fdny report on fatal fire, january 3, 2008

8/4/2019 FDNY report on fatal fire, January 3, 2008

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I. SUMMARY On Thursday, January 3, 2008, at 1914 hours, the New York City Fire Department's

Brooklyn Communications Office received a telephone alarm reporting a fire in apartment 14Mat 1700 Bedford Avenue. Brooklyn Box 3762 was transmitted at 1915 hours. The initialresponse was three Engine Companies, two Ladder Companies and one Battalion. EngineCompany 249 and Ladder Company 113 arrived at 1918 hours and proceeded to the 14th floor.The Engine Company 249 Officer, Lieutenant John H. Martinson, requested Battalion 38 totransmit a 10-75 signal after observing a heavy smoke condition in the 14th floor hallway.Battalion 38 transmitted a 10-75 signal at 1921 hours followed by a 10-77 signal at 1923 hours.Standard firefighting operations were initiated for a fire in a high-rise, fireproof, multipledwelling.

The fire building was a 25 story, fireproof (Class 1), multiple dwelling that was part of aseven building complex known as the Ebbets Field Apartments. The building complex wasconstructed in 1962 and occupied one city block. The dimensions of the building complex were

feet by 637 feet. The fire originated in the bedroom of apartment 14M. The occupants leftapartment door open when they exited the apartment. The fire caused the bedroom windowsfail. These factors in conjunction with a northwest wind created a heavy smoke condition in

Lieutenant John H. Martinson of Engine Company 249 was found unconscious in14M at 1943 hours. He was removed from the building and transported by Fireof New York (FDNY) Emergency Medical Service (EMS) to Kings County Hospital

that Lieutenant John Martinson's cause of death was smokeAs a result of the investigation into this fatality, the Safety and

Services Command makes the following recommendations:

Strictly enforce proper Self Contained Breathing Apparatus (SCBA) usage. All members should be aware of the location and well being of other team members, including their Officer. Re-emphasize the importance of the proper use of the firefighting helmet chinstrap.

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4. Re-emphasize the need for Engine Companies to team up for the duration of theoperation.

5. Continue to evaluate the implementation of positive pressure ventilation and use of windcontrol devices as initial operational tactics for fires in high-rise fireproof multipledwellings.

6. Revise and issue Firefighting Procedures "Multiple Dwelling Fires", section 6, Class AFireproof Multiple Dwelling Fires as a separate volume.

7. Implement a fire safety education campaign to educate the public on the importance ofclosing the fire room door and not obstructing self-closing doors.

8. The Command Channel and the Post Radio should be utilized at high-rise multipledwelling fires whenever a 10-77 signal has been transmitted.

9. Emphasize the importance of maintaining radio discipline during MAYDA YIURGENTsituations.

10. Re-emphasize that handie-talkie transmissions should be concise and direct. Handietalkie transmissions should be made using the unit designation and assigned position.

11. Train all members to be proficient in roll call procedures as per Communications ManualChapter 9, Addendum 2, "Emergency Roll Call Procedures."

SECTIONBAlthough the following did not have an impact on this incident, the Department should considerthese recommendations to improve safety and efficiency at future operations:12. Hard copies of important information, such as numerous apartments with occupants in

distress, should be sent via Mobile Data Terminal (MDT) in addition to notification onthe Department radio.

13. Emphasize the importance of reacting to a Personal Alert Safety System (PASS) Alarmsignal sounding during operations.

14. The CADS should reflect when a Division or Battalion is staffed by an Acting Chief.15. Ensure scissor stairs are properly labeled whenever inspecting or operating in buildings

serviced by scissor stairs.16. Establish an education and training program to present units in the field with the findings

and recommendations found in Fatal Fire Investigations.

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IV. FDNY OPERATIONS On Thursday, January 3, 2008 at 1914 hours, the New York City Fire Department's

Bedford Avenue, the Ebbets Field Apartments. At 1915 hours Box 3762 was

Engine Company 249 Ladder Company 113 Engine Company 280 Ladder Company 132 Engine Company 234 Battalion 38Engine Company 234 was assigned on the initial alarm as per the Critical Information

ispatch System (CmS). The CIDS information was as follows:MD 25STY 200X150 CLI- 4 LENGTHS HOSENEEDED-STAIR A HAS STDP-OS&Y VALVE 16 FLAPTS A,B,E,F,N&O HAVE BALCONIES- LONGDEAD END HALLS- MINRESP 32

On the evening of January 3,2008 at 1900 hours the National Weather Service at John F.Kennedy International Airport reported a temperature of 18 degrees Fahrenheit and wind fromthe north-northwest at 15 miles per hour.

At the time of the fire, Brooklyn Poly-Tech University was conducting tests on the roofof Fire Department headquarters, 9 MetroTech Center in Brooklyn. From 1920 hours to 1945hours they reported a temperature of 18 degrees Fahrenheit with an average wind speed of 11miles per hour from the northwest, with gusts up to 20 miles per hour.

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Photo 11Ebbets Field ApartmentsThe Ebbets Field Apartments were a seven building complex arranged in an H shape.

The buildings were attached but were not interconnected. The complex contained a total of1,321 apartments. The fire was located in 1700 Bedford Avenue, the center building of thecomplex. The fire building was a 25 story multiple dwelling of Class I fireproof constructionconsisting of steel, brick, concrete, gypsum board and plaster. This building contained 16apartments on each floor. There were six 2-bedroom apartments, six I-bedroom apartments andfour studio apartments on each floor. The fire apartment (14M) was a one-bedroom apartmenton the 14th floor. The building had four elevators that served all floors. Windows in the fireapartment were doubled paned glass and faced west. The public hallway was in the shape of across, which measured 131 feet by 53 feet and was 4 feet wide except for the elevator lobby,which was approximately 8Yz feet wide. The distance from stairway A (attack stairway) to thefire apartment door was approximately 60 feet (See Diagram 3).

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Diagram 3Floor Plan of Center Building, 1700 Bedford A venue

All floors in the fire building were served by three stairways. The stairway doors wereStairway A was a return type stairway that contained the only standpipeThe other two stairways were scissor type stairs. The scissor type stairs

labeled incorrectly. The stairway door lettering of the scissor type stairs did not alternatefloor to floor properly (See Diagram 4). (TI-lROUGHOUT TI-lIS REPORT STAIRWAYS BAND C

REFERRED TO AS TI-lEY WERE LABELED ON TI-lE DOOR TO EACH STAIRWAY AT THE TIME OF THE

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4th floor B ce. .+

. \ ; 3rd floor C .. B==== . . -====

2nd floor B. C==== .. . ~ ====. \ ;1st floor C B

==== . . . .-====Scissor Stairs labeledcorrectly

C B 4th floor\ t

C .... B 3rd floor==== . . -==== BC 2nd floor====. . . ~ e = = = = .\ ;C B 1 st floor

==== . . . .-====Scissor Stairs as labeled at 1700 Bedford Avenue

Diagram 4Scissor StairsThe exposures of the complex were designated as follows: Exposure #1 Bedford Avenue Exposure #2 Sullivan Place Exposure #3 McKeever Place Exposure #4 Montgomery StreetThe lobby entrance to 1700 Bedford Avenue was located on the concourse level. The

concourse was an area one story above grade level from Bedford Avenue.The Bureau of Fire Investigation determined the cause of the fire to be accidental. The

fire was started by a six-year-old child igniting combustible packaging material on the openflame of the kitchen stove. The child took the flaming material nto the bathroom where he triedto extinguish the fire. He was unable to extinguish the fire and the bathroom rug ignited. Thechild then brought the flaming material to the bedroom and placed it under the bed nearest thewindow (See Diagram 5). He left the bedroom and closed the door but did not tell his motherwhat had occurred. The burning material ignited the bed. When the mother became aware of the

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sh the fire, but was unable to. The occupants fled the apartmente door partially opened. A piece of cloth used as a draft stop at the bottom of the door,

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Chauffeur, entered that elevator. The members of Ladder Company 113, exclusive of theChauffeur, entered the lobby and conferred face-to-face with the members of Engine Company249. The Engine Company 249 members then took the first elevator to the Ith floor. TheLadder Company 113 members took the second elevator to the 12th floor. The Ladder Company113 Outside Ventilation Firefighter operated this elevator in Firemen Service for the duration ofthe fire.

The 2nd due units, Engine Company 280 and Ladder Company 132, arrived at 1700Bedford A venue at 1919 hours. Squad Company 1 was at the quarters of Engine Company 280and Ladder Company 132 when the Box was transmitted. Squad Company 1 was not part of theinitial response assignment, but proceeded in the direction of 1700 Bedford A venue when theBrooklyn Dispatcher reported receiving additional phone calls for smoke on the 14th floor.Squad Company 1 arrived at 1700 Bedford A venue at approximately 1920 hours, just behindEngine Company 234 and Battalion 38.

Lieutenant John Martinson and the members of Engine Company 249 exited the elevatoron the 12th floor. They then ascended stairway A to the 13 th floor. Lieutenant John Martinsonplaced the standpipe kit on the 13 th floor by the standpipe outlet and proceeded to the 14th floor.The members of Engine Company 249 prepared to connect their four lengths of 2Y2" hose to the13 th floor standpipe outlet in stairway A. When Lieutenant John Martinson opened the 14th floorstairway door he encountered a heavy smoke condition. Lieutenant John Martinson calledBattalion 38 at 1921:05, and transmitted via handie-talkie, "You can give a 10-75; we've got aheavy smoke condition on the 11h floor."

The Engine Company 249 Nozzle Firefighter verbally informed Lieutenant JohnMartinson that the M apartment was three doors down on the left. Lieutenant John Martinsonacknowledged, donned the facepiece of his SCBA and entered the public hallway on the 14thfloor at approximately 1922 hours. (mIS WAS mE LAST TIME LIEUTENANT JOHN MARTINSON WASSEEN OR HEARD FROM, ornER mAN VIA HANDlE-TALKIE, UNTIL HE WAS FOUND UNCONSCIOUS INTHE FIRE APARTMENT, TWENTY ONE MINUTES LATER AT 1943 HOURS.)

The Ladder Company 113 Inside Team and Roof Firefighter heard Lieutenant JohnMartinson transmit the 10-75 via handie-talkie after they exited the elevator on the Ith floor.

The Battalion 38 Firefighter transmitted a 10-75 to the Brooklyn Dispatcher at 1921:38.On receipt of the 10-75 signal, the Brooklyn Dispatcher assigned the following units:

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Squad Company 1 (already at the scene and operating as ordered by Battalion 38) Engine Company 248 Ladder Company 123 - Firefighter Assist and Search Team (FAST Unit). Rescue Company 2 Battalion 41Division 15 was notified of the 10-75 and directed the Brooklyn Dispatcher to assign

Division 15 to the Box.Battalion 38 called Lieutenant John Martinson via handie-talkie in order to verify the

CIDS information on the response ticket and to determine the attack stairway. Lieutenant JohnMartinson replied, "10-4 Chief." Battalion 38 made a handie-talkie transmission to all units thatthe hallways are in the shape of a cross and not a T (See Diagram 3).

While on the concourse level, prior to entering the building, the Ladder Company 132Officer notified Battalion 38 via handie-talkie of a heavy wind condition. The Ladder Company132 Inside Team and Outside Ventilation Firefighter then entered the lobby. At 1922 hoursBattalion 38 ordered Ladder Company 132's Officer to check the compactor shaft for possiblefire. (THE EBBETS FIELD APARTMENTS HAD A HISTORY OF COMPACTOR FIRES.)

The initial call reported a fire in apartment 14M. As the Ladder Company 113 InsideTeam passed the 13 th floor, the Ladder Company 113 Officer ordered the Ladder Company 113Can Firefighter to check the l3 th floor for the M line of apartments. The Ladder Company 113Officer recalled hearing that the fire apartment was one door down and to the left. There was aheavy smoke condition when the Ladder Company 113 Inside Team arrived on the 14th floorlanding. At approximately 1923 hours, the Ladder Company 113 Inside Team donned theirSeBA facepieces and entered the public hallway.

Engine Company 249 members continued to connect their hoseline to the 13 th floorstandpipe outlet and flake out the hoseline in the 13th floor public hallway. Engine Company 280members arrived on the 13 th floor at approximately 1923 hours and began assisting EngineCompany 249 with their hoseline. Engine Company 280 helped flake the hoseline in the publichallway on the 13 th floor and up stairway A to the 14th floor. The Engine Company 280 ControlFirefighter flushed out the standpipe outlet on the 1t hfloor in preparation for a second hoseline.

As Engine Company 234 made their way to the 12th floor, the Officer received atransmission via handie-talkie from Battalion 38 to ensure the first hoseline was in operation andthen to check the layout of the floor below.

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At 1923 hours Battalion 38 transmitted a 10-77 to the Brooklyn Dispatcher and reportedstairway A as the attack stairway. The following units were dispatched:

Ladder Company 105 Ladder Company 111 Engine Company 219 - Certified First Responder-Defibrillator (CFR-D) Battalion 48 Battalion 37 - Safety Officer Safety Battalion 1 Field Communications Unit Rescue BattalionAt 1924 hours, Engine Company 249' s 2W' hoseline was connected to the standpipe

outlet on the 13 th floor. The hoseline was flaked out in the 13 th floor public hallway and upstairway A to the 14th floor stairway door. At 1924:12 Lieutenant John Martinson transmitted,"249, charge the line in the . .. " (NUMEROUS MEMBERS REPORTED HEARING TIllS TRANSMISSIONAS, "249, CHARGE TIlE LINE IN TIlE STAIRWAY.") The Engine Company 249 Control Firefighteracknow ledged that the hose line was being charged.

After Engine Company 249's hoseline was charged in the stairway, the Engine Company280 Officer anticipated that there might be a need for a second hoseline on the fire floor. Hedirected a member of Engine Company 280 to start a second hoseline. Two members of EngineCompany 280 connected their hoseline to the Ith floor standpipe outlet. Other members ofEngine Company 280 remained with the first hoseline.

The Ladder Company 113 Inside Team, after entering the 14th floor public hallway,proceeded left toward the hallway intersection. The Ladder Company 113 Forcible EntryFirefighter continued past the intersection to the stairway door labeled B. The Ladder Company113 Officer and Ladder Company 113 Can Firefighter made a left at the intersection andcontinued down the short public hallway to apartments 14J and 14K (See Diagram 3). TheLadder Company 113 Officer knocked on both apartment doors. A tenant in one of theapartments answered the door, opening it only slightly. The tenant informed the LadderCompany 113 Officer that the M apartment was down the public hallway and to the left. Theyproceeded back to the intersection to search for the M apartment. The visibility in the publichallway was zero and the heat condition was intensifying. The Ladder Company 113 Officer andLadder Company 113 Can Firefighter met up with the Ladder Company 113 Forcible Entry

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B. (TIlE PRECEDING EVENTS OCCURRED FROM1924 TO 1927 HOURS.)

At approximately 1924 hours the Ladder Company 113 Chauffeur took an elevator to thefloor with members of Ladder Company 132. The Ladder Company 132 Outside

his elevator in Firemen Service. The Ladder Company 113stairway door labeled B to ascend to the roof. The Ladder Company

Officer was informed by a member of Engine Company 249 that members of Ladder113 were searching to the left. The Ladder Company 132 Inside Team entered the 14th

The Squad Company 1 Inside Team arrived on the 12th floor at approximatelyand made their way up stairway A to the 14th floor. The Squad Company 1

at the concourse level on the exposure #3 side of the building.THE INVESTIGATION REVEALED TIlAT TIlE DEBRIS WAS AN AIR CONDmONER WHICH HAD FALLEN

TIlE BEDROOM OF TIlE FIRE APARTMENT.)The Squad Company 1 Chauffeur observed fire venting out two windows on the 14th

floor. He then entered the building carrying a Fire Window Blanket. The Squad Company 1Chauffeur left the Fire Window Blanket in the lobby and took an elevator to the 1 h floor.

After Engine Company 249' s hoseline was charged, the Engine Company 249 Nozzleand Back-Up Firefighters prepared to advance into the public hallway. The smoke condition instairway A made it difficult to find the closed stairway door. When the stairway door waslocated and opened, the Engine Company 249 Nozzle Firefighter was in a position behind thedoor and was unable to enter the public hallway. In order to advance the hose line the EngineCompany 249 Back-Up Firefighter took the nozzle and moved into the public hallway. (FROMTHIS POINT ON, ENGINE COMPANY 249 BACK-UP FIREFIGHTER OPERATED IN TIlE NOZZLE PosmONAND TIlE ENGINE COMPANY 249 NOZZLE FIREFIGHTER OPERATED IN TIlE BACK-UP POSITION.THROUGHOUT TIllS REPORT BOTII MEMBERS ARE REFERRED TO BY THEIR INmALLY ASSIGNED

At 1925:49 Lieutenant John Martinson transmitted via handie-talkie, "249 to Nozzle."The Engine Company 249 Nozzle and 249 Back-Up Firefighters were in the process of switchingvv.",uv " and advancing the charged 2W' hoseline into the public hallway and did not respond.

Engine Company 249 Control Firefighter made two attempts to respond to Lieutenant JohnThese hand ie-talkie transmissions were not acknowledged by Lieutenant John

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Martinson. At 1926:27, Battalion 38 contacted Lieutenant John Martinson via handie-talkie andasked, "John, did we find the fire apartment yet?" Lieutenant John Martinson replied,"Negative." Battalion 38 informed Lieutenant John Martinson that the M apartment should be tothe left of the stairway. Lieutenant John Martinson responded, "10-4 Chief."

13 thAt 1926 hours, Engine Company 234 was on the floor assisting EngineCompany 249 with their hoseline. The following additional companies arrived on the scene:

Rescue Company 2 Ladder Company 123 - FAST Unit Engine Company 248 Battalion 41At approximately 1927 hours the Engine Company 249 Back-Up and Nozzle Firefighters

advanced the charged 2Y2" hoseline to the intersection of the public hallway. The EngineCompany 249 Back-Up Firefighter called via handie-talkie for members to lighten up on the line.They were having difficulty advancing the charged hoseline. The Ladder Company 113 InsideTeam and the Engine Company 249 Back-Up and Nozzle Firefighters met at the intersection ofthe public hallway.

The Ladder Company 113 Officer used the thermal imaging camera to locate thedirection of the fire apartment. The Ladder Company 113 Officer led the members down thepublic hallway towards the fire apartment. The Ladder Company 113 Officer notifiedBattalion 38 via handie-talkie that they were making their way down the public hallway but hadnot found the fire apartment. The Engine Company 249 Chauffeur notified Lieutenant JohnMartinson and Battalion 38 via handie-talkie that the standpipe siamese was now being supplied.Battalion 38 acknowledged this transmission. Lieutenant John Martinson did not. (LIEUTENANTJOHN MARTINSON'S LOCATION WAS NOT KNOWN AT THIS TIME.)

At 1927 hours Battalion 38 was on the Concourse level and made a general handie-talkietransmission to all units warning them of the wind condition. (THE INVESTIGATION REVEALEDTHAT THE FIRE INTENSITY VARIED DUE TO THE WIND CONDITIONS. AT TIMES FIRE WAS VENTINGOUT THE WINDOWS OF THE FIRE ROOM AND AT OTHER TIMES FIRE WAS BEING BLOWN INTO THEAPARTMENT. THE CONDITIONS IN THE PUBLIC HALLWAY ALSO VARIED. SOME MEMBERS REPORTEDA MODERATE HEAT CONDmON, OTHER MEMBERS REPORTED A SEVERE HEAT CONDmON. THE

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INVESTIGA TION TEAM DETERMINED THIS TO BE A WIND IMPACTED FIRE, AS OPPOSED TO A WINDDRIVEN FIRE. I)

The Squad Company 1 Roof Firefighter proceeded up stairway A to the floor above thefire. The Ladder Company 113 and Ladder Company 132 Inside Teams had not yet located thefire apartment. At 1927:51 the Squad Company 1 Officer tried to contact Engine Company 249and tell them to hold up on bringing their hoseline down the public hallway until the fireapartment was located. At 1927:58 the handie-talkie recordings indicate that Lieutenant JohnMartinson's hand ie-talkie was keyed, however there was no recorded transmission. (THEINVESTIGATION TEAM BELIEVES LIEUTENANT JOHN MARTINSON WAS IN THE FIRE APARTMENT ANDWAS ATrEMPTING TO RESPOND TO THE TRANSMISSION FROM THE SQUAD COMPANY 1 OFFICER.THERE WERE OTHER HANDIE-TALKIE TRANSMISSIONS OCCURRING AT THIS TIME. IT IS NOT KNOWNIF THESE TRANSMISSIONS PREVENTED LIEUTENANT JOHN MARTINSON FROM RESPONDING, ORPREVENTED HIS TRANSMISSION FROM BEING HEARD OR RECORDED.)

At 1928 hours the Engine Company 234 Officer contacted his members via handie-talkieand directed them to bring the second line to the 14th floor. He then descended to the 13 th floorto try to identify the fire apartment. The Officer was unaware at this time that EngineCompany 280 had already started stretching a second hoseline.

While advancing the hoseline, the Engine Company 249 Back-Up Firefighter observedfIre rolling across the public hallway ceiling in the area between apartments Land M. TheEngine Company 249 Back-Up Firefighter opened the nozzle, knocked down the fire andadvanced the hoseline toward the fire apartment door. The Ladder Company 113 Inside Teamadvanced to apartment 14M and found the door open approximately one to two feet. The EngineCompany 249 Back-Up and Nozzle Firefighters operated the hoseline from the public hallwayinto the fire apartment.

At 1929: 18 the Ladder Company 113 Officer transmitted to Battalion 38 that they foundthe fire apartment. Battalion 38 notified the Ladder Company 113 Officer that the fire was outthe windows on the 14th floor in the rear of.the building.

wind driven fire implies a constant wind condition pressurizing the fire area. A wind impacted fire describes acondition that does not constantly pressurize the fire area. The variable wind conditions cause the heat, smokefire to fluctuate in direction and intensity in the fire apartment and public hallway.

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Diagram 6Apartment 14 MNote: Red Lines in the Bedroom Indicate the Fire Area.(OVER TIlE NEXT SEVERAL MINUTES, 1929 TO 1931 HOURS, TIlERE WERE SEVERAL ATTEMPTS TOVERIFY TIlE FIRE APARTMENT DESIGNATION.)

At 1930 hours, the Engine Company 234 Officer was in apartment 13K and transmittedthat the fire was in apartment 14K directly above him. At this time, the Squad Company 1Chauffeur was in apartment 13L. He looked out the window and believed the fire was directlyabove him in apartment 14L. Due to the conflicting reports about the location of the fireapartment, the Squad Company 1 Chauffeur did not want to add to the confusion by reportingthis to Command.

At 1931 hours, the Squad Company 1 Roof Firefighter in apartment 15M, reported toCommand that the fire was right below him in apartment 14M. Command acknowledged thistransmission and indicated the fire location would still have to be verified due to the conflictingreports he had received. (THE INFORMATION FROM TIlE SQUAD COMPANY 1 ROOF FIREFIGHTERPROVED TO BE ACCURATE.)

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The Ladder Company 132 Inside Team continued to search the public hallway to theof stairway A. The Ladder Company 132 Officer stated that the public hallway was

Some of the members of Engine Company 280 stood fast in stairway A on the 13 th floorhose line while the other members continued to assist with the first hoseline.if the second hose line would be required on the fire floor or the floor above.

of Engine Company 234 were dispersed between the 13 th and 14th floors in stairway AEngine Company 249 with the first hoseline. Engine Company 248, the 4th due Engine

1th floor.The Ladder Company 113 and 132 Chauffeurs entered the stairway door labeled B on the

12th floor and ascended to the roof. When they arrived on the roof, they found the bulkhead doorA, already opened. There were approximately 10 civilians who

self evacuated to the roof. The bulkhead doors to the evacuation stairways, labeled B and C,ere closed. There was a heavy smoke condition in both the Band C stairways. The Ladderompany 113 and 132 Chauffeurs vented the bulkhead doors of stairways labeled Band C.

Battalion 41 made his way up to the fire floor to assume command of fire flooroperations. Battalion 38 informed Battalion 41 via handie-talkie of the identity of the units thatwere operating in the building, and that he had ordered Ladder Company 123, the FAST Unit, tothe 13 th floor. Battalion 41 arrived on the 14th floor at approximately 1931 hours. He reportedfrom stairway A that the hose line was advancing.

The FAST Unit, Ladder Company 123, had taken an elevator to the 11th floor, thenascended stairway A to the 13 th floor. They familiarized themselves with the building layout andapartment locations on the 13 th floor.

There was a heavy smoke condition on the 15 th floor. While searching this floor, theLadder Company 132 Roof Firefighter entered an open smoke filled apartment and found an

nine year old girl. She was having difficulty breathing so he placed his SCBAl a c c ~ p H ~ c e on her face and removed her from the apartment. He brought her down to the lobby

an elevator from the 15 th floor.At 1932 hours the Squad Company 1 Roof Firefighter reported to Command that fire

threatening to extend to apartment 15M. He requested a fire extinguisher or a hoseline beto apartment 15M. The Squad Company 1 Chauffeur was in the public hallway at the

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floor and in the fire apartment were not able to determine and verify the fire apartmentdesignation due to the severe conditions on the fire floor.

The Engine Company 249 Back-Up Firefighter had been operating the nozzle from theentrance to the fire apartment. The Ladder Company 113 Officer entered the fire apartmentfollowed by the Engine Company 249 Back-Up Firefighter with the nozzle. There was novisibility and a high heat condition. The Engine Company 249 Back-Up Firefighter wasdirecting the stream into the living room area. The Engine Company 249 Nozzle Firefighterassisted on the hoseline just outside the fire apartment. The Ladder Company 113 Forcible Entryand Can Firefighters were in the public hallway just outside the fire apartment door. The EngineCompany 249 Control Firefighter was in the public hallway on the 14th floor assisting with thehoseline advance. The Engine Company 249 Door Firefighter had lost his helmet in the publichallway while advancing the hoseline. He was unable to locate his helmet. His head wasexposed to the high heat and hot water forcing him to evacuate into the stairway door labeled Bon the 14th floor.

At 1933 hours Division 15 arrived on the scene and assumed command. Battalion 38called Lieutenant John Martinson on the handie-talkie at 1933:04. The Battalion Handie-TalkieRecorder indicated that Lieutenant John Martinson's handie-talkie was keyed at 1933:09, butthere was no recorded transmission. (THE INVESTIGATION TEAM BELIEVES LIEUTENANT JOHNMARTINSON WAS IN THE FIRE APARTMENT AND WAS ATTEMPTING TO RESPOND TO BATTALION 38.THERE WERE OTHER HANDlE-TALKIE TRANSMISSIONS OCCURRING AT THIS TIME. IT IS NOT KNOWNIF THESE TRANSMISSIONS PREVENTED LIEUTENANT JOHN MARTINSON FROM RESPONDING, ORPREVENTED HIS TRANSMISSION FROM BEING HEARD OR RECORDED.)

At approximately 1934 hours Ladder Companies 105 and 111 were assigned to searchthe floors above the fire due to multiple phone calls reporting smoke throughout the building.The Ladder Company 132 Roof Firefighter arrived in the lobby with the civilian he removedfrom the 15 th floor. Engine Company 219, the CFR-D Engine, was just entering the lobby andtreated the civilian. When EMS Unit 31C arrived in the lobby, the patient was transferred totheir care.

At 1934 hours the Squad Company 1 Roof Firefighter was still in apartment 15M on thefloor above the fire. The fire caused the outer panes of the windows to crack and flames werevisible at the air conditioner sleeve. He called Command a second time and requested a hoselinebecause the fire was threatening to extend to apartment 15M.

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By approximately 1934 hours the Engine Company 249 Back-Up Firefighter hadadvanced the hoseline four to six feet inside the apartment. The Ladder Company 113 Officerwas located immediately to the right of the nozzle. The Ladder Company 113 Officerrepositioned to the left of nozzle. He realized the fire was to the left and ordered the hose streamoperated in that direction. The Engine Company 249 Nozzle Firefighter moved up on thehose line to a position about three feet inside the fire apartment door. The Ladder Company 113Forcible Entry Firefighter was just inside the apartment door. The Ladder Company 113 CanFirefighter was located just outside the fire apartment door (See Diagram 7).

The Squad Company 1 Chauffeur and Hook Firefighters were operating under the beliefthat the fire was in apartment 14L. They were unaware of the fire conditions in apartment 14M.Before forcing the door to apartment 14L they wanted the protection of a charged hose line. TheSquad Company 1 Hook Firefighter went to apartment 14M to get Engine Company 249 toreposition the hoseline to apartment 14L. This hoseline was already operating in apartment 14M,so he returned to the L apartment without the hoseline.

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.- L-113 Officer.- L-l13 Forcible Entry Firefighter L-113 Can Firefightere- E-249 Back-Up Firefighter.- E-249 Nozzle Firefighter

Arrows indicate hoseline

Diagram 7

--------- - - t

Approxinlate Location of Members in Apartment 14M at 1935 Hours.At This Time Lieutenant John Martinson's LocationWithin the Apartment Was Unknown

Due to the size of the building, the multiple phone calls reporting smoke throughout thebuilding, and the report of possible fire extension to the floor above, Battalion 38 ordered thetransmission of a 2nd alarm. The 2nd alarm was transmitted to the Brooklyn Dispatcher at 1935hours. The following units were assigned:

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Engine Company 235 Engine Company 220 Engine Company 214 Engine Company 207 - Satellite 6 Rehabilitation and Care Unit 2 Tactical Support Unit 2 Engine Company 240 Battalion 57At 1938 hours the following Ladder Companies were manually selected and assigned by

the Dispatcher: Ladder Company 157 Ladder Company 120

(DURING THE NEXT SEVERAL MINUTES NUMEROUS HANDlE-TALKIE TRANSMISSIONS WERE MADE.1WO OF THESE HANDlE-TALKIE MESSAGES PERTAINED TO MEMBERS RUNNING OUT OF AIR. THEREWERE ALSO VERBAL REPORTS BY MEMBERS ON THE 14TH FLOOR OF A MEMBER RUNNING OUT OFAIR. BATTALION 41 TRANSMITTED AN URGENT MESSAGE VIA HANDlE-TALKIE TO BATTALION 38THAT A MEMBER WAS OUT AIR AND THAT HE DIRECTED RESCUE COMPANY 2 TO LOCATE THEMEMBER.)

Battalion 38 transmitted to Engine Company 234, "Do you have the second line up onfifteen?" Engine Company 234 Officer answered, "Negative." Battalion 38 was unaware thatEngine Company 280 had stretched a second hose line and Engine Company 234 was nowbacking up Engine Company 249.

At 1935:26 the Ladder Company 113 Officer called the Ladder Company 113 ForcibleEntry Firefighter on the handie-talkie and asked, "Are you OK?" The Ladder Company 113Forcible Entry Firefighter transmitted, "Yeah, I'm running out ofair, (unintelligible) up here."The Ladder Company 113 Officer transmitted at 1935:51, "113 to Irons and Can, back outwe're running out of ... " (THE FORCIDLE ENTRY FIREFIGHTER IS ALSO KNOWN AS THE IRONS

At approximately 1936 hours, the Ladder Company 113 Forcible Entry Firefighter wasjust inside the fire apartment door when his air supply was depleted. As he exited the fireapartment he removed his SCBA facepiece and yelled he was out of air. The smoke and heat... v .. '. . . . . . ." .. " in the public hallway were severe. The Ladder Company 113 Can Firefighter was just

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outside of the fire apartment and assisted the Ladder Company 113 Forcible Entry Firefighterdown the public hallway toward the stairway.

The Engine Company 249 Back-Up Firefighter was unable to direct the stream onto themain body of fire in the bedroom or advance in that direction. The immediate area inside the fireapartment was now becoming extremely hot. The Engine Company 249 Back-Up Firefighterdescribed the conditions in the fire apartment as sudden waves of intense heat and bright whiteorange light coming from the bedroom fire area. The vibralert of the Engine Company 249Back-Up Firefighter activated and the Ladder Company 113 Officer directed the Engine 249Back-Up Firefighter to exit the fire apartment with him. The Ladder Company 113 Officerstarted to leave and was hit in the face with the hose stream. The hose stream displaced hisfacepiece and dislodged his helmet. He dropped the thermal imaging camera and hand light andmoved behind the Engine Company 249 Back-Up Firefighter to readjust his facepiece and puthis helmet back on. After the blast of heat subsided, the Engine Company 249 Back-UpFirefighter shut down the nozzle and turned to his right. He reported placing the nozzle againstthe left shoulder of a member as he quickly exited the apartment. He was unable to identify thismember. (NO MEMBER INTERVIEWED BY THE INVESTIGATION TEAM REPORTED RECEIVING THENOZZLE. LIEUTENANT JOHN MARTINSON'S LOCATION WITHIN TIlE FIRE APARTMENT WAS UNKNOWNAT THIS TIME.)

As the Engine Company 249 Back-Up Firefighter and the Ladder Company 113 Officerrapidly exited the fire apartment, they each collided with the Engine Company 249 NozzleFirefighter. The Engine Company 249 Nozzle Firefighter reported one member striking him onthe right side and then another member striking him on the left side. He was knocked over andpushed into the public hallway with his helmet and SCBA facepiece becoming dislodged. As theLadder Company 113 Officer exited the fire apartment he observed the nozzle in a closedposition on the floor. The Engine Company 249 Nozzle Firefighter moved to the area betweenthe fire apartment door and the dead end of the public hallway between the M and N apartments.He adjusted his SCBA facepiece and helmet and began to exit toward the stairs. As he passedthe fire apartment door he heard water flowing from the hose line inside the apartment but wasunaware if anyone was in the apartment. His vibralert had activated, so he continued to exit byfollowing the hoseline toward the stairway A.

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- L-113 Officer - L-l13 Forcible Entry Firefighter - L-l13 Can Firefighter - E-249 Back-Up Firefighter - E-249 Nozzle Firefighter

Diagram 814th Floor Hallway at 1937 Hours

Approximate Location ofL-113 Inside Team and E-249 Back-Up and Nozzle Firefighters

(OllIER MEMBERS WERE IN THE PUBLIC HALLWAY AT THIS TIME BUT ARE NOT SHOWN IN THISDIAGRAM.)As the Engine Company 249 Back-Up Firefighter exited toward stairway A, he collidedwith other members in the public hallway. He was completely exhausted, lost his balance, andfell several times as he followed the hoseline back to stairway A. The Ladder Company 113

exited behind the Engine Company 249 Back-Up Firefighter.

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The Ladder Company 113 Forcible Entry Firefighter was out of air and in distress in thepublic hallway when the Ladder Company 113 Can Firefighter assisted him through the stairwaydoor labeled B on the 14th floor. They descended to the 13 th floor stairway landing. At 1937:28the Ladder Company 113 Can Firefighter transmitted a request via handie-talkie for EMS on the13 th floor. Members in the public hallway on the fire floor were unaware that the member whowas out of air had reached the safety of the 13 th floor. They were shouting through their donnedfacepieces about a member who was out of air. These shouts were heard by Battalion 41 whowas in stairway A. At 1937:37 Battalion 41 transmitted a message via handie-talkie to Battalion38, "I got a guy screaming he's got no air. Ijust sent Rescue in to find him." At this time, thehigh heat, heavy smoke and flue like conditions in the public hallway hampered operationsseverely. Members in stairway A were not aware of who was exiting the fire floor via the otherstairways. This complicated the process of accounting for members.

The Engine Company 249 Door Firefighter was unaware of the location of the othermembers of his unit. Without his helmet he re-entered the public hallway from the stairway doorlabeled B on the 14th floor to rejoin his unit. When he reached the fire apartment door he heardthe hose line operating inside. He was not able to discern if anyone was operating the hoseline.Due to the heat condition in the public hallway and the activation of his vibralert, he exitedtoward stairway A.

Engine Company 219, the CFR-D Engine Company, arrived on the 13 th floor with theirCFR-D equipment and several folded lengths of 2Y2" hose. Engine Company 280 moved theiruncharged hoseline to the stairway door labeled B on the 13 th floor. Engine Company 234 stoodfast in stairway A awaiting orders to relieve Engine Company 249.

The Ladder Company 105 Inside Team continued to search stairway A from the 15thfloor to the roof. The Ladder Company 105 Outside Team continued to search the evacuationstairways from the 15 th floor to the roof. Ladder Company 111 began a search of the 15 th floor.Ladder Company 123, the FAST Unit, assisted members exiting the fire floor.

Battalion 38 directed Engine Company 248 to stretch a hoseline to the 15 th floor. Thiswas in response to the Squad Company 1 Roof Firefighter's report of fire threatening apartment15M. Engine Company 248 members began stretching a hoseline from the 11th floor standpipeoutlet up stairway A to the 13 th floor. The hoseline then crossed over to the stairway door

13 th 15 thlabeled C on the floor and continued to the floor. Two members from Engine

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of their hose and assisted Engine Company 248 with the

At 1937 hours Division 15 contacted Battalion 41 via handie-talkie to determine theocation of the member who was running out of air. This transmission was not acknowledged by

The Squad Company 1 Hook Firefighter moved to apartment 14M for a second time toget the hose line. The Squad Company 1 Chauffeur completed forcible entry into apartment 14L.When he discovered there was no fire in apartment 14L, the Squad Company 1 Chauffeurproceeded toward apartment 14M to rejoin the Squad Company 1 Hook Firefighter.

At 1938:08 Lieutenant John Martinson transmitted, "249's out of air, 249's out of air."This transmission was given rapidly and was barely audible on the Battalion Handie-TalkieRecorder. There was noticeable distress in Lieutenant John Martinson's voice. Thistransmission was not heard or acknowledged by any member. It occurred in the midst ofnumerous handie-talkie transmissions that were of an urgent nature and focused on the memberof Ladder Company 113 who was known to be out of air and in need of assistance. (LIEUTENANTJOHN MARTINSON HAD BEEN OPERATING L'lDEPENDENTLY SL'lCE 1922 HOURS WHEN HE ENTEREDTHE PUBLIC HALLWAY. HIS LOCATION WAS NOT KNOWN TO OPERATING MEMBERS UNTIL HE WASFOUND UNCONSCIOUS JUST L'lSIDE THE FIRE APARTMENT AT 1943 HOURS.)

The Ladder Company 113 Officer exited the public hallway into stairway A. He wasunaware of the location of his Forcible Entry and Can Firefighters who had already exited thepublic hallway via the stairway door labeled B on the 14th floor. The Ladder Company 113Officer called the Ladder Company 113 Forcible Entry and Can Firefighters numerous times viahandie-talkie to come to the stairway.

At 1938:34 Battalion 41 who was in stairway A transmitted, "1131nside Team come onout to the stairwell." There was no response to this transmission. At 1938:52 Battalion 41transmitted, "41 to 1131nside Team. 1 want you outside the apartment." Ladder Company 113Officer answered, "10-4, 1 just made it to the stairway." (THE ATTACK AND EVACUATIONSTAIRWAYS WERE CONGESTED Wfrn MEMBERS. DUE TO MEMBERS EXITING THE FIRE FLOOR FROMDIFFERENT STAIRWAYS THERE WAS A GREAT DEAL OF CONFUSION CONCERNL'lG THE LOCATION OFTIlE MEMBERS FROM LADDER COMPANY 113.)

At 1939 hours Division 15 attempted to gain control of the handie-talkie traffic. He didthis in order to verify if the member who was running out of air had been located. He

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transmitted, "Command, Command to all units. Hold your messages. Command to all units,hold your messages. Command to the 41. Do you have the guy who was running out ofair?Command to the 41. Do you have the guy that was running out ofair K?" At the same timeBattalion 41 and the Ladder Company 113 Officer were also trying to verify the sameinformation.

At 1940 hours Division 15 continued his efforts to contact Battalion 41 without success.Battalion 41 transmitted, "All members stay off the radio. This is the 41 Battalion. 41 to 113Irons." The Ladder Company 113 Forcible Entry Firefighter transmitted, "113 Irons is OK inthe stairway." Ladder Company 113 Can Firefighter who had returned to the fire floortransmitted, "113 Can, I'm OK. I'm doing a search of the hallway."

The Squad Company 1 Hook Firefighter returned to the fire apartment door and heardwater flowing. He picked up the hoseline; the nozzle was open enough to cause it to startwhipping around. He pulled approximately three feet of hoseline toward him until he could holdthe nozzle. He briefly operated the nozzle from the fire apartment doorway into apartment 14Mand then shut down the nozzle. He started to bring the hoseline back to apartment 14L. TheSquad Company 1 Chauffeur met him about five feet from apartment 14M and told him thatthere was no fire in apartment 14L. The Squad Company 1 Hook Firefighter felt a blast of heaton his back and then turned the hoseline toward apartment 14M. The Squad Company 1Chauffeur backed him up as he advanced the nozzle back to the fire apartment and operated thehose line from the apartment door.

At 1941 hours Battalion 41 contacted Division 15 and stated, "I got all membersaccounted for at this time. All members of113 Truck are accounted for."

Battalion 37, the Safety Officer, arrived on the 13 th floor and was advised by members ofEngine Company 249 that their Officer and Control Firefighter were still on the fire floor.Battalion 37 attempted to contact the Engine Company 249 Officer via handie-talkie at 1941:43.There was no recorded response from Lieutenant John Martinson.

The Engine Company 249 Control Firefighter was still in the public hallway assisting onthe hoseline between apartment 14L and the fire apartment. Many members passed him in thepublic hallway in both directions. He was unsure of their identity. The hoseline was bowed atthe end of the public hallway near apartment 14N. The Engine Company 249 Control Firefighterfollowed the hoseline to the end of the public hallway. He heard a handie-talkie transmissionthat Engine Company 249 was being relieved by Engine Company 234. His vibralert activated

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and he began to exit the public hallway by following the hoseline. He exited into the stairwaydoor labeled B on the 14th floor.

Engine Company 234 was assigned by Battalion 41 to relieve Engine Company 249 onthe hoseline. Engine Company 234 members began to advance into the public hallway fromstairway A toward the fire apartment. As the Engine Company 249 Control Firefighter wasexiting the public hallway he passed the members of Engine Company 234 following thehoseline toward the fire apartment.

The Squad Company 1 Chauffeur relieved the Squad Company 1 Hook Firefighter andassumed control of the nozzle. The Squad Company 1 Hook Firefighter was exhausted, low onair and proceeded to exit. The Squad Company 1 Chauffeur remained on the hoseline in thedoorway of the fire apartment with his back against the door jamb. From this position he wasable to direct the hose stream toward the bedroom.

The Squad Company 1 Roof Firefighter had set up for a possible life saving rope rescuewhile in the living room of apartment 15M. He was located directly above the fire apartment andcould hear water hitting the living room windows of apartment 14M. These windows were stillintact; he could see water from the hose stream being forced out of the window jambs and the airconditioner sleeve. At 1942 hours the Squad Company 1 Roof Firefighter gave direction to themembers operating the hose line in the fire apartment by transmitting, "Alright, whoever was justoperating that line you were in the right apartment. You got to go to the bedroom to your left,right when you come through the door."

Engine Company 248, with the assistance of two members of Engine Company 219, theCFR-D Unit, continued to stretch their hoseline to the 15 th floor. Engine Company 280 membersstood fast with a dry hoseline.

At 1942:19 Battalion 41 attempted to contact Lieutenant John Martinson via handietalkie, "41 to 249." At 1942:21 Battalion 41 transmitted via handie-talkie, "/ got 234 coming into take over your line." There was no recorded response to either transmission from LieutenantJohn Martinson.

Ladder Company 132 Officer, who had been searching the opposite end of the publichallway advanced toward the fire apartment.

Command contacted the Squad Company 1 Roof Firefighter in apartment 15M todetermine if fire had extended into that apartment and if a hoseline was in position. The SquadCompany 1 Roof Firefighter responded that one pane of the double pane bedroom window in

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apartment 15M was failing. Engine Company 248's hose line was still in the process of beingstretched.

The Squad Company I Chauffeur started advancing the nozzle into the fire apartmentwhen he noticed the reflective stripes of a bunker coat on the floor in front of him. SquadCompany I Chauffeur shut down the nozzle and at 1943:12 transmitted, "member down."

Lieutenant John Martinson was found approximately three feet inside the apartment lyingon his right side with his head toward the kitchen and his feet toward the bedroom. LieutenantJohn Martinson was unconscious with his helmet and SCBA facepiece off. There was no airescaping from his SCBA. The Squad Company I Chauffeur rolled Lieutenant John Martinson toa supine position. Battalion 41 transmitted at 1943:18, "Is there a MAYDAY in there?" At1943:23 Battalion 41 transmitted, "Did anyone give a MAYDAY?"

Lieutenant John MartinsonRed lines indicates fire area o Squad Company 1 Chauffeuro Engine Company 234 Back-Up

Ladder Company 132 OfficerDiagram 9Location of Lieutenant John Martinson When Found in the Fire ApartmentPage 42 of88


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The Engine Company 234 Back-Up Firefighter followed the hoseline through the heavysmoke condition into the fire apartment. He physically bumped into the Squad Company 1Chauffeur just after the "member down" message was transmitted. The Engine Company 234Back-Up Firefighter began to assist with the removal of Lieutenant John Martinson from theapartment. At 1943:31 he transmitted, "MAYDAY, MAYDAY, MAYDAY, Engine 234 Back-Upto Command, MAYDAY. We got a member down." (NONE OF THE MEMBERS INTERVIEWEDREPORTED BEING AWARE OF THE ACTIVATION OF LIEUTENANT JOHN MARTINSON'S PASS ALARM.HOWEVER, THE BATTALION HANDlE-TALKIE RECORDINGS REVEALED A PASS ALARM SOUNDING INTHE BACKGROUND DURING THIS MAYDAY TRANSMISSION.)

The Engine Company 234 Back-Up Firefighter moved to the other side of LieutenantJohn Martinson and grabbed his legs. He noticed that Lieutenant John Martinson did not have ahelmet, SCBA facepiece or gloves on. The Squad Company 1 Chauffeur and the EngineCompany 234 Back-Up Firefighter moved Lieutenant John Martinson to a seated position,pivoted him so that his back was toward the apartment doorway and lowered his upper body outof the door into the public hallway.

The Ladder Company 132 Officer was in the public hallway at the apartment door whenhe heard the Engine Company 234 Back-Up Firefighter give the MAYDAY transmission. TheLadder Company 132 Officer assisted in removing Lieutenant John Martinson from the fireapartment into the public hallway. There continued to be a high heat condition at the fireapartment door. As Lieutenant John Martinson was being removed, the Engine Company 234Back-Up Firefighter took control of the nozzle and protected the members removing LieutenantJohn Martinson by operating the hoseline in the fire apartment. The Ladder Company 123 Canand the Squad Company 1 Forcible Entry Firefighters quickly moved to this location and assistedwith the removal of Lieutenant John Martinson.

Battalion 41 activated the FAST Unit, Ladder Company 123. The members of LadderCompany 123 had already moved to the 14th floor and were assisting the distressed members.Ladder Company 111 members left the 15 th floor and proceeded to the 14th floor when theyheard the MA YDA Y transmission.

At 1944 hours the Ladder Company 113 Officer contacted the Ladder Company 113 CanFirefighter and asked if he gave a MAYDAY. The Ladder Company 113 Can Firefighterresponded that he did not give a MAYDAY. At 1944:39 the Safety Officer, Battalion 37transmitted to Command, "We're missing the Officer of 249 .. " (THIS IS THE FIRST

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TRANSMISSION INDICATING TIIAT LIEUTENANT JOHN MARTINSON WAS UNACCOUNTED FOR.) A fewseconds later Battalion 37 transmitted via handie-talkie that the Engine Company 249 ControlFirefighter was also missing.

At approximately 1945 hours the Ladder Company 132 Officer, the Squad Company 1Chauffeur, the Squad Company 1 Forcible Entry Firefighter and the Ladder Company 123 CanFirefighter continued to work on the removal of Lieutenant John Martinson. Lieutenant JohnMartinson's SCBA and bunker coat were loose which interfered with his removal. Theyremoved his SCBA and left it in the public hallway near the fire apartment. In the attempt tocarry Lieutenant John Martinson his bunker coat was unintentionally pulled off.

The Ladder Company I I I Officer and Forcible Entry Firefighter advanced down thepublic hallway and encountered the members working on the removal of Lieutenant JohnMartinson. The Ladder Company 123 Can Firefighter grabbed Lieutenant John Martinson's feet.The Squad Company I Chauffeur and the Squad Company 1 Forcible Entry Firefighter hadLieutenant John Martinson by the arms. They carried him face-down toward the stairway doorlabeled B on the 14th floor. Several other members assisted in the removal by clearing the publichallway.

The Engine Company 234 Back-Up Firefighter operated the hoseline during the removalof Lieutenant John Martinson. He was unable to advance the hoseline toward the bedroom firearea so he backed the hoseline out into the public hallway and closed the apartment door.

Lieutenant John Martinson was carried through the stairway door labeled B on the 14thfloor. The Squad Company 1 Officer made a rapid evaluation of Lieutenant John Martinson'scondition and determined that he was unconscious and not breathing. At 1945:41 Battalion 37transmitted, "MAYDAY is out on the B staircase on the l,fh floor." Battalion 37 was unable toidentify the unconscious member.

At 1946:45 the Squad Company 1 Officer transmitted, "Squad 1 to the 15. UnconsciousFirefighter coming down the stairs now, we need ALS on the 1ih floor now." Division 15replied, "Command 10-4, ALS is on the way up... " Lieutenant John Martinson was moved tothe l3 th floor where Engine Company 219, the CFR-D Unit, was staged. The Engine Company219 Control and Nozzle Firefighters immediately provided oxygen and started performing

13 thpatient assessment as Paramedics from EMS Unit 38S3 arrived on the floor. EMSParamedics performed their initial assessment on Lieutenant John Martinson and determined thathe was not breathing and had no pulse. The defibrillator could not be employed due to water

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- - - ~ - - ~ ~ - - - - - - -

Lieutenant John Martinson was placed in the stokes basket and

At 1948:52 the Rescue Battalion transmitted, "One member is being worked on, in full13th floor. EMS is with him now." (THE IDENTITY OF THE UNCONSCIOUS

S NOT KNOWN TO MANY OF THE OPERATING MEMBERS.)Lieutenant John Martinson, in the stokes basket, was moved to an elevator. Due to the

of the elevator, the stokes basket had to be placed on an angle with one end ofChest compressions were continued in the elevator en-route to the

On arrival at the concourse level at approximately 1952 hours, additional EMS membersof Lieutenant John Martinson. Lieutenant John Martinson

d on Bedford A venue. Lieutenant John Martinson wasted to Kings County Hospital where he was pronounced dead at 2021 hours. The cause

While Lieutenant John Martinson was being taken out of the 14th floor public hallway,ine Company 234 members maintained the fire apartment door in the closed position. After

of the hoseline. The111 Inside Team, Rescue Company 2 Chauffeur, Roof, and Can Firefighters

in the public hallway behind Engine Company 234. The members from Ladder Companyand Rescue Company 2 entered the apartment behind Engine Company 234 and proceededand living room.

Ladder Company 105 continued to search the floor above and assisted Engine Companyand Squad Company 1 Roof in apartment 15M.

At 1947 hours the Engine Company 234 Nozzle Firefighter advanced the hoselineof fire. The Squad Company 1

" ..they're getting water on the fire now .. " Ladder Company III and Rescue Company 2of the fire apartment. Lieutenant John Martinson's

et was found behind the fire apartment door by the Rescue Company 2 Can Firefighter.Division 15 requested an additional FAST Unit to replace Ladder Company 123. At

hours Ladder Company 122 was designated the additional FAST Unit.

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The use of the three stairways continued to add to the confusion. During the next severalminutes there were many handie-talkie transmissions attempting to account for members. At1949 hours and at 1951 hours Battalion 41 transmitted MA YDA Y messages in an attempt toidentify the missing member from Engine Company 249 (Lieutenant John Martinson).Lieutenant John Martinson had already been removed. At 1952:21 Battalion 38 transmitted viahandie-talkie that all members from Engine Company 249 were accounted for. He also statedthat the Engine Company 249 Officer was under the care of EMS.

At approximately 1954 hours Car 13A arrived on the scene and assumed command. At1956 hours the Engine Company 234 Officer reported that the main body of fire in the fireapartment had been extinguished. At 1957 hours Battalion 41 reported that the primary searchin the fire apartment was negative.

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v. FINDINGS 1. The Investigation Team was unable to account for Lieutenant John Martinson's actions

from the time he entered the public hallway on the 14th floor at approximately 1922 hoursuntil he lost consciousness immediately after his last transmission at 1938 hours. WhenLieutenant John Martinson was found unconscious in the fire apartment at 1943 hourshis: Facepiece was not on his face Helmet was not on his head Protective hood was in a down position around his neck Gloves were not on his hands SCBA cylinder was depletedThe Investigation Team believes that Lieutenant John Martinson entered the fireapartment to search prior to the flue like condition developing. He remained in theapartment either trapped by these conditions or unaware of them. The kitchen, diningarea, and living room were not in the flue path and therefore not subject to the windintensified conditions. Lieutenant John Martinson remained in the apartment until his airsupply was depleted. Then he removed his facepiece, made a handie-talkie transmissionand inhaled highly heated gases. These highly heated gases closed down his airwaywhich prevented him from breathing causing him to immediately lose consciousness.

2. SCBA # 249-1 worn by Lieutenant John Martinson was impounded by Safety Commandat the scene. This SCBA was a Scott 4.5 positive pressure breathing apparatus with aCBRN EZ flow II regulator and a 45-minute cylinder. The facepiece belonged to anotherOfficer assigned to Engine Company 249. MSU records indicate that both members werefitted for the same size facepiece.This SCBA was tested on January 10,2008 at MSU. The cylinder was empty at the timeof testing. The high pressure coupling was found loose. The manual shut off switch wasin the off position. The HEADS-UP DISPLAY (HUD) wire was broken at the coupling.The facepiece was found with the nose cup right inhalation valve missing. The SCBAand facepiece passed Scott Posicheck 3 testing at MSU. The HUD was not able to be

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tested due to the broken wire and therefore, considered "Failed" during the preliminaryvisual inspection.It is not known when the high pressure coupling became loose or when the HUD wirebroke. The Investigation Team believes that the high pressure coupling was not loosewhen it was used by Lieutenant John Martinson. This conclusion is based on the fact thatthe SCBA lasted for approximately 17 minutes which would be unlikely if the highpressure coupling was loose during use. The 17 minute duration is estimated from thetime Lieutenant John Martinson donned the SCBA facepiece to his handie-talkietransmission stating he was out of air. The SCBA, facepiece and cylinder were sent toIntertek Testing Services for independent analysis. This independent testing corroboratedthe results obtained at MSU.On January 3,2008 at 1800 hours this mask was inspected as per roll call procedure. Nodefects were noted. This inspection and the results are reflected in the 1800 hoursCompany Journal entry made by Lieutenant John Martinson. The Investigation Teamconcluded that Lieutenant John Martinson's SCBA, PASS, and End of Service TimeIndicators were all working properly while used at this fire.

3. The Investigation Team examined the possibility that this may have been a wind drivenfire. The fire apartment door remained partially open when the occupants fled. Windowsin the bedroom of the fire apartment faced west and failed due to the heat prior to orshortly after Fire Department arrival. A northwest wind caused the products ofcombustion to be driven through the fire apartment and into the public hallway. Thestairway doors were self closing which initially kept most of the smoke and heat in thepublic hallway. The attack stairway bulkhead door was opened by civilians who fled tothe roof. The only element preventing a flue like situation at this point in the fire was theclosed attack stairway door on the 14th floor. The advance of the first hoseline into thepublic hallway completed the path from the bedroom of the fire apartment to the publichallway into the attack stairs and to the attack stair bulkhead. This allowed the windgusts to intensify conditions at the apartment entrance and in the public hallway.Members reported that conditions in the hallway varied from moderate heat to blisteringheat. Although the conditions in the hallway were severe at times, many effects thatwould be expected at a wind driven fire were not found at this fire:

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Numerous members were able to operate in the public hallway for the duration ofthe fire

Plastic light fixtures and plastic covered wire raceways at the ceiling level wereintact in most of the public hallway

There was a lack of spalling in the public hallway At times fire auto exposed the windows on the floor above cracking the outer

paneThe wind was not constant; at times it gusted and swirled throughout the H-shapedconfiguration of the building. The fire at times was issuing out the windows with force.At other times it was blowing into the windows. These facts led the Investigation Teamto conclude that this fire was impacted by the wind but not wind driven.The Department along with Brooklyn Polytechnic University and the National Institute ofStandards and Technology (NIST) is currently researching wind driven fires. TheDepartment is currently conducting an ongoing pilot program, "Wind Driven Fires" usingPositive Pressure Fans, Fire Window Blankets and High-Rise Nozzles.Members did not recall hearing a PASS Alarm signal when Lieutenant John Martinsonwas found. A review of the handie-talkie recordings indicates that a PASS Alarm wassounding in the background when the MAYDA Y transmission was being made. PASSAlarm signals are common occurrences on the fireground and are sometimes purposely orsubconsciously ignored by members.

The working and exit time of the SCBA depends on many factors. Cylinders rated toprovide 30, 45 or 60 minutes do not provide this amount of time. The 45 minute ratedcylinders used at this fire lasted approximately 15 to 20 minutes

The first available elevator was used by Engine Company members only. The elevatorwas small and only able to accommodate a maximum of five members. This preventedthe 1st Engine Company and Ladder Company from complying with FirefightingProcedures Multiple Dwelling Fires section 6. L3F, which states that the elevator shouldbe shared by both the Engine and Ladder Company members.

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7. A Firemen Service elevator was brought to the fire floor and floor above during fireoperations. An elevator that serviced the fire floor was used during fire operations totransport a civilian from the floor above the fire. These actions placed members and thecivilian in jeopardy.

8. The 1 t and 2nd Ladder Companies operated elevators in Firemen Service for the durationof the fire. A Firemen Service elevator was ordered to the 13 th floor to assist membersevacuating. This expedited the removal of Lieutenant John Martinson.

9. Some members operated contrary to Department polices and procedures: Members entered an IDLH area to conduct a search without being teamed up with

another member (All Unit Circular 329) Members entered the smoke filled public hallway without a charged hoseline

(Fire fighting Procedures Multiple Dwelling Fires 6.2.1.A.2) Some members exiting the IDLH were not accompanied to a safe area by another

SCBA equipped member (Training Bulletin SCBA 2.1.7, 3.6.2, All Unit Circular220)

At least two members continued to operate in an IDLH atmosphere after theirSCBA End of Service Indicators (HUD and vibralert) were activated. Theycontinued to operate until their cylinders were depleted Two members removed their SCBA facepieces when their cylinders wheredepleted instead of removing the regulator from the facepiece. The facepiecewith the regulator removed still provides physical protection to the member's faceand allows for rapid application of the FAST Pak regulator

A member shared his SCBA facepiece with a civilian during removal from thefloor above the fire. Facepiece sharing hampers the search for an exit, increasesthe exposure to airborne contaminants such as carbon monoxide, and depletes thelimited air supply in less time, thus posing risk to both victim and rescuer

10. The CFR-D Engine Company did not maintain unit integrity. Two members wereordered by their Officer to assist another unit stretching a hose line.

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The 2nd due Engine Company initially assisted the 1 t due Engine Company but did nottearn up with them for the duration of the fire. Some members of the 2nd EngineCompany stretched a second hoseline. According to Firefighting Procedures MultipleDwelling Fires, the 3rd to arrive Engine is responsible for stretching the second hoseline.There were delays and confusion accounting for members operating on the fire floor. Officers must account for their members at all times. However, it was not

addressed in Department publications that Firefighters should also account fortheir Officer

Roll call procedures were not conducted in a timely fashion. Chief Officers wereunable to determine which members were reported being out of air

The presence of the three stairways in conjunction with the heavy smokeconditions added to the difficulty in accountability. Members operating in onestairway were not aware of members entering and exiting the other stairways

Members were not aware Lieutenant John Martinson was out of air; their focuswas drawn to another member known to be out of air and in need of assistance

There was difficulty in identifying Lieutenant John Martinson after he wasremoved from the fire floor because he did not have on his helmet, bunker coat,SCBA or Officer's shirt

A member on the floor above the fire prepared for a life saving rope rescue. The lifesaving rope was tied off to a substantial object and in position for deployment ifnecessary. This member also gave clear and accurate reports from the apartment abovethe fire.After Lieutenant John Martinson was found, the Engine Company 234 Back-UpFirefighter transmitted a clear and concise MAYDAY for a member down. He locatedthe nozzle and operated the hoseline to protect the members removing Lieutenant JohnMartinson. After Lieutenant John Martinson was removed from the fire apartment theEngine Company 234 Back-Up Firefighter backed the hoseline out of the apartment andclosed the door. This improved the conditions in the hallway and allowed the othermembers of Engine Company 234 to regroup and make an effective attack on the fire.

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Engine Company 234 remained focused on their extinguishment duties which expeditedthe removal of Lieutenant John Martinson.

15. After being discovered in apartment 14M Lieutenant John Martinson was quicklyremoved from the IDLH. It took approximately four minutes to remove him from the fireapartment to the floor below. According to a December 2003 Fire Engineering article,"Rapid Intervention Isn't Rapid," by Steve Kreis, the average removal time of a downedFirefighter is approximately 22 minutes.Even with the rapid removal, the Medical Examiner stated that if Lieutenant JohnMartinson had been intubated within one to two minutes after losing consciousness, hestill would have had significant complications and his survival would have been doubtfuLNine minutes transpired from the time Lieutenant John Martinson lost consciousnessuntil he was removed to the 13th floor. The Medical Examiner indicated this time frameallowed no chance for survival.

16. During the fire operations at this incident, at least seven members reported that theirhelmets were dislodged while operating. None of these members were wearing thehelmet chinstrap and their helmets were completely dislodged.

17. Ventilation procedures at high-rise fireproof multiple dwelling fires need to be furtherstudied and evaluated. Fire Window Blankets may have had a positive effect on theoutcome of this fire. Fire Window Blankets were brought into the building but were notin position to be deployed. At the time of the fire, Department procedures did not requireFire Window Blankets to be brought above the fire at high-rise fires.Note: The Department is currently conducting an ongoing pilot program, "Wind DrivenFires" using Positive Pressure Fans, Fire Window Blankets and High-Rise Nozzles.

18. The bulkhead door of the attack stairway was left open by civilians exiting to the roof.This information was not relayed to the Incident Commander by members arriving at theroof.

19. Hoselines were stretched via the evacuation stairway. Once the attack stairway ISdesignated, all hoselines should be stretched and operated from this stairway.

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The in-line pressure gauge was placed on the standpipe outlet. It was not used to sethoseline pressure or monitored during operations to ensure that proper pressure wasmaintained.

Handie-talkie communications at the scene did not give a clear and concise picture of fireconditions or the actions taken by units. Lieutenant John Martinson failed to maintain frequent handie-talkie

communication with Command and other members operating. He did not makean emergency notification until his air supply was depleted. Many Firefighters,who are trapped, lost or out of air do not call for help in a timely manner. Theytend to try to resolve problems themselves until it is too late to be rescued withoutserious consequences

Conditions that existed in the hallways, stairways, floor above and fire floor werenot communicated to Command. Knowledge of these conditions would havegiven the Incident Commander better situational awareness and may haveprompted him to reevaluate his strategy and tactics

The status of searches on the fire floor and floors above were not communicatedto Command until later in the operation

The designation of the attack stairway was not transmitted on the handie-talkie tounits on the scene

Notification of the self evacuation of civilians to the roof and the additionalventing of the bulkhead doors by members were not communicated to Command

First names were used by some members in handie-talkie transmissions instead ofunit designation with assigned positions. Situational awareness will not beconveyed to other members when communications are conducted in this manner

A civilian was found and removed from the floor above without notifyingCommand

Many members operating at this fire were not equipped with an Emergency Alert Buttonon the remote handie-talkie microphone.

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Note: All MX 3500 handie-talkies have been equipped with an Emergency Alert Buttonon the remote microphone as of July 2008. Members transmitting MAYDAY or URGENT messages did not activate the

Emergency Alert Button Chief Officers attempting to gain control of the handie-talkie network did not use

the Emergency Alert Button23. Progress reports were not transmitted to the Brooklyn Dispatcher in accordance with the

Communications ManuaL24. The incident duration times were not transmitted by the Brooklyn Dispatcher until late in

the operation.25. During critical stages of the fire the Primary Tactical Channel became overwhelmed by

numerous transmissions. The Command Channel was not established until after the removal of Lieutenant

John Martinson The Post Radio was not utilized until later in the operationNote: Neither the Post Radio nor the Command Channel are required at operations in

high-rise fireproof multiple dwellings.26. Ladder Companies assigned on the 2nd alarm after a 10-77 signal are not automatically

selected and dispatched by the CADS. The Dispatcher must manually select these units.This resulted in a delay of more than three minutes from the transmission of the 2nd alarmto the assignment of the Ladder Companies. Although this had no impact on the outcomeof this incident this delay could be critical at future incidents.

27. The Brooklyn Dispatcher notified Battalion 38 of phone calls from approximately 20apartments throughout the building. Although no problems were reported at this incident,the potential for error is great when attempting to manually transcribe this amount ofinformation.

28. The Battalion Handie-Talkie Recorder is a valuable investigative and educational tool.Present technology only allows for a maximum of six handie-talkie identifiers to berecorded for each recorded segment. Specific transmissions are not definitively identified.

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9. The early arrival of a Department photographer greatly assisted in the documentation ofunit operations and the subsequent investigation of this fire. The photographs providedtime stamped pictures of interior and exterior operations during the fire.

. The Daily Chief Officer Schedule at the start of the 6x9 tour was incorrect. This led the1st arriving Battalion Chief to be unaware that an Acting Battalion Chief (ABC) was theAll-Hands Chief.

1. Stairways Band C were scissor type stairs. These stairways were mislabeled; thestairway door labeling should have alternated from floor to floor. The stairways shouldbe designated, not stairway doors. In this building, the stairway doors were labeledvertically with the same letter above one another and did not reflect the proper stairwaydesignation.

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VI. CAUSESCT CAUSESSmoke inhalation and thermal burns.

CT CAUSESChild playing with fire on kitchen stove.

of occupant to fully close the apartment door when exiting the apartment.to team up with another member when entering an IDLH.

Failure to leave the IDLH when the End of Service Time Indicators, HEADS-UPDISPLAY (HUD) and vibralert activated.

of 11 to 15 miles per hour with gusts up to 20 miles per hour.

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VII. RECOMMENDATIONS A

Proper SCBA usage must be strictly enforced. All Chief and Company Officers shalltake any and all measures to ensure that the Department's SCBA policy (AUC 220) isfollowed. Leave the IDLH when the End of Service Time Indicators, (HUD and vibralert)

activate Team up with other members when entering, operating in and leaving an IDLH Prohibit facepiece sharing Keeping the facepiece in place and removing the regulator when the SCBA airsupply has been exhausted and the member is unable to exit the IDLHAll members shall maintain an awareness of other team members during operations. It isinherent of the Company Officer's responsibility to be aware of the location and status oftheir members during fire operations. Members must also maintain awareness of thelocation and status of their Officer.

Re-emphasize the importance of the proper use of the firefighting helmet chin strap.Failure to utilize the chin strap can result in serious consequences which affectsoperations as well as members' personal safety. When a helmet is lost or dislodged, themember is at risk of serious injury and is no longer effective in conducting assignedtasks. No member should enter or operate in an IDLH without a helmet.

Re-emphasize the need for Engine Companies to team up for the duration of theoperation. This is needed for rapid placement of the hoseline, advancement of thehose line, and to ensure that members are readily available for relief.

The Fire Department should continue to evaluate the implementation of positive pressureventilation and the use of wind control devices as initial operational tactics for fires inhigh-rise fireproof multiple dwellings.

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6. Firefighting Procedures Multiple Dwelling Fires, section 6, "Class A Fireproof MultipleDwelling Fires" should be revised and issued as a separate volume. A workgroup shouldbe formed to revise the document. The revision of this document should emphasize andexpand on the following: Controlling the fire apartment door Control of ventilation by the Incident Commander Strategies and tactics of ventilation procedures Elevator operations Standpipe operations

7. A fire safety education campaign should be implemented to inform the public of theimportance of closing the fire room door, as well as apartment doors, in case of fire. Thefire safety education campaign should also emphasize the importance of not disabling orobstructing the self closing devices on apartment doors. This information could beprovided to the public through the Fire Safety Education Unit as well as the FDNY publicwebsite. The FDNY should encourage other public and private agencies, such as theNew York City Housing Authority and Con Edison, to participate in this fire safetyeducation campaign.

8. Establish a Command Channel whenever a 10-77 signal is transmitted. This willalleviate handie-talkie traffic on the Primary Tactical Channel and will improve overallcommunications. The Post Radio should be utilized as soon as possible to provide animproved communications link between the Command Post and the Operations Post.

9. Emphasize the importance of maintaining radio discipline during MAYDAY/URGENTsituations. All hand ie-talkie transmissions should cease, except those related to theMA YDA Y URGENT or critical information related to the fire.

10. Re-emphasize to all members that handie-talkie transmissions should be concise anddirect. Transmissions must be made using unit designation and assigned position, not themember's name

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Train all members to be proficient in roll call procedures as per Communications ManualChapter 9, Addendum 2, "Emergency Roll Call Procedures."

at future operations:The Dispatcher should relay important information such as numerous apartments withoccupants in distress to the Incident Commander via the MDT as well as the Departmentradio. The printed copy from the MDT will ensure the accuracy of this information.Emphasize the importance of reacting to a PASS Alarm signal sounding duringoperations. When a PASS Alarm is activated in the full cycle for ten seconds, themember hearing the alarm should immediately notify the Incident Commander. Animmediate investigation of the alarm must be made to determine the cause. The results ofthe investigation must be transmitted to the Incident Commander as soon as possible.PASS Alarm signals have become so common during routine operations on thefireground that many members have a tendency not to hear them and/or disregard them.Research the feasibility of developing other PASS Alarm signals such as using verbalunit designations.

The CADS should reflect when a Division or Battalion is staffed by an Acting Chief. Forexample, the Acting Battalion Chief, Battalion 99, could be indicated on the responseticket as ABC99 instead of BC99.

Ensure scissor stairs are properly labeled whenever inspecting or operating in buildingsserviced by scissor stairs. Mislabeled scissor stairs can cause confusion during fireoperations. This information should be relayed to the Incident Commander as soon as itis discovered. Detailed information on scissor stairs should be incorporated into Firefighting

Procedures "Fireproof Multiple Dwellings"

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The labeling of scissor stairs should be included on the Multiple DwellingBuilding Inspection Fonn A-291 and Inspection Guide 3 for Fireproof MultipleDwellings

Corrective action must be taken whenever scissor stairs are improperly labeled Scissor stairs should be included in the CIDS infonnation

16. Establish a training program to visit field units to review and discuss the findings andrecommendations found in Fatal Fire Investigations.

fdny report on fatal fire, january 3, 2008

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