He spent his last moments wandering alone in a room he should never have entered, suffering heat exhaustion from a 1,000-degree inferno used by Miami-Dade Fire Rescue Department to train recruited firefighters.
Mitchell's first live firefight on Aug. 8, 2003 was a tragic series of errors documented in a report released this week by the Miami-Dade County Office of Safety.
The department refused to comment on the report, which highlights the department's failures to meet safety standards and seeks structural changes. The report did not recommend criminal or other legal action against anyone involved.
But some fire-rescue officials did talk about the report on Wednesday.
''Just about everything you could think of went wrong at the same time,'' said acting Battalion Chief Stan Hills, president of the fire-rescue union. ``Any one of those factors could have been overcome, but the combination was deadly.''
''It was a mess built on long-standing problems within the fire department,'' said Fire Rescue Capt. Jerome Byrd Sr. ``You have to understand the egos and the inner workings of the department to comprehend it.''
Byrd was one of three assigned training instructors in the fatal firefighting session at the Resolve Fire & Hazard Response Center, a private fire-training school at Port Everglades. Byrd found Mitchell's prone body on the second level of the steel passageway meant to imitate the hull of a ship.
The other two instructors had already fled the simulator, complaining of heat exhaustion and malfunctioning equipment. Byrd said that they did not radio him to inform him of their departure. By the time Byrd and the session's other four recruits staggered out and realized someone was missing, it was too late.
''They had a group of lives in their hands, and they let one of them go out of sheer negligence,'' said Mitchell's mother, Jeanne Wilcox. ``Someone should be held accountable.''
''The recruit training department had a closed-door policy,'' said Byrd. 'They had an `I am God' mentality, and they shut everyone out.''
''I was complaining almost daily to the training bureau about their philosophy and methods,'' said Byrd, who had a decade of experience in recruit training before returning to fighting fires. With trainers in demand, however, he volunteered. ``They said I was out of recruit training, but that I could go to this last burn.''
The report said that the department made ''a serious mistake'' by excluding the Safety Office from reviewing and assessing the recruit training. Hills agreed. ''The Safety Office needs to be someone who can walk into any office, and whose sole job is to target unsafe practices and equipment,'' he said. Hills said one-fourth of the workforce suffers injuries that cause them to lose at least one day of work every year.
Had regulations been followed, for example, an ambulance and a Rapid Intervention Team should have been poised outside the facility.
There was no safety plan for the exercise -- an exercise that the report, Byrd and Hills all agree was too complicated for recruits facing their first fire.
Hills said the accident pointed up the importance of radios, which the union had been lobbying to get for training exercises. He said he had testified for several years about this need, which was finally filled last month through union contract negotiations.
On the day of the fatal exercise, in violation of regulations, no one had walked Mitchell and the other recruits through the simulator before the fires were lit. Mitchell had never seen the structure before he glimpsed it through smoke that made visibility ''poor'' to ''nonexistent'' in some areas, according to the report.
Complicating matters was a door that was mistakenly left open within the simulator. Mitchell walked through that door, losing precious time.
The National Fire Protection Association, the Broward State Attorney's Office, the National Institute for Occupational Safety and Health, and the Fire Standards and Training Division of the state fire marshal are still investigating.
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