Вы находитесь на странице: 1из 13
'­ SAFETY AND INSPECTION SERVICE COMMAND . FINAL INVESTIGATIVE REPORT FATAL FIRE AT BOX 22-8943

'­ SAFETY AND INSPECTION SERVICE COMMAND . FINAL INVESTIGATIVE REPORT FATAL FIRE AT BOX 22-8943 150-28
'­ SAFETY AND INSPECTION SERVICE COMMAND . FINAL INVESTIGATIVE REPORT FATAL FIRE AT BOX 22-8943 150-28

SAFETY AND INSPECTION SERVICE COMMAND

. FINAL INVESTIGATIVE

REPORT

FATAL FIRE AT BOX 22-8943 150-28 127 m STREET QUEENS, NEW YORK

JUNE 3, 1999

VOLUME I

. FINAL INVESTIGATIVE REPORT FATAL FIRE AT BOX 22-8943 150-28 127 m STREET QUEENS, NEW YORK
. FINAL INVESTIGATIVE REPORT FATAL FIRE AT BOX 22-8943 150-28 127 m STREET QUEENS, NEW YORK
. FINAL INVESTIGATIVE REPORT FATAL FIRE AT BOX 22-8943 150-28 127 m STREET QUEENS, NEW YORK

,

I

u.

SUMMARY

At 1855:20 hours, on June 3,1999, the Queens Communications Office of the New York City Fire Department received a telephone alarm reporting a structural fire at the address 150-28 127 Street, Queens. Engine Company 331, Engine Company 285, Ladder Company 173, Ladder Company 142 and Battalion 39 were assigned to respond at 1855 :40 hours. A second source for the alarm was received at 1856:09 and Engine Company 225 was assigned to respond. At 1900 hours, due to additional calls, Rescue 4·and Squad 270 were assigned.

Engine Company 331, the first arriving engine company, transmitted signal 10-75 at 1901 hours. Upon receipt of the 10-75 signal, the Queens dispatcher assigned Battalion 51, Engine Company 293 and Division 13 to respond to the fire. The fire was located in the cellar of a Class 4, one story, twenty foot by forty foot, private dwelling. There was a heavy smoke condition, but no fITe showing. Engine 331 hooked up to a hydrant in immediate proximity to the fire building and stretched an 1-3/4" hoseline from their apparatus to the exposure two side entrance door.

At approximately 1902 hours, Ladder Company 173, the first arriving ladder company, forcible entry team donned their masks at the side entrance and descended into the cellar to search for victims and to locate the fire. Engine 331 immediately followed them with a charged line. The cellar staircase was very narrow, and the base of this stair ended in dose proximity to the exposure one cellar wal1. The cellar was heavily charged with smoke, however, there was not an excessive amount of heal. The cellar area was heavily congested with furnishings, boxes and other household items. Engine 331 opened the line as a precautionary measure to prevent fITe from getting behind them, but was unable to place water directly on the fire.

At 1904 hours, Ladder 142, the second to arrive Ladder Company, entered the fire building on the first floor and proceeded to search for victims and ventilate the first floor. Squad 270 arrived at 1906 and started to search and ventilate the first floor. Engine 285, the second to arrive engine, arrived on the scene at 1907 hours. They stretched a 1-3/4" hoseline to the front door.

Battalion 39 transmitted a 10-84 signal by department radio when they arrived at 1907 hours and began to assess the situation. Battalion 39 heard Ladder 173 Outside Vent position attempt to communicate with Ladder 173 Officer, Captain Fowler, on the handi-talkie, and the response was garbled. Battalion 39 contacted Captain Fowler, and inquired about conditions in the cellar. Captain Fowler stated there was no problem, but he was running low on air. During this communication, Battalion 39 heard vibralert alarms sounding over the handi-talkie. The Safety Battalion believes that the vibralert alarms Battalion 39 heard were those of Captain Fowler, the Engine 331 officer and Nozz/eman. Battalion 39 immediately contacted Squad 270 and ordered the officer to relieve Ladder 173 in the cellar. Battalion 39 then contacted Engine 331 and . inquired if they needed relief. Engine 331 Officer said that they did need relief. Battalion 39 then ordered Engine 225 to relieve Engine 331 in the cellar. At this time, Captain Fowler ordered the line to back out. Engine 331 attempted to back their line out of the cellar. Captain Fowler called for the Can position saying, "Where's my probyT' The Can position was operating behind the Nozzle position, lending a hand on the line. He answered "I'm right here Cap." He moved toward the Captain who was operating further toward the rear of the cellar. Captain Fowler was standing up and coughing. He stated to the Can position "I'm out of air. I need air. II The Can position

removed his regulator, held the regulator up to Captain Fowler's face and opened the purge valve. He gave some air to the Captain and took .the regulator back for himself. At this point the Can position's vibralert started to sound. He gave the regulator back to the Captain two additional times. After the third sharing of the regulator, Captain Fowler stated "We've got to give a Mayday." The Captain took one more breath of air Jrom the regulator and stated "Mayday, Mayday." The Safety Battalion believes that Captain Fowler was never able to transmit that message over the handi-talkie. Captain Fowler collapsed immediately after stating "Mayday, Mayday," and asking the Can position "Which was the way out". After collapsing and before losing total consciousness, Captain Fowler tried crawling toward the rear of the cellar. Ladder 173 Can position then activated his own pass alarm.

Ladder 173 Can position then attempted to drag Captain Fowler out of the cellar. He succeeded in moving the Captain a short distance. Squad 270 Roof position heard the PASS alarm and moved toward the sound. He located Ladder 173 Can position and Captain Fowler. He placed the Can position on the line, and the Can position left the cei1ar, running completely out of air at the base of the stairs. Squad 270 Roof position then transmitted a Mayday for a downed fuefighter and started removal efforts.

Battalion 39 acknowledged the Mayday and communicated this information to Squad 270 Officer. Squad 270 Officer and Chauffeur responded to the cellar and assisted Squad 270 Roof with the removal of Captain Fowler. They began to drag him out. This was very difficult due to tight quarters, heavy smoke and flames starting to roll across the ceiling. Squad 270 Officer ran out of air and transmitted a Mayday. He also called for a line and a mask for Captain Fowler. The Officer of Squad 270 operated without his SCBA for a period of time and then left the cellar.

When the first Mayday was transmitted Battalion 39 went to the side cellar entrance and supervised the rescue efforts. Members of Ladder 155, the FAST truck, Ladder 107 and Rescue 4 removed Captain Fowler from the cellar.

At 1931 hours, Captain Fowler was removed from the building. He was taken to Jamaica Hospital by Fire Department ambulance and died as a result of his injuries on June 4, 1999 at 09] 5 hours. The cause of death as his injuries on June 4, 1999 at 09] 5 hours. The cause of death as listed on the autopsy report was smoke inhalation with carbon monoxide intoxication.

(FOWLER

4-4.doc)

4

cause of death as listed on the autopsy report was smoke inhalation with carbon monoxide intoxication.

III.

MISHAP

The Queens Communications office of the New York City Fire Department received a telephone alarm reporting a structural fire at 150-28 127 th Street at 1855:20 hours on June 3,1999. The officer and members of Ladder Company 173 acknowledged their response to this alann at ] 856:09 hours. They arrived at the scene of the fire at approximately 1902 hours and found that the fire was located in a one story, Class 4, private dwelling measuring approximately twenty feet by forty feet.

The Officer and Forcible entry team of Ladder 173 entered the fire building at the side entrance, which was, located on the exposure two side of the fire building. They went down the interior stair to the cellar, to search for victims, the location of the fire and to vent the fire area.

Captain Fowler operated near the rear of the cellar. He called for a line and Engine Company 331 brought their line to the rear of the cellar. They operated the line intemlittently for a few minutes. They did not see any fire because of the heavy smoke condition in the cellar. The heat condition at this time was, according to witness statements, slight.

Battalion 39 arrived at the front of the fire building at, according to the timeline, approximately 1909 hours. He contacted Ladder 173, on the handi-talkie, to inquire about the conditions in the cellar. Captain Fowler replied that there was no problem, but he was running low on air. Battalion 39 acknowledged this message and could hear several vibralert alarms sounding, on his handi-talkie, at this time. Battalion 39 then contacted Squad 270 and ordered them to locate Ladder 173 in the cellar.

At approximately 1909 hours, Captain Fowler ordered everyone to back out of the cellar. The Back-Up position of Engine 331was located at the base of the cellar stairs and verbally directed members toward his location. The Officer of Engine 331 ran out of air in his SCBA near the base of the stairs. The Forcible Entry position of Ladder 173 shared his facepiece with the Officer of Engine 331 and together they left the cellar and exited the building. The Nozzle position backed up with the hoseline until he ran out of air and followed the line back to the base of the stairs and exited the building.

Ladder 173 Can position was leaving the cellar, as ordered, when he heard Captain Fowler call him. The Can position went to Captain Fowler and spoke with him. Captain Fowler was standing up at the time and he was coughing. His facepiece was off and he told the Can position that he was out of air. Ladder 173 Can position removed his regulator from his facepiece and placed it up to Captain Fowler's mouth. He then turned the purge valve on. He shared the regulator with Captain Fowler a total of three times and immediately after the first sharing his vibralert started to operate. Captain Fowler stated that they had to give a mayday. Captain Fowler then said "Mayday, Mayday," asked the Can position which was the way out, and immediately collapsed to the floor. Captain Fowler struggled with the Can position by attempting to crawl toward the rear of the cellar before losing total consciousness.

Ladder 173 Can position activated his PASS alarm and started to drag Captain Fowler toward the cellar stairs. He was successful moving the Captain a few feet when Squad 270 Roof relieved him. Ladder 173 Can then exited the building.

(FOWLER.4.4.doc)

5

Captain Fowler wasremoved-ffom-the eeUar-at-approximately 1931-hou.rs-H~was taken to Jamaica Hospital by Fire Department ambulance. Captain Fowler died on June 4,1999 at 0915 hours as a result of injuries suffered on June 3,1999.

[FOWLER - 4-4.doc]

6

:

)

i

8943.

FINDINGS:

At 1855:20 hems en June 3,1999, the Queens effiee-ofFire Communications received a telephone alarm reporting a fire at ] 2ih Street and Old South Road in Queens. A total of six telephone calls were received for that location from 1855:40 hours through 1858:48 hours.

The dispatcher assigned the following units to respond at 1855 :40 hours: Engine Company 331, Engine Company 285, Ladder Company 173, Ladder Company 142 and Battalion 39. A second source was received at 1856:09 and Engine Company 225 was assigned to respond to the reported location. AiJ units acknowledged their response between 1856:03 hours and 1856:57 bours. Engine 285 acknowledged their response with a 10-14 signal, while out of quarters procuring the meal. Battalion 39 transmitted signal} 0-12 at 1857:24 hours.

The mobile data terminal system was out of service from the beginning of the operation until approximately 2025:0] hours. The only 10-84 times that the Safety Battalion were able to determine were the verbal) 0-84 signals transmitted by Battalion 39 and Division 13. The Safety BattaJion, using a multiple event sequence chart developed by them, estimated aJl other times of arrival.

Every emergency is accorded an aJarm assignment by the Fire Department, which is made up of

fire units that are geographicaJly closest to the incident location, assuming they are available for response. The Safety Battalion has found that the units that actually responded to the incident did not make up an optimal first alarm assignment for the incident location. This situation was apparently caused by a pre-existing error in the alarm assignment for box 8943. The optimal first alarm assignment for box 8943 is the following: Engine Company 302 is the first due engine, Engine Company 308 is the second due engine, Ladder Company 155 is the first due ladder, Ladder Company 173 is the second due ladder and Battalion 51 would be the first due battaJion. Engine Company 33] would be assigned as the third due engine. The Safety Battalion is aware that the alarm assignment has been updated to reflect the optimal assignment for box

A1though it

At the time ofthe transmission for box 8943, Engine 308 was in service in quarters.

should have been designated the second due engine company on a first alarm assignment, at this

incident, it was actually designated the second due engine company on the second aJarm.

However, the Safety Battalion notes that not all the units that made up the optimaJ alarm assignment were available for response at the time of the incident. Engine Company 302 and Ladder Company 155 were both assigned to Queens box 8706 at 134 Avenue and 159 Street, and therefore were unavailable at the time box 8943 was transmitted.

Battalion 51, which should have been the normally assigned Chief for box 8943, was in service in quarters at the time the 10-75 for box 8943 was transmitted but was not assigned due to the pre-existing error in the alarm assignment.

At the time of the receipt of the alarm, Battalion 39 was enroute to quarters of Division 15 for a division conference. He was located at Hegeman Avenue and Amboy Street, in Brooklyn, when he received the alarm. The assignment of Battalion 39 instead of Battalion 51 caused a delay in a Chief Officer's presence at the fire scene for a period of approximately four minutes.

(FOWLER.4-4.doc]

7

The alamrbox-located on the n<Jrtheasl€0merof 127 1i1 Street and Old South Road was permanently disabled, prior to the time of the fire, as part of the New York City Fire Department's alarm box removal program. The" face and inner mechanism had been removed from the alarm b(}kTh~-Safety Battalion believes that the disabled status of alarm box 8943 had no effect on the mishap because the Safety Battalion was wmble to identify anyone who tried to report the fire by using the alarm box. In addition, nearby boxes were not used to report the fire.

Records obtained from

4, 1999, three violation orders were issued. The first order was for failure to maintain the rear,

side yard and cellar, causing a dangerous condition. The second order was for the illegal storage of five unregistered vehicles at the rear of the premises. The third order was for work without a permit in the cellar of 150-28 127 1i1 Street. The violation noted construction of partition walls creating approximately four rooms and a narrow passageway and installation of wiring in the partition walls and the ceilings.

the

Department of Buildings of the City of New York show that, on June

At 1900: 14 hours, due to numerous phone caJls reporting smoke at Old South Road and 127 rh Street, the Queens communications office assigned Rescue 4 and Squad 270 to respond to box

8943. Rescue 4 acknowledged their response from quarters at 1900:30 hours and Squad 270

acknowledged at ]901 :34 hours while in service on the air.

Engine Company 33] transmitted radio signal 10-75 due to smoke issuing from a private dwelling located at the northwest comer of Old South Road and 127 1i1 Street at 1901: 16 hours. The address of the fire building was 150-28 127th Street. Upon receipt of the 10-75 signal, Engine Company 293, Battalion 51 and Division 13 were assigned to respond and they acknowledged their responses between 1901:45 hours and 1902:41 hours.

Engine 331 tested and hooked up to the hydrant located at the northwest comer of Old South

his company-to stretch an 1-3/4"

hose line from the pumper to the side entrance door located on the exposure two side of the fire

building.

Road and 127 1i1 Street when they arrived. The officer ordered

Ladder 155 went 10-8 via department radio from box 8706 after hearing the dispatcher annoUQce box 8943 over the radio. Ladder 155 inquired if the dispatcher had another run for them. The dispatcher replied "Negative, stay in service one five five." Ladder 155 acknowledged the order.

The Safety Battalion, using a multiple event sequence chart developed by them, estimated Ladder 173 arrived on the scene at approximately 1902 hours. Captain Fowler and the members of the Forcible Entry team went to the side entrance door located on the exposure two side of the fire building. There, they donned their facepieces, entered the building and went to the cellar to locate the fire, search for victims and ventilate the fire area.

The cellar stairs were narrow and terminated close to the exposure one wall of the cellar in an area approximately thirty-three inches wide by twenty-eight inches in depth. Units then had to make an immediate left tum through a narrow twenty-four inch doorway to enter the cellar fire area.

Engine 331 stretched their line to the side entrance door and called for water. At this point the Nozzle position had difficulty donning his facepiece. He switched places with the Back-Up position and then the Officer and Nozzle team proceeded to the cellar with their charged hose line. After their arrival in the cellar, Engine 331 opened their line as a precautionary measure and operated the line to their right for a short period of time:

Captain Fowler went through the doorway at the base of the stairs and went to the rear of the cellar. The cellar was extremely cluttered with large amounts of furnishings, boxes, personal items and-other-household goods_ Captain Fowler caHed for the line to be moved to the rear before Engine 33] their operated line.

Officer of Engine 331 did not locate the fire. Captain Fowler advised the Officer of Engine 331 that the fire was straight back.

Ladder 173 Outside Vent position requested pt:rmission from Captain Fowler to ventilate the cellar windows. Captain Fowler told the Outside Vent position to vent the cellar windows. The Outside Vent position vented the windows on the exposure two side of the building and one cellar window on the exposure four side. Ladder 173 Chauffeur and Ladder 173 Roof position provided additional ventilation at the cellar level and on the first floor.

Due to the concealed location of the fire it is probable that Captain Fowler never ascertained the specific location of the fire. The fire was located in a closed room that was blocked off from the rest of the cellar by large amounts of furnishings and boxes.

The first floor of the fire building was vented and searched by Ladder] 42. Engine 285 stretched an 1-3/4" hoseline from Engine 331 apparatus to the front entrance of the first floor. Engine 225, the third to arrive engine, assisted Engine 285 stretching the line to the front entrance. Ladder 142 reported to Battalion 39 that the primary search of the first floor was negative.

Captain Fowler contacted Ladder 173 Outside Vent.

understand Captain Fowler's garbled message.

four to five attempts to contact Captain Fowler. Battalion 39 heard the attempts made by the Outside Vent position.

Ladder 173 Outside Vent was unable to

Ladder 173 Outside Vent was unsuccessful in his

Battalion 39 then contacted Captain Fowler. He advised the Battalion that there was fire in the basement and aline was in operation there. The Battalion inquired about the condition of the men and the fire in the cellar. The Captain advised the Battalion that everyone was all right but that they were running low on air. Battalion 39 could hear vibralert alanns-sounding at the time of this transmission. Battalion 39 ordered Squad 270 to locate Ladder 173 in the cellar and then inquired about the condition of Engine 331 and his members. Engine 331 told the Battalion that

he could use a relief. The Battalion then ordered Engine 225 to relieve Engine 331. The Safety Battalion believes that the time at this point is approximately 1909 hours.

Captain Fowler ordered Engine 331 to back out their line and inquired as to the location of Ladder 173 Can position. The Can position was located toward the front of the cel1ar. He told the Captain were he was and started to move toward the Captain's position, The Can position and the Captain joined up toward the rear of the cellar.

The Officer and Nozzle position of Engine 331 started to leave the fire area after Captain Fowler ordered the line to back out. Their vibralert alarms were operating at that time. The Officer of Engine 331 ran out of air while he was moving toward the cellar stairs. Ladder 173 Forcible Entry position shared his facepiece with the Officer of Engine 331 and both were able to leave the cellar.

(FOWLER - 4-4.doc]

9

Eaptam-Fowler was standing with hjs facepiece off, at the time the Can position found him. He was coughing and told the Can position that "I'm out of air. I need air." The Can position took his regulator out of his facepiece, held the regurator up to Captain Fowler's face and operated the

purgevaf ve.

and the Can position exchanged the regulator two additional times and Captain Fowler infonned the Can position that they had to transmit a mayday. After taking an additional breath from the shared regulator, Captain Fowler said "Mayday, Mayday." He also asked the Can position" Which was the way out?" Captain Fowler then collapsed to the floor, the Can position activated his PASS device and started to drag Captain Fowler toward the cellar stairs. The Safety Battalion believes that the recovery effort was started at this time and the time was approximately 1912

hours.

The vibraJert alarm on the Can position's mask began to operate. Captain Fowler

The Safety Battalion does not believe that Captain Fowler transmitted a mayday over the handi­ talkie because there are no witness statements to confirm the mayday transmission.

Based on the 1O~84 signal transmitted by Battalion 39, at 1907 hrs and then allowing approximately 2 minutes to get dressed, come to the front of the building and contact Ladder 173, the Safety Battalion, believes that at this time, the SCBA being worn by the members in the cellar were already out of work time. The Safety Battalion believes the work lime for SCBA was between 5 and 6 minutes.

The Officer of Squad 270 verbally ordered Squad 270 Floor Above team positions to locate Ladder 173 in the cellar. He then ordered, via handi-talkie, Squad 270 Roof to also locate Ladder 173. All of these members then entered the cellar. Squad 270 Can position had previously been ordered to the cellar by Squad 270 Officer.

After entering the cellar Squad 270 Roof followed the line in order to locate the Ladder . Company. He heard a PASS device sounding in the full alarm mode. He also heard a report that they couldn't contact the Captain of Ladder 173 via handi-talkie. As he crawled toward the rear of the cellar he honed in on the PASS alann and someone cal1ing "Over here. Over here." Squad 270 Roof reached the person calling out and found Ladder 173 Can position with Captain Fowler. The Can position's vibralert alarm was sounding and Squad 270 Roof put the firefighter on the line so he could guide himself out of the cellar.

Squad 270 Roof continued the. removal of Captain Fowler when the Officer of Squad 270 located Squad 270 Roof. Squad 270 Officer ordered the Roof position to continue with the removal effort willIe he looked for the line. This removal effort continued until the Roof position ran out of air near the base of the stairs.

Engine 225 went to the side cellar entrance. At this point Squad 270 was assisting members of

Engine 331

then entered the cellar. Engine 225 followed the line into the cellar and found a butt at the base of the stairs. This indicated that there was at least one length of hose in the fire area at that time. The line was coiled from ceiling to floor and the nozzle was located approximately ten to twelve feet into the cellar towards the rear. Engine 225 Officer and Back~Up position helped Squad 270 try to move Captain Fowler. Engine 225 Nozzle opened the line to push back fire that was rolling

over at the ceiling level.

and Ladder 173 out of the cellar. Engine 225 waited until the stairs were clear and

Squad 270 Officer was unable to locate the nozzle and he returned to assist Squad 270 Roof with

the removal of Captain Fowler. It was very debris on the cellar floor.

[FOWLER·4-4.docJ

difficult to accomplish because of built up water and

10

Squad 270 Officer's SCBA ran out of air and,he operated without a facepiece for a period of time. He suffered chemical bums to his throat as a resuJt of this. He transmined a MaydaysignaJ

for himself because he was vent the cellar.

out of air. He also

re~quested that a fog line be placed in operation to

Fire vented out of the cellar window located at the rear of exposure four side of the fire building. Battalion 51 had Engine 293 extinguish fire on the exterior of the fire building above where the cellar window had vented and ignited the siding above the cellar window. Engine 293 and Engine 302 extinguished the fire from the outside after all members were ordered out of the cellar by Division 13. Both units operated into the first floor rear bedrooms and into the cellar at different times. Both units were aware that there were units operating in the cellar.

Rescue 4 was originally assigned to 8943 at 1900: 14 hours. While responding to the box location, Battalion 50 transmitted a 10-75 for box 5528, an occupied multiple dwelling fire at Wexford Terrace and Kingsland Place. Rescue 4 officer contacted the dispatcher to ascertain if Battalion 39 was going to use them at 8943 because they were just passing Battalion 50's 10-75. The dispatcher made an unsuccessful attempt to contact Battalion 39. At 1910:53, the dispatcher redirected Rescue 4 to respond to box 5528. At 1912:31, the dispatcher assigned Rescue 2 to box 8943. Subsequently, Rescue 4 became available from 75-5528 and was reassigned to 75­ 8943, resulting in Rescue 2's release from box 8943.

Division 13 transmitted a second alarm at 1919:08 hours. He also notified the dispatcher that there was a member down in the cellar. The dispatcher informed Rescue 4 to expedite their response and he reassigned Rescue 2 to respond to the fire at 1919:43 hours.

Ladder 155, the FAST truck, was ordered by Battalion 39 to find an alternate way into the cellar. They looked for an alternate way and were unable to find any. They reported backto Battalion 39 and were ordered into the cellar to remove Captain Fowler.

Division 13 ordered Ladder 107, to' assist with the removal of Captain Fowler. After Ladder 107 went down the cellar stairs, Battalion 39 ordered Rescue 4 into the cellar to remove Captain Fowler. Many units and individuals participated in the removal of Captain Fowler. Ladder 155, Ladder 107 and Rescue 4 accomplished the final removal.

Many individuals had the experience of rurrning out of air with their SCBA at this fire. The Safety Battalion believes that units of the first alarm assignment, operating in thecel1ar, required relief approximately six minutes after entering the cellar. Members operating on the first floor exited the fire building approximately eight minutes after entering the building when they were completely out of air. Squad 270 Officer operated on the first floor for approximately five minutes and then went directly down to the cellar. He was out of the cellar at approximately 1916 hours and operated without a facepiece for a period of time. The 10-84 time for Squad 270 was estimated to be 1906 hours.

The Safety Battalion was able to determine that, according to interviews, l"here-were at least eighteen firefighters, at various times, operating on the stairs or in the cellar during the rescue effort. This number varied at times because members ran out of air and were forced to leave. The rescue effort was significantly delayed due to the physical layout of the cellar, the narrow cellar stairs, the accumulation of household goods and the number of personnel involved.

(FOWLER· 4-4.docJ

I1

-TIle Safety Battalion believes that Captain Fowler entered the building at approximately 1903 hours. His vibralert alarm started to sound at approximately 1909 hours. He collapsed at approximately 1912 hours and was removed from the building at approximately 1931 hOUTS.

Captain Fowler was taken from the fire scene to Jamaica Hospital by Fire Department ambulance. He died as a result of his injuries on June 4, 1999 at 0915 hours. The autopsy report stated that Captain Fowler had a clinical history of carbon monoxide intoxication of sixty percent at Jamaica Hospital on June 3,1999. The cause of death was smoke inhalation with carbon monoxide intoxication.

[FOWLER - 4-4.doc:]

12

on June 3,1999. The cause of death was smoke inhalation with carbon monoxide intoxication. [FOWLER -

VI. CAUSES OF THE MISHAP:

DIRECT

Member while operating in the fire area was in an atmosphere that contained smoke, high levels of carbon monoxide and other products of combustion. The member failed to follow SCBA procedures by not exiting the fire area when the vibralert alann on his SCBA started to operate. Upon depletion of his air supply, he removed his facepiece and inhaled high levels of products of combustion.

The entrance to the storage room, where the fire was located, was concealed by household goods. This caused a delay in locating the fire.

INDIRECT

IllegaJ renovations of the cellar created narrow passageways. This construction impeded the removal of Captain Fowler.

Vast amounts of furniture and other household goods stored in the cellar severely limited the ability of members to move Captain Fowler from where he collapsed to the safety of the outside of the building.

CONTRIBUTING

At the time of the fire, there was no Department policy that addressed the removal of a downed firefighter.

The lack of operational discipline on the part of some members caused overcrowding of the cellar area and stairs. This hindered the effort to remove Captain Fowler.

[FOWLER·4-4.docl

21

VII.

RECOMMENDATIONS

• The department should review all alann assigrunents to determine their accuracy and possible need for updating.

• The department should use training scenarios and critiques to emphasize the need for all members to maintain operational discipline.

• The department should conduct a program to determine the operational and escape time limits of all department assigned SCBA.

• The department should consider replacing 30-minute SCBA cylinders with 45-minute cylinders.

• Members leaving an Irrunediately Dangerous Life and Health (I.D.L.H.) atmosphere, when the vibraJert sounds, should also notify the Incident Corrunander that they are exiting that area.

• Serious injuries and lossoflife happen early in the fire. Currently, the FDNY does not record handie-talkie communications at this point in the fire. Technology is available to provide reorders in the Battalion car to record our handi-talkie corrununications and preserve them for use in an investigation of this type.

(FOWLER - 4.4.docJ

22