Report: Hartford firefighter became entangled in furniture fighting an October blaze in which he was killed.
HARTFORD, CT
City firefighter Kevin Bell leg became entangled in wrought iron furniture fighting an October blaze in which he was killed, a report into Bell's death has concluded.
Also among the 22 conclusions in the Hartford Fire Department's board of inquiry report is that there was a failure to properly search the room in which Bell was trapped and that other firefighters did not hear Lt. John Moree's "mayday" distress call. The department released its report Friday into the death of Bell, the first city firefighter to die in the line of duty in 40 years.
Interim Assistant Fire Chief Scott Brady said Friday that the lack of acknowledgement of the "mayday" call delayed the search for Bell and that other factors occurring simultaneously led to Bell's death.
"It was the worst possible scenario at the worst possible time," he said, adding that if those factors occurred at other fires in a singular nature or even in a different order there would have been a different outcome.
Bell, a six-year veteran assigned to Engine 16, died Oct. 7 while fighting a fire at 598 Blue Hills Ave. The fire department set up the board of inquiry to review the matter and the department's response to the fire.
The department issued its report although the State Police Fire and Explosion Investigative Unit is still investigating the cause and origin of the fire as well as how Bell died. State police spokesman Kelly Grant said Friday that the investigation is pending and detectives are awaiting test results that she would not identify.
Brady said Friday that the department released the report now because it was just completed and members of the department and the families of Bell and other firefighters injured that night deserve to know what happened.
"As a department we need to know so that we can make changes," Brady said. "We need to take advantage of all of our information."
The report provides a detailed timeline into firefighters' actions that day, both inside and outside the building. It doesn't assign blame for Bell's death, but lists a number of factors that contributed.
Among those factors:
•A lack of training for new deputy chiefs and a lack of understanding of when it was appropriate for chief officers to assume command of an incident. The report mentions that acting Assistant Chief Terry Waller arrived at the scene and "chose not to assume any role in the Incident Management System." Brady explained that there are scenes in which the highest-ranking officer does not take command.
•There was a time delay in the forcible entry into the building "in zero visibility environments." The report points out that about 10 minutes after arrival, entry had not been made into the area of the building where Bell would eventually be trapped.
•There was a "lack of understanding in regards to utilization of hose streams to cool down thermal layering and a lack of understanding with regard to fire stream management."
•Failure to recognize the need to ventilate the roof in a timely manner, failure to immediately put a ladder up against the structure and provide a secondary point of egress and failure to properly implement the evacuation directive.
•Improper implementation of the Mayday Directive. According to the report, Moree told investigators that Bell's vibralert alarm activated, indicating that he had only 25 percent of his air cylinder volume remaining in his self-contained breathing apparatus (SCBA), while they were working on the second floor. Moree told Bell they would be leaving the building to change the cylinder and turned to follow the hoseline out the door expecting Bell to follow. When he didn't, Moree said, he went back following the hoseline and found the nozzle unattended.
Moree said he searched for Bell and transmitted a mayday message. Audio recordings confirm that a mayday was called in at the 15:57 mark, according to the report, which added that a subsequent sentence was muffled and that the radio transmission was also muffled and at very low volume.
Moree stated that after searching the room further without success he called in a second mayday, which according to the report cannot be comfirmed by audio recordings. Moree left the building when his vibralert alarm activated.
The report found that the incident commander, James McLoughlin, never acknowledged that the mayday call was made and that no personnel interviewed heard them either.
Other factors cited were:
•Underutilization and/or lack of proper use of a thermal imaging camera and a lack of spare equipment, including thermal imaging cameras.
•The lack of use of helmet chin straps and ear flaps and personal rescue equipment.
•The "lack of crew integrity in regards to working in teams of at least two."
•The inability of firefighters to maintain composure under adverse conditions
•The failure to implement a personal accountability report (PAR) directive in an efficient manner. The report found that at the 18-minute mark McLoughlin made several attempts to reach Engine 16 by radio and verify that they were all out of the building, with no response.
At the 19:06 mark McLoughlin requested a PAR check with no response and at the 21:51 mark Deputy Chief Leigh Shapiro also attempted to locate Bell by radio without response, according to the report.
According to the report, at the 24-minute mark a rapid intervention team (RIT) consisting of Engine 5 and Tacticial Unit 1 went to the second floor to find Bell.
Just over eight minutes had passed since Moree's initial mayday call and the RIT team's being deployed. Within 20 seconds Lt. William Brady heard Bell's personal alert safety system device and said, "We have a man down at the top of the stairs, right side."
According to the report, RIT members found Bell and tried to remove him but couldn't because his leg was tangled in a piece of wrought iron furniture. His air cylinder was empty and his face piece fully intact and seated on his face, the report said.
"This is a really hard, personal assessment," Brady said, adding that the board of inquiry "did a phenomenal job to tell it like it is."
The National Institute for Occupational Safety and Health (NIOSH) has still not completed its final report on Bell's death. A spokeswomen said Friday that a draft of the final report is nearly done and that the completed report is expected to be done by the end of October.
NIOSH did complete a preliminary report of the breathing apparatus Bell was wearing and concluded that one of the alarms that should have warned Bell that his air tank was running out of air was not working properly when he died.
The
medical examiner's office ruled Bell's death an accident caused by lack
of "breathing gas." The death certificate states that Bell's SCBA ran
out of air while he was fighting the fire. It also lists cardiac
hypertrophy as a contributing factor in his death.City firefighter Kevin Bell leg became entangled in wrought iron furniture fighting an October blaze in which he was killed, a report into Bell's death has concluded.
Also among the 22 conclusions in the Hartford Fire Department's board of inquiry report is that there was a failure to properly search the room in which Bell was trapped and that other firefighters did not hear Lt. John Moree's "mayday" distress call. The department released its report Friday into the death of Bell, the first city firefighter to die in the line of duty in 40 years.
Interim Assistant Fire Chief Scott Brady said Friday that the lack of acknowledgement of the "mayday" call delayed the search for Bell and that other factors occurring simultaneously led to Bell's death.
"It was the worst possible scenario at the worst possible time," he said, adding that if those factors occurred at other fires in a singular nature or even in a different order there would have been a different outcome.
Bell, a six-year veteran assigned to Engine 16, died Oct. 7 while fighting a fire at 598 Blue Hills Ave. The fire department set up the board of inquiry to review the matter and the department's response to the fire.
The department issued its report although the State Police Fire and Explosion Investigative Unit is still investigating the cause and origin of the fire as well as how Bell died. State police spokesman Kelly Grant said Friday that the investigation is pending and detectives are awaiting test results that she would not identify.
Brady said Friday that the department released the report now because it was just completed and members of the department and the families of Bell and other firefighters injured that night deserve to know what happened.
"As a department we need to know so that we can make changes," Brady said. "We need to take advantage of all of our information."
The report provides a detailed timeline into firefighters' actions that day, both inside and outside the building. It doesn't assign blame for Bell's death, but lists a number of factors that contributed.
Among those factors:
•A lack of training for new deputy chiefs and a lack of understanding of when it was appropriate for chief officers to assume command of an incident. The report mentions that acting Assistant Chief Terry Waller arrived at the scene and "chose not to assume any role in the Incident Management System." Brady explained that there are scenes in which the highest-ranking officer does not take command.
•There was a time delay in the forcible entry into the building "in zero visibility environments." The report points out that about 10 minutes after arrival, entry had not been made into the area of the building where Bell would eventually be trapped.
•There was a "lack of understanding in regards to utilization of hose streams to cool down thermal layering and a lack of understanding with regard to fire stream management."
•Failure to recognize the need to ventilate the roof in a timely manner, failure to immediately put a ladder up against the structure and provide a secondary point of egress and failure to properly implement the evacuation directive.
•Improper implementation of the Mayday Directive. According to the report, Moree told investigators that Bell's vibralert alarm activated, indicating that he had only 25 percent of his air cylinder volume remaining in his self-contained breathing apparatus (SCBA), while they were working on the second floor. Moree told Bell they would be leaving the building to change the cylinder and turned to follow the hoseline out the door expecting Bell to follow. When he didn't, Moree said, he went back following the hoseline and found the nozzle unattended.
Moree said he searched for Bell and transmitted a mayday message. Audio recordings confirm that a mayday was called in at the 15:57 mark, according to the report, which added that a subsequent sentence was muffled and that the radio transmission was also muffled and at very low volume.
Moree stated that after searching the room further without success he called in a second mayday, which according to the report cannot be comfirmed by audio recordings. Moree left the building when his vibralert alarm activated.
The report found that the incident commander, James McLoughlin, never acknowledged that the mayday call was made and that no personnel interviewed heard them either.
Other factors cited were:
•Underutilization and/or lack of proper use of a thermal imaging camera and a lack of spare equipment, including thermal imaging cameras.
•The lack of use of helmet chin straps and ear flaps and personal rescue equipment.
•The "lack of crew integrity in regards to working in teams of at least two."
•The inability of firefighters to maintain composure under adverse conditions
•The failure to implement a personal accountability report (PAR) directive in an efficient manner. The report found that at the 18-minute mark McLoughlin made several attempts to reach Engine 16 by radio and verify that they were all out of the building, with no response.
At the 19:06 mark McLoughlin requested a PAR check with no response and at the 21:51 mark Deputy Chief Leigh Shapiro also attempted to locate Bell by radio without response, according to the report.
According to the report, at the 24-minute mark a rapid intervention team (RIT) consisting of Engine 5 and Tacticial Unit 1 went to the second floor to find Bell.
Just over eight minutes had passed since Moree's initial mayday call and the RIT team's being deployed. Within 20 seconds Lt. William Brady heard Bell's personal alert safety system device and said, "We have a man down at the top of the stairs, right side."
According to the report, RIT members found Bell and tried to remove him but couldn't because his leg was tangled in a piece of wrought iron furniture. His air cylinder was empty and his face piece fully intact and seated on his face, the report said.
"This is a really hard, personal assessment," Brady said, adding that the board of inquiry "did a phenomenal job to tell it like it is."
The National Institute for Occupational Safety and Health (NIOSH) has still not completed its final report on Bell's death. A spokeswomen said Friday that a draft of the final report is nearly done and that the completed report is expected to be done by the end of October.
NIOSH did complete a preliminary report of the breathing apparatus Bell was wearing and concluded that one of the alarms that should have warned Bell that his air tank was running out of air was not working properly when he died.
Bell had been in the house for less than 21 minutes, according to records. A cylinder is rated for 30 minutes of air, but there are factors that go into how long a firefighter's air bottle lasts, including level of exertion or how much air is taken in with each breath.
Bell was responsible for carrying a hose to the second floor and putting water on the fire.
A second firefighter, Jason Martinez, was seriously injured when he passed out and fell from a second-floor window in front of the building. He sustained burns on 10 percent of his body and was taken to Bridgeport Hospital's burn unit. He was released Oct. 30 and has not returned to work.
According to the board of inquiry report, Martinez was struck with a hose stream — most likely from Bell's hose — and knocked out. When he regained consciousness he was couldn't find his helmet or SBCA face piece.
Martinez told investigators that his head and eyes were burning and that he tried to wet his gloves to cool down his head before searching for the window on the front of the house. After communicating with firefighters outside the house and being told a ladder was coming, Martinez passed out again and tumbled out of the window to the ground.
Other firefighters injured by Bell's hose stream, the report indicates, were Lt. Scott Cunningham and firefighter Colin McWeeny.
NIOSH also tested Martinez's breathing apparatus and found that it had not been tested in the past five years, as required by federal law. Bell's air cylinder had been pressure-tested in April 2013. They also concluded that the second breathing apparatus did not meet NIOSH's pressure tests because it "did not maintain positive pressure" throughout the 30-minute testing period.
The two units were returned to the fire department but cannot go back into service until they are "repaired, tested, cleaned, and any damaged components replaced and inspected by a qualified service technician."
In April Conn-OSHA issued citations and fines to the fire department over equipment-related issues, including a failure to ensure that all firefighters had been fit-tested for their SCBA in the past year and a failure to ensure that all self-contained breathing apparatus air cylinders were tested every five years, as required by federal law.
The Conn-OSHA investigation also found that the department did not issue, or require the use of, protective fire/heat resistant hoods by firefighters responding to the blaze, that not all firefighters had received required medical evaluations prior to annual fitness testing, and that the department failed to ensure that firefighters wore helmets or wore equipment properly.
OSHA investigators also said that several firefighters were not properly wearing ear flaps or chin straps at the fire in which Bell died.
Initially, the agency levied a $1,000 fine per violation, the maximum allowed. The agency later reduced the department's fine from $5,000 to $4,000 after meeting with city officials.
Fire Chief Carlos Huertas said Friday that the department has implemented many changes already and that more were being planned to address shortcomings found in the report.
"This tragedy has caused us to look intensely at what we do," Huertas said.
Hartford Mayor Pedro Segarra said Friday that the report "speaks to existing serious concerns" that are being addressed through changes in leadership structure and that the department will do what is necessary to continue to protect residents and firefighters.