Feds: Firefighter mistakes contributed to Daryl Gordon's death
Jeremy Fugleberg, jfugleberg@enquirer.com 6:25 p.m. EDT July 26, 2016
The fire grew, causing heavy smoke and poor visibility for Gordon and other rescuers.
A series of mistakes by Cincinnati firefighters contributed to the growth of a March 2015 fire, which caused heavy smoke and poor visibility for rescuers searching the building, indicated a federal investigation released today.
One of those firefighters, Daryl Gordon, fell to his death when he stepped into an elevator shaft.
The investigation by the Centers for Disease Control’s National Institute for Occupational Safety and Health, largely agrees with an investigation released in late June by the Cincinnati Fire Department, and its recommendations.
Both reports conclude that Gordon died on March 26 because he walked through a malfunctioning elevator door that should have been locked. But the reports also highlight mistakes and oversights by CFD personnel.
"Things start going wrong. It's how you stop that snowball effect, where things keep going wrong, that prevents bad things from happening," Gregory Potter, CFD's district chief for training told The Enquirer. "At this fire, little things just kept mounting up."
Firefighters failed to quickly contain the fire; it grew and filled the five-story Madisonville apartment building with smoke. The smoke reduced visibility for rescuers, including Gordon, as they searched the building.
On an order from a superior, firefighters broke the glass patio door of the apartment where the fire started, letting in air which in turn fed the fire, both reports state.
“The fire growth could have been delayed if the patio door had remained intact as the fire would have reached a ventilation limited state,” the NIOSH report stated.
Neither report explains why the patio door was knocked out. But Potter said firefighters on the scene were following an old theory that recommends breaking out the windows to vent gasses from the building before firefighters enter to fight the fire.
Early-arriving firefighters caught a hose on a stairwell, which limited its reach. They didn’t spray down a smoke-filled hallway to cool it and limit the fire’s growth -- again, a move not in line with updated firefighting practices, Potter said.
They then retreated from the building after a second also-short hose bucked, knocking off a firefighter’s helmet in the increasingly hot, smoky hallway.
"What happened here was they took it out but they weren't ready to put water on the fire so the fire got bigger and hotter faster," Potter said. "In theory, what you want to do is coordinate those things."
More than 20 minutes after arriving at the apartment building, firefighters had yet to spray a drop of water inside the building, according to the CFD report.
“This delay in getting water onto the fire contributed to the smoke conditions on all floors of the five-story apartment building,” the NIOSH report concluded.
When Gordon opened a door to the elevator shaft and fell, visibility was down to 5 feet or less, the report stated.
The fire started when an apartment resident fell asleep with food on the stove in an apartment with no working smoke detector. The building has no sprinkler system.
Gordon was the first on-duty fatality for CFD since firefighter Oscar Armstrong III died fighting a fire in March 2003. Gordon was married, with two children.
Both the CFD and NIOSH highlighted a raft of communication problems and other coordination and training issues that demanded improvement. In their investigation report released earlier this month, CFD officials pledged to rectify 44 problems they had identified.
"It's hard for the guys. We're critical on ourselves to a fault" with the goal of getting better, Potter said.
As is standard practice among fire departments, the NIOSH report will be circulated so other departments can learn from it.
Matt Alter, president of the Cincinnati Firefighters Union Local 48, said the firefighters will take the two reports and learn the most they can from them. But he noted the department faced staffing brownouts in recent years and has a small training staff, factors that led to a "fallout effect" of lagged training for both veterans and recruits alike.
"Here at Local 48, we look at that and say we have to do whatever we can in our power to make sure the tragic events of March 26, 2015, are never repeated," he said. "If that means having enough people on the truck to make sure that we can keep citizens as safe as possible, and the firefighters as safe as possible, then that's what has to be done."