A NIOSH investigation has found that the Tarrytown Fire Department lacked standard operating procedures for confined space technical rescues in the death of a firefighter in the fall of 2010.
Firefighter John Kelly climbed down into a manhole at the firehouse to assist a public works official who was unresponsive on Sept. 6, 2010 and also became stricken and later died.
NIOSH also found that factors in his death included unrecognized hazards involved with confined space and ineffective incident management for the operation.
Investigators said not long after the worker went into the manhole to seek the reason for a clog, firefighters noticed he was at the bottom of the ladder. They assumed he fell, and was injured while climbing down.
"The victim went to his pickup truck and put his boots on, then returned and entered the manhole before the gas meter was ready to be used. The victim entered the manhole, without PPE or SCBA, and made it half way down the access ladder and then fell to the bottom," NIOSH investigators wrote.
They added that the fire chief wasn't aware the firefighter went into the manhole until the DPW supervisor advised him that there was a second person unresponsive.
The chief then called for assistance, and ordered that no one else go into the manhole.
A gas detection meter was tied to a rope and lowered into the hole. Witness reports stated that the meter alarmed, one witness stating that the meter read 11.4 percent oxygen and another witness stating that the meter read 14 percent oxygen, investigators said.
NIOSH officials explained the rescue: "Two engines and one ladder truck from the department involved were on scene and started to set up for a rescue attempt. Note: The sewer manhole opening was only 24 inches in diameter and opened up to a 5 foot diameter once through the opening. The depth to the bottom of the manhole was reported as 18 feet. A tripod was set up over the manhole and a fan put in service blowing fresh air into the manhole. One firefighter donned an SCBA face piece while the SCBA cylinder and back pack were tied off and lowered with the firefighter while he entered the manhole with a separate rope and descended down the vertical manhole pipe. An oxygen cylinder and mask for the victim was lowered in with the firefighter. The firefighter placed the oxygen mask on the victim and tied a rope on the victim and other firefighters hoisted him out of the sewer pipe."
Once rescued, personnel performed CPR on the victims and they were transported to the hospital where they were pronounced dead.
The county coroner reported the cause of death was asphyxia due to low oxygen and exposure to sewer gases.
NIOSH listed the following recommendations to departments to prevent a repeat of the deadly incident:
* Ensure that firefighters are properly trained and equipped to recognize the hazards of and participate in a confined space technical rescue operation
* Ensure that standard operating procedures regarding technical rescue capabilities are in place and a risk benefit analysis is performed to protect the safety of all responders
* Ensure that an effective incident management system is in place that supports technical rescue confined space operations
* Ensure that a safety officer properly trained in the technical rescue field being performed is on scene and integrated into the command structure.
