company 290 Nozzle Firefighter stated thatafter one member passed by him, another member then passed him in a more frantic state

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and a third member collided with him. The force of the collision caused the EngineCompany 290 Nozzle Firefighter to be knocked down onto his back. His helmet andacepiece were dislodged. The use of the chinstrap prevented his helmet and facepiece

from becoming completely dislodged. He shut down the nozzle, placed it on the stair,and exited the building via the front entrance.

After reaching the front stoop, the Ladder Company 103 Officer and the LadderCompany 103 Forcible Entry Firefighter immediately realized that Firefighter Sclafanidid not exit the building with them. The Ladder Company 103 Officer returned to the topof the cellar stairs and heard a Personal Alert Safety System (PASS) alarm sounding. Hetated that he heard air escaping under pressure from a SCBA. The Ladder Company 103

Officer stated that the airflow had a high-pitched sound. He stated that this sounddiffered from the sound of an undonned SCBA facepiece without the manual shut offbutton depressed. On hearing the PASS alarm and high-pitched airflow, the LadderCompany 103 Officer transmitted a MAYDAY via his handie-talkie. The time wasapproximately 1348 hours.

Battalion 44 did not hear the Ladder Company 103 Officer transmit a MAYDAY.mmediately after this MAYDAY was transmitted, Battalion 44 ordered via handie-talkie

for all "Trucks" to get off the fIrst floor until a hose line was in position. Battalion 44'sstrategy was to extinguish this fire via the exterior rear cellar entrance. His tactics wereto have Engine Company 290 maintain their position of protecting the fIrst floor withtheir hose line while Engine Company 332 attacked the fIre via the exterior rear cellarentrance.

The heat venting up the interior cellar stairs had intensified. Visibility on the stairsas zero. The Engine Company 290 Officer located at the top of the stairs also heard the

sound of pressurized air at the half landing. He stated that it sounded like the airflowfrom the SCBA was "quicker" than when the manual shut off of the SCBA is notdepressed.

The Ladder Company 103 Officer called for Engine Company 290's hose line.The Engine Company 290 Officer pulled the hose line up the stairs. The EngineCompany 290 Officer then gave the nozzle to the Engine Company 290 Back Up

irefighter who operated the hose line down the stairs from the fIrst floor. The LadderCompany 103 Officer was on the fIrst floor when his helmet was dislodged after being

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front of the fire building and were assigned to the MAYDA Y operation. LadderCompany 120 attempted to enter the ftre building via the front stoop. They were unableto enter due to numerous members positioned on the exterior front stoop.

On arrival, Rescue Company 2 heard the second MAYDAY transmission. TheRescue Company 2 Officer arrived in front of the fire building after Ladder Company120 was assigned to the rescue effort and split his company into two teams to locate thedowned member. One team went to the rear while his team attempted to gain accessthrough the front door. The Rescue Company 2 Officer and the Ladder Company 120Officer were both now on the front stoop attempting to gain access. Battalion 44 orderedhe Rescue Company 2 Officer to address the MAYDAY.

Battalion 44 then redirected Ladder Company 120 to search the stairway betweenthe ftrst and second floor to ensure that the member was not located on this stair. LadderCompany 120 proceeded to the second floor via the interior stair and performed vent,entry and search (VES) of the stairway and second floor. The results of this search werenegative and Ladder Company 120 reported these results to Battalion 44.

Squad Company 252 also heard the second MAYDAY transmission as theyrrived on the scene. They reported into Battalion 44 and were ordered to fmd another

point of entry into the cellar to address the MAYDAY. Squad Company 252 proceededto the rear.

Battalion 58 reported into Battalion 44 and was ordered to supervise operations inthe rear at approximately 1351 hours.

Division 15 arrived in front of the ftre building and assumed command after abrief exchange of information with Battalion 44. Division 15 ordered Battalion 44 tosupervise the rescue operation. The time was approximately 1353 hours.

Initial Operations in the RearAs the operations were being conducted in the front, members converged near the

rear entrance stair. Engine Company 332's charged hose line was standing fast in therear yard at the exposure #2 - #3 comer. The Engine Company 332 Officer attempted tocontact both Battalion 44 and Engine Company 290 several times via hand ie-talkie torequest permission to advance the hose line into the cellar. The Engine Company 332Officer wanted to ensure that his hose line would not be in opposition to Engine

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Company 290' s hose line. While theEngine Company 332 Officer was trying to contactBattalion 44, he observed fire venting out of the cellar window on the exposure #2 side,extending up the exterior of the fire building to the underside of the eaves. EngineCompany 332 extinguished this fITe on the exterior without the stream entering the cellarwindow. The Engine Company 332 Officer was then mistakenly informed by a memberin the rear yard that Engine Company 290 was out of the cellar and in front of the fITebuilding. The Engine Company 332 Officer then ordered his hose line advanced throughthe exterior rear cellar door to extinguish the fITe in the cellar. The time wasapproximately 1353 hours.

Initial Operations in the FrontAs Engine Company 332 was knocking down the fITe on the exposure #2 side,

Engine Company 290 operated their hose line from the top of the upper cellar stairs justinside the front entrance. When the Engine Company 290 Back Up Firefighter's vibralertalarm activated, he handed the nozzle to the Engine Company 290 Door Firefighterdirectly behind him. The Engine Company 290 Back Up Firefighter then left the fITebuilding via the front door to replace his SCBA cylinder. The Engine Company 290Door Firefighter operated the hose line at this location for approximately two minutesand then began to advance the hose line down the upper cellar stair. During this time, theLadder Company 103 Officer and the Ladder Company 103 Forcible Entry Firefighterascended the upper stair and exited the fire building via the front door.

The Engine Company 290 Door Firefighter was unaware of Firefighter Sclafani'slocation as he advanced the nozzle down the upper stair unassisted. On reaching the halflanding, he discovered Firefighter Sclafani. The Engine Company 290 Door Firefightershut the nozzle down and laid it on the half landing. Engine Company 290's hose line didnot operate again until after Firefighter Sclafani was removed from the fITe building.

The Engine Company 290 Door Firefighter attempted to pull Firefighter Sclafaniup the stairs, but was unable to do so. The Engine Company 290 Door Firefighter statedthat there was a heavy object (coat rack) on top ofFirefighter Sclafani that he was unableto remove. The Engine Company 290 Door Firefighter re-positioned himself on the halflanding at the lower stair but was still unsuccessful in his attempt to remove him. Thetime was now approximately 1356 hours.

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When the Ladder Company J03 Officer was exiting the front door, he informedthe Rescue Company 2 Officer that Firefighter Sclafani was right there on the stairs. The

escue Company 2 Officer and the Rescue Company 2 Can Firefighter proceeded downthe upper cellar stair to the half landing and operated with the Engine Company 290 DoorFirefighter. The Rescue Company 2 Officer stated that he heard the PASS alarmsounding at this time. There was an extremely high heat condition and zero visibility.

With great difficulty, the Rescue Company 2 Officer removed the 70-pound metalcoat rack that was on top of Firefighter Sclafani. The Rescue Company 2 Officer statedthat he then verbally called for a Life Saving Rope to assist in the removal of Firefighter

clafani. While operating with Rescue Company 2, the Engine Company 290 DoorFirefighter's vibralert alarm activated. The Engine Company 290 Door Firefighter thenexited the fire building via the front entrance at approximately 1358 hours.

The Rescue Company 2 Officer attempted several times to get FirefighterSclafani's body into a position for removal. He stated that he made a handie-talkietransmission requesting assistance. This handie-talkie transmission was neveracknowledged. After a short period of time, he was handed some nylon tubular webbingy the Rescue Company Can Firefighter and was unsuccessful in his attempt to attach the

webbing to Firefighter Sclafani. The heat condition on the half landing was becominguntenable.

The Rescue Company 2 Officer was aware that there was a hose line on the halflanding. The Rescue Company 2 Officer ordered the Rescue Company 2 Can Firefighterto find the nozzle, and get the hose line into operation. The Rescue Company 2 CanFirefighter located the nozzle but was unable to move it because the hose line wasentangled in the items on the half landing. At approximately 1402 hours, the intense heatforced these members ofRescue Company 2 to exit the building via the front entrance.

When the Rescue Company 2 Officer reached the front entranceway, hetransmitted the following message via handie-talkie:"Rescue 2 to 1-5 Urgent. We have to have a line at this front door." Division 15 replied, " Repeat Rescue." Rescue 2 Officer replied, "We have to have another hose line at this front door to make it down the stairs." The time was 1403 hours.

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Division 15 then ordered Engine Company 236, who was standing fast in the frontyard with a charged hose line, to bring their hose line into the frre building via the frontentrance.

Operations in the RearEngine Company 332 encountered a heavy frre condition as they advanced their

hose line into the cellar from the rear exterior cellar entrance. The Ladder 107 InsideTeam entered the cellar behind Engine Company 332. The Ladder Company 103 OutsideVentilation Firefighter, Chauffeur and Roof Firefighters also entered the cellar followedby the Rescue Company 2 Chauffeur, Roof 1, Roof 2, and Forcible Entry Firefighters.The Squad Company 252 Officer entered the cellar, but exited immediately due to thenumerous members already at this location. While extinguishing the frre in the cellar,Engine Company 332 had difficulty maneuvering their hose line due to the numerousmembers operating at this location. Two members had their helmets dislodged by thestream.

After Engine Company 332 entered the cellar, Battalion 58 arrived in the rearyard to supervise operations. Battalion 58 ordered Engine Company 231 to stretch a backup hose line to the rear yard. Engine Company 231 stretched a 1% inch hose line fromEngine Company's 236 apparatus via the vacant lot on the exposure #4 side.

After searching in the cellar for approximately seven minutes, the LadderCompany 103 Roof Firefighter's vibralert alarm activated. The Ladder Company 103Roof Firefighter was now in the rear cellar bedroom. He saw light from the bedroomwindow on the exposure #4 side and decided to exit via this window. He had tocompletely remove his SCBA and facepiece in order to fit through the window.

The Ladder Company 175 Roof Firefighter and the Ladder Company 120 OutsideVentilation Firefighter, operating in the exposure #4 alleyway, assisted the LadderCompany 103 Roof Firefighter out of the window. The Ladder Company 170 Officerwitnessed the removal and transmitted a handie-talkie message to Division 15 stating thata member was being removed from the cellar window on the exposure #4 side. Herequested EMS to this location. The Ladder Company 103 Roof Firefighter was removedat approximately 1402 hours.

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The Ladder Company 103 Roof Firefighter made it very clear to the membersassisting him that he was not the MAYDAY in the cellar. This information was relayedo Division 15. Ladder Company 120 went to the exposure #4 alleyway and assisted

carrying the Ladder Company 103 Roof Firefighter to the front yard. The LadderCompany 103 Roof Firefighter was then turned over to EMS. The Ladder Company 103Roof Firefighter was transported to Brookdale Hospital by EMS where he was treatedand released.

The Ladder Company 103 Outside Ventilation Fireftghter was also searching inthe cellar. His vibralert alarm activated. While attempting to locate the rear cellar door,he Ladder Company 103 Outside Ventilation Fireftghter saw the cellar window on the

exposure #2 side and exited through this window. The Ladder Company 170 Chauffeur,who was in the driveway on the exposure #2 side, assisted him out the cellar window.The time was approximately 1403 hours.

Engine Company 332 operated in the cellar for approximately 10 minutes andextinguished most of the fire in the cellar before their hose line developed a hole.Battalion 58 ordered Engine Company 231 to bring their hose line into the cellar toeplace Engine Company 332's hose line. Battalion 58 notifted Division 15 that he was

switching the hose lines in the cellar.

Operations in the FrontSeveral members of Squad Company 252, Ladder Company 120 and Ladder

Company 107 were operating together on the ftrst floor. They searched the first floor,and then removed the sheetrock around the cellar stairway enclosure on the first floor inn attempt to ventilate the cellar stair.

While Engine Company 236 was repositioning their hose line to the frontentrance, Engine Company 225 Nozzle Fireftghter attempted to pull Engine Company290' s hose line up the cellar stairs from the ftrst floor landing, but he was unable to movethe hose line. The Engine Company 225 Officer and Engine Company 225 NozzleFirefighter descended the upper cellar stair in an attempt to locate the nozzle of EngineCompany 290's hose line and found Fireftghter Sclafani on the half landing. No other

embers were with Fireftghter Sclafani when they found him. The heat condition on thehalf landing made it impossible to operate without the protection of a hose line. The

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Engine Company 225 Officer and Engine Company 225 Nozzle Firefighter ascended theupper stair to the front door. As the members of Engine Company 236 donned their facepieces near the front entrance, the Engine Company 225 Officer told them to bring theirhose line down the stairs and to the left.

As the Engine Company 225 Officer exited the fire building, the Squad Company252 Hook Firefighter descended the upper stair to the half landing and found FirefighterSclafani. Squad 252 Hook Firefighter was alone with Firefighter Sclafani at this time.He realized that a hose line was needed and went back up the stairs to get a hose line.Engine Company 236 entered the first floor of the fire building via the front entrance andbegan to advance the hose line down the upper cellar stair at approximately 1404 hours.

The Squad Company 252 Hook Firefighter met the Engine Company 236 NozzleFirefighter at the top of the upper stair and guided him past Firefighter Sclafani to thelower stair. As Engine Company 236 slowly descended the lower stair to the cellar floorthey opened their hose line and extinguished visible fire. They continued to operate thehose line, advancing approximately ten feet into the cellar. Conditions on the halflanding improved significantly once this hose line was in operation between the fire andFirefighter Sclafani. The time was now approximately 1406 hours.

As Engine Company 236 advanced their hose line in the front of the cellar, theEngine Company 236 Officer stated the unusual heat conditions indicated there could bean opposing hose line. He notified Battalion 44 via handie-talkie. Battalion 44 directedBattalion 58 to have Engine Company 231' s hose line shut down and have them back outof the rear of the cellar.

The Rescue Company 2 Officer, and the Rescue Company 2 Can and HookFirefighters followed Engine Company 236's hoseline down the upper cellar stair to thehalf landing. They joined with the Squad Company 252 Hook Firefighter, who wasalready operating at this location. The Rescue Company 2 Officer was handed one end ofa life saving rope and attempted to wrap it around Firefighter Sclafani's torso. Beforethis could be accomplished, members operating outside the fire building prematurelypulled the rope out of the Rescue Company 2 Officer's hand. The Rescue Company 2'sHook Firefighter, who was operating on the upper stair, maintained a hold on the ropeand was able to pass the end of the rope back down to the half landing. The RescueCompany 2 Officer and the Squad Company 252 Hook Firefighter then attached the rope

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Firefighter Sclafani may have removed his facepiece for other unknown reasons.

3. Firefighter Sclafani's SCBA # 103-3 was confiscated by the Safety Command atBrookdale Hospital. This SCBA was a Scott 4.5 positive pressure breathingapparatus with an EZ flow II regulator and a 45-minute luxfer cylinder. Thefacepiece belonged to another member of Ladder Company 103. This SCBA was tested on January 24, 2005 at the Mask Service Unit (MSU). The cylinder was found to be empty at the time of testing. The manual shut off switch was found in he open position. The low-pressure hose was separated between the quick

connect and the pressure reducer assembly. I f the facepiece was removed without the manual shut off button depressed or if the low-pressure hose was severed, then the air supply in the cylinder would deplete at a minimum rate of 400 liters per minute. A full 45-minute cylinder has approximately 1835 liters of air and would be depleted in approximately four to five minutes. The SCBA, facepiece and cylinder were sent to Intertek Testing Services for analysis

4. The low-pressure hose on Firefighter Sclafani's SCBA was found separatedbetween the quick connect coupling and the pressure reducer assembly. Thedamaged SCBA was sent to Intertek Testing Services for analysis. The lowpressure hose was evaluated for resistance to splitting during an applied heat load and flex. A pristine sample of a low-pressure hose was subjected to multiple energy types and then flexed approximately 135 degrees in an effort to replicate the exposure conditions present to cause deterioration and subsequent separation of the hose. It was found that when the low-pressure hose was subjected to radiant heat energy of one calorie per square centimeter per second, for a 30 second period and then flexed, the low-pressure hose exhibited similar damage of blistering, flaking and split similar to the low-pressure hose of Firefighter Sclafani's SCBA. The investigative team could not determine at exactly what moment the low-pressure hose of Firefighter Sclafani's SCBA became damaged.

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5. Two members positioned at the top of the interior cellar stairs reported hearing airleak under pressure from a SCBA immediately after Firefighter Sclafani wasnoticed missing. The Ladder Company 103 Officer reported hearing airflow witha high-pitched sound coming from the half landing. The Engine Company 290Officer reported hearing an air leak from the half landing that was "quicker" thanwhen the SCBA manual shut-off button is not depressed.

6. On December 30,2004, SCBA # LI03-3 was placed out of service and sent toMSU for an air leak where the low-pressure hose connects to the regulator. Thelow-pressure hose, regulator, and PASS alarm were replaced. The SCBA wassubjected to a visual and functional test using the Scott Posichek3 testingprocedures. The SCBA passed both the visual inspection and the function testsand placed back in service on January 5, 2005.

7. Firefighter Sclafani's PASS alarm was heard sounding by the Ladder Company103 Officer from the half landing immediately after it was discovered thatFirefighter Sclafani was missing. Numerous other members also reportedhearing the PASS alarm sounding during the operations.

8. After Firefighter Sclafani was found unconscious on the half landing, a hose lineoperated from the top of the cellar stairs to protect the members attempting toremove Firefighter Sclafani. After approximately five minutes, this hose lineadvanced to the half landing. This hose line was shut down and the nozzle wasplaced on the half landing when the member operating the hose line attempted toremove Firefighter Sclafani. This hose line became entangled on the half landingand was unable to be put back into operation. Removal operations continued onthe half landing for approximately ten minutes without the protection of a hoseline. Both the Incident Commander and Chief Officer assigned to the rescueeffort were unaware that this hose line was not operating during this time. Theabsence of an operating hose line between the fIfe and the distressed memberseverely hampered the removal operation.

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9. Firefighter Sclafani was removed from the fire building approximately 22 minutes after the frrst MAYDAY was transmitted. Difficulties encountered on the half landing included:

Extreme high heat Unusually heavy dense smoke condition Small working area, which was further reduced by numerous items

stored on the half landing Firefighter Sclafani's position on the half landing and lower cellar

stair.

10. When Firefighter Sclafani was found unconscious without his facepiece on his face, there was no attempt to establish an air supply for him, even though he was in an atmosphere that was Immediately Dangerous to Life and Health (IDLH). Providing the unconscious Firefighter with an air supply is not adequatelyaddressed in AUC 320 FIREFIGHTER ASSIST AND SEARCH TEAM - FASTUNIT, and Training Bulletin Unconscious Firefighter Removal

( 11. Numerous members were crowded together at both the front entrance and the exterior rear cellar entrance. These members impeded access and egress at these locations.12. The MAYDAYS were not transmitted via handie talkie in the proper format as

per Chapter 9 of the Communications Manual. The initial MAYDAY transmitted was never acknowledged. These initial and subsequent MAYDAY transmissions were not clear as to who gave the MAYDAY, what the MAYDAY was for, and where the MAYDAY was located. Many incoming members and members operating at the scene were not aware of the status of the removal operations and when the member was actually removed from the building. The member transmitting the MAYD AY s did not activate the emergency alert button on the

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13. After the MAYDAY was acknowledged on scene, Battalion 44 immediatelytransmitted a second alarm.

14. Preliminary and progress reports were not transmitted until approximately 32minutes into the operation. Communication between the BrooklynCommunication Office and the Incident Commander were not according toDepartment guidelines as outlined in the Communication Manual. The dispatcherprompted both the Battalion and Division for preliminary and progress reports.Both the fIrst arriving Battalion and the Division did not have regularly assigned

. .-- - - . . - -- . . .--rFirefighters working this tour.

15. As the FAST Unit arrived on the scene, a MAYDAY was transmitted via handie talkie. The FAST Unit did not take the full complement of FAST tools/equipmentto the Command Post.

16. Once the FAST Unit was deployed at this operation, they were not replaced asrequired by Department procedures. The Incident Commander did not notify thedispatcher that the FAST Unit was being put to work.

17. During fire operations at this incident, at least seven members reported that theirhelmets were dislodged while performing fIre related tasks. Six of the membershad their helmets completely dislodged and were not wearing the helmetchinstrap. One member, because his chinstrap was properly used, did not have hishelmet completely dislodged.

18. Battalion 44 special called an additional Engine Company and Ladder Companywhen the presence of window bars was reported. Early removal of the windowbars played a key role in the ability for two members, disorientep and low on air,to exit the cellar through two separate cellar windows (31" X 16 W'). The specialcalled Ladder Company assisted in the complete removal.

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19. Engine Companies were all staffed with five fIrefighters for this tour due to theweather conditions. The additional members helped in the rapid positioning ofinitial hose lines and back up hose lines at this operation. The Engine Company290 Control Firefighter located and cleared the hydrant of snow. He also assisted hooking up to the hydrant. Engine Company 332 was able to stretch numerous lengths of hose from Engine Company 290' s apparatus through the heavy snow to the front of the fIre building. They were then able to reposition this hose line to the rear in a "timely fashion." Engine Company 231 also was able to stretch a back-up hose line through the heavy snow to the rear ofthe fIre building without a

elay.

20. The adverse weather conditions played a key role in the operations at this fIre.The fire took place in the aftermath of a bfuz;a-with accumulations between 12and 18 inches of snow. The temperature on this day only reached a high of 20 degrees with a wind chill factor near zero degrees. The average wind speed was 24 miles per hour with gusting winds of up to 48 mph. Although response was lowed due to the snowstorm, no units reported a significant delay in their

response.

21. The hand ie-talkie communications at the scene did not provide a clear and concisepicture to the Incident Commander of fIre conditions and the status of the rescue effort, i.e.:

Changing fire conditions in the cellar were not reported to theIncident Commander.

Information transmitted via handi-talkie was at times incomplete.The exact location and nature of injuries were not transmitted to theIncident Commander.

The fIrst MAYDAY transmitted was not acknowledged. The Incident Commander ordered all Ladder Company members off

the fIrst floor. This order was not directed to specific units, was not

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VUe CAUSESDIRECT CAUSES1) Inhalation of toxic levels of carbon monoxide and other gases.2) Inhalation of heated products of combustion. 3) Third degree burns to head and torso and upper extremities.

INDIRECT CAUSES1) Dislodgement or removal of the SCBA facepiece in a toxic and heated environment. 2) Physical conditions of the interior stairway half landing leading to the cellar. Thisnarrow landing had numerous boxes, a coat rack and an umbrella stroller on it thatfurther reduced the width of the landing.3) Combustibles in close proximity to a portable electric heater.4) Absence of an operating hose line between the fire and the removal effort in a timelymanner.5) Failure to provide an air supply with an SCBA to the unconscious firefighter. BASIC CAUSES1) Sustained winds of 24 miles per hour (mph) with wind gusts up to 48 mph. 2) Heavy fire load in the cellar area, including foam rubber furnishings. 3) Unusual interior cellar stairway configuration. 4) Delayed notification to the Fire Department.

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VIII. RECOMMENDATIONS 1. Develop a procedural guide to assist Chief Officers in formulating a strategy to

manage a MAYDAY for distressed members. These procedures should addressan overall rescue plan for the Incident Commander while continuing to addressthe developing emergency operations. These procedures shall be incorporatedinto department publications where appropriate.

2. Develop and implement training for Chief Officers that will focus on theprocedures and the active management of a MAYDAY operation. This trainingcould include tabletop, functional, and full-scale exercises. This training could beconducted at the Bureau of Training, during multi unit drill, during CommandChief and Division conferences.

3. Re-emphasize the importance of using the proper format when transmitting aMAYDAY as per Communications Manual Chapter 9, section 9.4. Theemergency alert button shall be used, and all handie-talkie messages must beacknow edged.

4. Amend the Communications Manual Chapter 9, section 9.4 to include: Theemergency alert button must be used during any MAYDAY or URGENTtransmission. I f the member transmitting the MAYDAY or URGENT is unableto activate the emergency alert button, then the Incident Commander must usethis button to gain control of the handie-talkie network.

5. Amend the Communications Manual and other appropriate documents to requirethat every time a MAYDAY is transmitted, the Incident Commander mustannounce the MAYDAY on the handie-talkie and on the appropriate Departmentborough radio frequency. This will aid in alerting all members on the scene awell as incoming units of the emergency situation. An announcement shall alsobe made on both radios when the MAYDAY situation has been resolved.

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6. Incorporate all pertinent in(ormation and procedures pertaining to distressedmembers into a single guide. Numerous department documents currently addressifferent areas relating to this subject. This guide would provide that all related

information is incorporated into an inclusive publication for reference.

7. Re-evaluate Firefighting Procedures Volume 1, Book 6, Private Dwellings,Chapter 3, section 2, pertaining to first due Engine and Ladder Company operations at cellar fires in private dwellings having an exterior cellar entrance.

. Amend Firefighting Procedures Volume 1, Book 6, Private Dwellings, Chapter 5section 1.2.B, by adding the following: "Type and location of interior stairs."This added information would provide the Incident Commander with adescription of the layout and unusual configurations that may hinder operations.

9. Re-emphasize that the first due Ladder Company Outside Team must perform aquick exterior survey and notify their Officer and Incident Commander of theonditions found, coordinate VES with the Inside Team, and vent the fire

area/room when ordered. This information is contained in Firefighting Procedures Private Dwellings.

10. Equip each Ladder, Rescue and Squad Company with an additional SCBA to betaken by the unit assigned or designated as the FAST Unit. This will provide adedicated and readily available air supply for the distressed member.

11. Amend AUC 320, FIREFIGHTER ASSIST AND SEARCH TEAM - FASTUNIT, to specify member assignments. This should include designating amember to ensure that the distressed member has an adequate air supply.

12. Re-emphasize the importance of the FAST Unit bringing the full complement ofFAST tools and equipment to the Command Post or Operations Post.

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13. Reinforce to all members the need to maintain building entrances and stairwaysunimpeded. Stairway Management must be conducted at all operations for thesafety of members and effective operations. Every level of command has aresponsibility to ensure that the stairs are not overcrowded and can be rapidlyused as either a means of egress or access in case of an emergency. They are notto be used as staging areas.To alleviate overcrowding on stairways:

Chief Officers should assign only the units or members necessary toaccomplish a task. They shall ensure that companies maintain operationaldiscipline.

Company Officers must control members to ensure that they do notimpede access or egress on a stairway or at a building entrance. Theyshall ensure that members maintain operational discipline.

Firefighters on a stairway must be conducting active operations. Standingfast on a stairway is dangerous and unacceptable.

14. Re-emphasize that handie-talkie transmissions must be concise and directed tospecific members or units. Unacknowledged transmissions must be regarded asnot being received, and will need to be retransmitted. I f handie-talkiecommunications cannot be established, consider using alternate means such assending a member with the message.

15. Re-emphasize to all Chief Officers the importance of transmitting preliminary andprogress reports as required by the Communications Manual. When a Battalionor Division is not staffed with a regularly assigned or trained Firefighter, theChief Officer must ensure these vital communications are transmitted.

16. Battalion and Division Commanders must ensure that units in their command arestaffed with an appropriate number of Firefighters trained to work as Battalionand Division Firefighters.

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17. Re-emphasize the importance of notifying the dispatcher when the FAST Unit isput to work. This notification will ensure that the dispatcher immediately assigns

nother FAST Unit.

18. Develop and issue documentation regarding the proper use and maintenance ofthe frrefighting helmet and the proper use of the chinstrap. The use of the helmetchins rap should be mandatory during operations. Failure to properly utilize allPPE can result in serious consequences affecting operations as well as a members'personal safety. I t is the Officer's responsibility to ensure that a member wears

PE, but it is the member's responsibility to wear the PPE correctly.

19. Research and/or develop a drag rescue device that can be incorporated into thepresent PPE to assist in the removal of incapacitated members.

20. Amend Safety Bulletin 84, Window Bars, section 4, to include the followingsentence: "An Engine on the scene or a special called Engine could provide anexterior hose line to protect civilians or members trapped behind the window bars inside the building or members removing the window bars. "

21. All Unit Circular 314, Incident Command and Safety Investigations, toincorporate appropriate subsections of sections 5, 6, 7, and 9 of All Unit Circular 317, Ciime Scene Operations,.to ensure the frre scene is immediately secured and properly documented. The proper safeguarding of the fire scene and equipment is ssential to a thorough investigation of serious firefighter injuries or fatalities.

22. Expand the training program titled, "CellarlUnconscious Firefighter Removal"that is currently being piloted by Division 13 to all Divisions. This programprovides hands-on training in the removal of an unconscious member. This drill is conducted in quarters for on duty members in full frrefighting gear. During the course of this drill, members stretch hose lines, utilize the thermal imaging

amera to locate the simulated frre and search for a downed member. The member is then packaged and removed.

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23. Reinforce to all members of the Department the dangers of carbon monoxide.Removing the SCBA facepiece in a contaminated atmosphere is extremelyhazardous. Emphasis should be placed on the extremely short exposure timenecessary to receive an incapacitating or lethal dose.

24. The Bureau of Fire Prevention should work with the Department of Buildings toimplement an effective procedure to ensure the administrative company is notifiedwhen a building is constructed or renovated using lightweight wood I beamconstruction. Units notified of such conditions must evaluate the hazard andsubmit a cms card.

fdny report on fatal fire, january 23, 2005

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