FDNY report on fatal fire, June 4, 1999

8/4/2019 FDNY report on fatal fire, June 4, 1999

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u. SUMMARYAt 1855:20 hours, on June 3,1999, the Queens Communications Office of the New York CityFire Department received a telephone alarm reporting a structural fire at the address 150-28 127Street, Queens. Engine Company 331, Engine Company 285, Ladder Company 173, LadderCompany 142 and Battalion 39 were assigned to respond at 1855 :40 hours. A second source forthe alarm was received at 1856:09 and Engine Company 225 was assigned to respond. At 1900hours, due to additional calls, Rescue 4and 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 Company293 and Division 13 to respond to the fire. The fire was located in the cellar of a Class 4, onestory, twenty foot by forty foot, private dwelling. There was a heavy smoke condition, but no fITeshowing. Engine 331 hooked up to a hydrant in immediate proximity to the fire building andstretched 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, forcibleentry team donned their masks at the side entrance and descended into the cellar to search forvictims and to locate the fire. Engine 331 immediately followed them with a charged line. Thecellar staircase was very narrow, and the base of this stair ended in dose proximity to thexposure one cellar wal1. The cellar was heavily charged with smoke, however, there was not anexcessive amount of heal. The cellar area was heavily congested with furnishings, boxes andother household items. Engine 331 opened the line as a precautionary measure to prevent fITefrom 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 onthe first floor and proceeded to search for victims and ventilate the first floor. Squad 270 arrivedat 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 andegan to assess the situation. Battalion 39 heard Ladder 173 Outside Vent position attempt toommunicate 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.aptain Fowler stated there was no problem, but he was running low on air. During thisommunication, Battalion 39 heard vibralert alarms sounding over the handi-talkie. The Safety

ofCaptain Fowler, thengine 331 officer and Nozz/eman. Battalion 39 immediately contacted Squad 270 and orderedthe officer to relieve Ladder 173 in the cellar. Battalion 39 then contacted Engine 331 andif 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 theline to back out. Engine 331 attempted to back their line out of the cellar. Captain Fowler calledfor the Can position saying, "Where's my probyT' The Can position was operating behind theNozzle position, lending a hand on the line. He answered "I'm right here Cap." He moved towardthe Captain who was operating further toward the rear of the cellar. Captain Fowler was standingup and coughing. He stated to the Can position "I'm out of air. I need air. The Can positionI[FOWLER -4-4.doc]


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removed his regulator, held the regulator up to Captain Fowler's face and opened the purgevalve. He gave some air to the Captain and took .the regulator back for himself. At this point theCan position's vibralert started to sound. He gave the regulator back to the Captain twoadditional times. After the third sharing of the regulator, Captain Fowler stated "We've got togive 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 thatmessage 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 beforelosing total consciousness, Captain Fowler tried crawling toward the rear of the cellar. Ladder173 Can position then activated his own pass alarm.Ladder 173 Can position then attempted to drag Captain Fowler out of the cellar. He succeededin moving the Captain a short distance. Squad 270 Roof position heard the PASS alarm andmoved toward the sound. He located Ladder 173 Can position and Captain Fowler. He placedthe Can position on the line, and the Can position left the cei1ar, running completely out of air atthe base of the stairs. Squad 270 Roof position then transmitted a Mayday for a downedfuefighter and started removal efforts.Battalion 39 acknowledged the Mayday and communicated this information to Squad 270Officer. Squad 270 Officer and Chauffeur responded to the cellar and assisted Squad 270 Roofwith the removal of Captain Fowler. They began to drag him out. This was very difficult due totight quarters, heavy smoke and flames starting to roll across the ceiling. Squad 270 Officer ranout 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 thecellar.When the first Mayday was transmitted Battalion 39 went to the side cellar entrance andsupervised the rescue efforts. Members of Ladder 155, the FAST truck, Ladder 107 and Rescue 4removed Captain Fowler from the cellar.At 1931 hours, Captain Fowler was removed from the building. He was taken to JamaicaHospital by Fire Department ambulance and died as a result of his injuries on June 4, 1999 at09] 5 hours. The cause ofdeath as listed on the autopsy report was smoke inhalation with carbonmonoxide intoxication.

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III. MISHAPThe Queens Communications office of the New York City Fire Department received a telephonealarm reporting a structural fire at 150-28 127th Street at 1855:20 hours on June 3,1999. Theofficer 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 thatthe fire was located in a one story, Class 4, private dwelling measuring approximately twentyfeet 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 interiorstair 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 331brought 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 conditionat this time was, according to witness statements, slight.Battalion 39 arrived at the front of the fire building at, according to the timeline, approximately1909 hours. He contacted Ladder 173, on the handi-talkie, to inquire about the conditions in thecellar. 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 hishandi-talkie, at this time. Battalion 39 then contacted Squad 270 and ordered them to locateLadder 173 in the cellar.At approximately 1909 hours, Captain Fowler ordered everyone to back out of the cellar. TheBack-Up position of Engine 331was located at the base of the cellar stairs and verbally directedmembers toward his location. The Officer of Engine 331 ran out of air in his SCBA near the baseof the stairs. The Forcible Entry position of Ladder 173 shared his facepiece with the Officer ofEngine 331 and together they left the cellar and exited the building. The Nozzle position backedup with the hoseline until he ran out of air and followed the line back to the base of the stairs andexited the building.Ladder 173 Can position was leaving the cellar, as ordered, when he heard Captain Fowler callhim. The Can position went to Captain Fowler and spoke with him. Captain Fowler was standingup at the time and he was coughing. His facepiece was off and he told the Can position that hewas out of air. Ladder 173 Can position removed his regulator from his facepiece and placed itup to Captain Fowler's mouth. He then turned the purge valve on. He shared the regulator withCaptain Fowler a total of three times and immediately after the first sharing his vibralert startedto 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 collapsedto the floor. Captain Fowler struggled with the Can position by attempting to crawl toward therear of the cellar before losing total consciousness.Ladder 173 Can position activated his PASS alarm and started to drag Captain Fowler toward thecellar stairs. He was successful moving the Captain a few feet when Squad 270 Roof relievedhim. Ladder 173 Can then exited the building.

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arrival.

8943.

FINDINGS:At 1855:20 hems en June 3,1999, the Queens effiee-ofFire Communications received atelephone alarm reporting a fire at ]2ih Street and Old South Road in Queens. A total of sixtelephone 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 secondsource was received at 1856:09 and Engine Company 225 was assigned to respond to thereported location. AiJ units acknowledged their response between 1856:03 hours and 1856:57bours. Engine 285 acknowledged their response with a 10-14 signal, while out of quartersprocuring 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 untilapproximately 2025:0] hours. The only 10-84 times that the Safety Battalion were able todetermine were the verbal) 0-84 signals transmitted by Battalion 39 and Division 13. The SafetyBattaJion, using a multiple event sequence chart developed by them, estimated aJl other times of

Every emergency is accorded an aJarm assignment by the Fire Department, which is made up offire units that are geographicaJly closest to the incident location, assuming they are available forresponse. The Safety Battalion has found that the units that actually responded to the incidentdid not make up an optimal first alarm assignment for the incident location. This situation wasapparently caused by a pre-existing error in the alarm assignment for box 8943. The optimalfirst alarm assignment for box 8943 is the following: Engine Company 302 is the first dueengine, Engine Company 308 is the second due engine, Ladder Company 155 is the first dueladder, Ladder Company 173 is the second due ladder and Battalion 51 would be the first duebattaJion. Engine Company 33] would be assigned as the third due engine. Th e Safety Battalionis aware that the alarm assignment has been updated to reflect the optimal assignment for box

At the time ofthe transmission for box 8943, Engine 308 was in service in quarters. A1though itshould have been designated the second due engine company on a first alarm assignment, at thisincident, 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 alarmassignment were available for response at the time of the incident. Engine Company 302 andLadder Company 155 were both assigned to Queens box 8706 at 134 Avenue and 159 Street, andtherefore were unavailable at the time box 8943 was transmitted.Battalion 51, which should have been the normally assigned Chief for box 8943, was in servicein quarters at the time the 10-75 for box 8943 was transmitted but was not assigned due to thepre-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 adivision conference. He was located at Hegeman A venue and Amboy Street, in Brooklyn, whenhe received the alarm. The assignment of Battalion 39 instead of Battalion 51 caused a delay in aChief Officer's presence at the fire scene for a period of approximately four minutes.

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Captain Fowler went through the doorway at the base of the stairs and went to the rear of thecellar. The cellar was extremely cluttered with large amounts of furnishings, boxes, personalitems and-other-household goods_ Captain Fowler caHed for the line to be moved to the rearbefore Engine 33] their operated line.Officer of Engine 331 did not locate the fire. Captain Fowler advised the Officer of Engine 331that the fire was straight back.Ladder 173 Outside Vent position requested pt:rmission from Captain Fowler to ventilate thecellar windows. Captain Fowler told the Outside Vent position to vent the cellar windows. TheOutside Vent position vented the windows on the exposure two side of the building and onecellar window on the exposure four side. Ladder 173 Chauffeur and Ladder 173 Roof positionprovided 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 thespecific location of the fire. The fire was located in a closed room that was blocked of f from therest 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 stretchedan 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 frontentrance. Ladder 142 reported to Battalion 39 that the primary search of the first floor wasnegative.Captain Fowler contacted Ladder 173 Outside Vent. Ladder 173 Outside Vent was unable tounderstand Captain Fowler's garbled message. Ladder 173 Outside Vent was unsuccessful in hisfour to five attempts to contact Captain Fowler. Battalion 39 heard the attempts made by theOutside Vent position.Battalion 39 then contacted Captain Fowler. He advised the Battalion that there was fire in thebasement and aline was in operation there. The Battalion inquired about the condition of themen and the fire in the cellar. The Captain advised the Battalion that everyone was all right butthat they were running low on air. Battalion 39 could hear vibralert alanns-sounding at the timeof this transmission. Battalion 39 ordered Squad 270 to locate Ladder 173 in the cellar and theninquired about the condition of Engine 331 and his members. Engine 331 told the Battalion thathe could use a relief. The Battalion then ordered Engine 225 to relieve Engine 331. The SafetyBattalion 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 ofLadder 173 Can position. Th e Can position was located toward the front of the cel1ar. He toldthe Captain were he was and started to move toward the Captain's position, The Can positionand 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 ofEngine 331 ran out of air while he was moving toward the cellar stairs. Ladder 173 ForcibleEntry position shared his facepiece with the Officer of Engine 331 and both were able to leavethe cellar.(FOWLER - 4-4.doc] 9


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Eaptam-Fowler was standing with hjs facepiece off, at the time the Can position found him. Hewas coughing and told the Can position that "I'm out of air. I need air." The Can position tookhis regulator out of his facepiece, held the regurator up to Captain Fowler's face and operated thepurgevaf..ve. The vibraJert alarm on the Can position's mask began to operate. Captain Fowlerand the Can position exchanged the regulator two additional times and Captain Fowler infonnedthe Can position that they had to transmit a mayday. After taking an additional breath from theshared 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 activatedhis PASS device and started to drag Captain Fowler toward the cellar stairs. The Safety Battalionbelieves that the recovery effort was started at this time and the time was approximately 1912hours.The Safety Battalion does not believe that Captain Fowler transmitted a mayday over the handitalkie because there are no witness statements to confirm the mayday transmission.Based on the 1 O ~ 8 4 signal transmitted by Battalion 39, at 1907 hrs and then allowingapproximately 2 minutes to get dressed, come to the front of the building and contact Ladder173, the Safety Battalion, believes that at this time, the SCBA being worn by the members in thecellar were already out of work time. The Safety Battalion believes the work lime for SCBA wasbetween 5 and 6 minutes.The Officer of Squad 270 verbally ordered Squad 270 Floor Above team positions to locateLadder 173 in the cellar. He then ordered, via handi-talkie, Squad 270 Roof to also locate Ladder173. All of these members then entered the cellar. Squad 270 Can position had previously beenordered 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 thatthey couldn't contact the Captain of Ladder 173 via handi-talkie. As he crawled toward the rearof the cellar he honed in on the PASS alann and someone cal1ing "Over here. Over here." Squad270 Roof reached the person calling out and found Ladder 173 Can position with CaptainFowler. The Can position's vibralert alarm was sounding and Squad 270 Roof put the firefighteron 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 locatedSquad 270 Roof. Squad 270 Officer ordered the Roof position to continue with the removaleffort willIe he looked for the line. This removal effort continued until the Roof position ran outof air near the base of the stairs.Engine 225 went to the side cellar entrance. At this point Squad 270 was assisting members ofEngine 331 and Ladder 173 out of the cellar. Engine 225 waited until the stairs were clear andthen entered the cellar. Engine 225 followed the line into the cellar and found a butt at the baseof 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 twelvefeet into the cellar towards the rear. Engine 225 Officer and B a c k ~ U p position helped Squad 270tr y to move Captain Fowler. Engine 225 Nozzle opened the line to push back fire that was rollingover at the ceiling level.Squad 270 Officer was unable to locate the nozzle and he returned to assist Squad 270 Roof withthe removal of Captain Fowler. It was very difficult to accomplish because of built up water anddebris on the cellar floor.[FOWLER4-4.docJ 10
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Squad 270 Officer's SCBA ran out of air and,he operated without a facepiece for a period oftime. He suffered chemical bums to his throat as a resuJt of this. He transmined a MaydaysignaJfor himself because he was out of air. He also r e ~ q u e s t e d that a fog line be placed in operation tovent the cellar.

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 thecellar window had vented and ignited the siding above the cellar window. Engine 293 andEngine 302 extinguished the fire from the outside after all members were ordered out of thecellar by Division 13. Both units operated into the first floor rear bedrooms and into the cellar atdifferent 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 boxlocation, Battalion 50 transmitted a 10-75 for box 5528, an occupied multiple dwelling fire atWexford Terrace and Kingsland Place. Rescue 4 officer contacted the dispatcher to ascertain ifBattalion 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 dispatcherredirected Rescue 4 to respond to box 5528. At 1912:31, the dispatcher assigned Rescue 2 tobox 8943. Subsequently, Rescue 4 became available from 75-5528 and was reassigned to 758943, resulting in Rescue 2's release from box 8943.Division 13 transmitted a second alarm at 1919:08 hours. He also notified the dispatcher thatthere was a member down in the cellar. The dispatcher informed Rescue 4 to expedite theirresponse 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 Battalion39 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 107went down the cellar stairs, Battalion 39 ordered Rescue 4 into the cellar to remove CaptainFowler. 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. TheSafety Battalion believes that units of the first alarm assignment, operating in thecel1ar, requiredrelief approximately six minutes after entering the cellar. Members operating on the first floorexited the fire building approximately eight minutes after entering the building when they werecompletely out of air. Squad 270 Officer operated on the first floor for approximately fiveminutes and then went directly down to the cellar. He was out of the cellar at approximately1916 hours and operated without a facepiece for a period of time. The 10-84 time for Squad 270was estimated to be 1906 hours.The Safety Battalion was able to determine that, according to interviews, l"here-were at leasteighteen firefighters, at various times, operating on the stairs or in the cellar during the rescueeffort. This number varied at times because members ran out of air and were forced to leave. Therescue effort was significantly delayed due to the physical layout of the cellar, the narrow cellarstairs, the accumulation of household goods and the number of personnel involved.

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VI. CAUSES OF THE MISHAP:DIRECTMember while operating in the fire area was in an atmosphere that contained smoke, high levelsof carbon monoxide and other products of combustion. The member failed to follow SCBAprocedures 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 ofcombustion.The entrance to the storage room, where the fire was located, was concealed by household goods.This caused a delay in locating the fire.INDIRECTIllegaJ renovations of the cellar created narrow passageways. This construction impeded theremoval of Captain Fowler.Vast amounts of furniture and other household goods stored in the cellar severely limited theability ofmembers to move Captain Fowler from where he collapsed to the safety of the outsideof the building.CONTRIBUTINGAt the time of the fire, there was no Department policy that addressed the removal of a downedfirefighter.The lack of operational discipline on the part of some members caused overcrowding of thecellar area and stairs. This hindered the effort to remove Captain Fowler.

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VII. RECOMMENDATIONS The department should review all alann assigrunents to determine their accuracy and possibleneed for updating. The department should use training scenarios and critiques to emphasize the need for allmembers to maintain operational discipline. The department should conduct a program to determine the operational and escape timelimits of all department assigned SCBA. The department should consider replacing 30-minute SCBA cylinders with 45-minutecylinders. 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 thatarea. Serious injuries and lossoflife happen early in the fire. Currently, the FDNY does notrecord handie-talkie communications at this point in the fire. Technology is available toprovide reorders in the Battalion car to record our handi-talkie corrununications and preservethem for use in an investigation of this type.

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FDNY report on fatal fire, June 4, 1999

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Transcript of FDNY report on fatal fire, June 4, 1999