NIOSH Cites Incident Commander's Lack of Experience in New Haven, CT, Firefighter LODD

An investigation into the death of a New Haven firefighter who died battling a blaze at a home in 2021 contends that a “lack of experience and knowledge” prevented the incident commander at the scene from receiving “critical” information about the fire and its “rapidly changing” condition.

The investigation, which was conducted by the National Institute for Occupational Safety and Health, included more than half a dozen recommendations being made to the New Haven Fire Department that could have potentially helped prevent the tragedy. The line of duty death report was released Tuesday following the investigation into the death of 30-year-old Ricardo Torres, Jr., outlining a number of practices NIOSH investigators believe could help prevent further deaths.

“This has not been an easy time,” John A. Alston, Jr., chief of the New Haven Fire Department, said at a news conference on Tuesday afternoon. “Four years is a long time to wait for a report like that. The biggest take away for me is it broke my heart. It was a tragedy.”

Alston said some of the recommendations made by NIOSH officials have already been addressed by the fire department in the wake of Torres’ death. Others, he said, encouraged training in things like sizing up fires, crew integrity, air management and dealing with below grade or basement fires — all of which Alston said New Haven firefighters were trained on prior to the tragedy.

“Those are the key contributing factors,” Alston said.

The chief conceded that a 360-degree size-up of the fire was not done during the blaze, which was one of the recommendations made following the investigation. But given the urgency crews faced to rescue a woman who was trapped in the home, Alston said he believes the “right decision” was made to focus on the rescue efforts.

Torres was killed on May 12, 2021, while battling a fire at a 2 ½ story, single-family home at 190 Valley St. where an elderly resident was rescued and multiple other firefighters were injured. A fire lieutenant was seriously injured and had to be rescued from the home, and two additional firefighters suffered minor injuries, according to the report.

Crews were dispatched to the home at 12:46 a.m. and found that the balloon frame structure with a full lookout basement was ablaze, the report said. Minutes later, dispatchers informed crews one person was still in the home on the first floor and that the fire was in the basement.

As crews entered the home to look for the trapped resident, Torres, who was a part of Engine 6, attached a hose line to a hydrant before his crew stretched the line to the second floor of the home, according to the report — which details a minute-by-minute timeline of the fire.

A little more than 10 minutes after the fire was reported, a crew from another engine got the woman who was trapped in the home safely out. Shortly after 1 a.m., Torres’ lieutenant reported high heat and heavy smoke conditions on the second floor, the report said. Minutes later, he reported that his crew was still searching the second story.

According to the report, the lieutenant told multiple crew members, including Torres, that they needed to leave to change air cylinders. The lieutenant became separated from Torres and, in the confusion, the lieutenant’s face piece and helmet became dislodged, the report said.

At 1:15 a.m., Torres notified his lieutenant that he was disoriented on the second floor. He said he could not find his way out of the room he was in.

Torres at some point ran out of air and either walked or crawled between a radiator and a couch in the living room, according to the report. He called a mayday in at 1:16 a.m. Two minutes later, the lieutenant called a mayday in as well.

Shortly thereafter, a crew member found the lieutenant in the living room near the entrance to the kitchen. He had his face piece off and was standing when the firefighter found him, at which point he said “help me” and fell into the firefighter, the report said. The firefighter tried to get the lieutenant to the stairs but ended up in a bedroom where he knocked the glass out of a window.

Crews using ground ladders tried getting the lieutenant out of the window, but he was too heavy, the report said. The firefighter who initially found the lieutenant then had to evacuate because he was low on air.

Once he was on the ground, he advised others where the lieutenant was, according to the report. At 1:21 a.m., a firefighter entered the home and found Torres lying near a couch. He had his face piece on but was out of air, the report said. Another firefighter arrived shortly thereafter and tried to help get Torres out through the front windows, but they were not able to.

The pair became low on air and had to get out of the home. They told others where Torres was before he was brought downstairs and out of the home at 1:33 a.m., according to the report. The lieutenant was rescued and brought out of the home around the same time by other firefighters.

Torres and the lieutenant were taken to an area hospital at 1:36 a.m. Torres was pronounced dead at 2:12 a.m., the report said. An autopsy later found he died of asphyxia.

The lieutenant was later transferred to a trauma hospital with a hyperbaric chamber, the report said.

One of the difficulties crews faced was that many of them were going back into the home to attempt the rescues and they had a rapidly declining air supply, according to Alston.

Following the investigation into the incident, NIOSH officials issued a total of nine recommendations to the New Haven Fire Department. The first encouraged an initial and ongoing size-ups at structure fires.

“At this incident, the initial focus of the first-due companies was to rescue the female occupant located on the first floor,” investigators wrote. “There was no initial scene-size-up or risk assessment conducted that was communicated to (incident command).”

Investigators also recommended company officers and firefighters maintain crew integrity when operating in “the hazard zone.”

“It is the responsibility of every firefighter and company officer to always stay in communication or contact with crew members by visual observation, voice or touch while operating in the hazard zone,” the report said. “All firefighters should maintain the unity of command by operating under the direction of their company officer. The ultimate responsibility for crew integrity and ensuring no members get separated or lost rests with the company officer. A mayday should be called if any member cannot be accounted for during a personnel accountability report.”

According to Alston, firefighters are trained about crew integrity at the academy and throughout their careers.

“There’s a difference between training and experience,” Alston said. “Crew integrity is something that is bred into us. Whether it was training or lack of experience, we don’t know.”

NIOSH officials also recommend fire officers and firefighters receive proper training and use the principles of air management and fire ground survival procedures.

“Air management is a program that the fire service can use to ensure that firefighters have enough breathing air to complete their primary mission and escape an unforeseen emergency,” the report said.

Air management also includes ensuring air cylinders are full at the start of someone’s shift and recognizing the system’s “heads-up display” when the cylinder is getting close to empty, according to the report.

“A low-air emergency for one crew member should be treated as an emergency for the entire team, requiring the entire team to exit simultaneously, maintaining crew integrity,” according to the report.

“The rescue of a lost, missing, trapped or injured firefighter is time sensitive, investigators wrote. “A very narrow window of survivability exists for a firefighter who is out of air or trapped in a hazardous environment.”

According to Alston, city officials looked at larger tanks following the incident but he noted that the trade-off is that they are heavier and can make it harder to move around. He said the old air tanks triggered a warning when they were down to 25% and that the new ones being used trigger the same warning at 33%.

Investigators also contend that, during the incident, “the fire department had no defined tactics for fighting a basement fire,” the report said.

“Early identification of basements and their access points are critical during the initial on-scene size up and a component of the 360-degree size up,” NIOSH officials wrote.

“The presence or lack of a basement must be communicated to everyone involved to minimize or eliminate the opportunity for fire crews to end up working above a basement without their knowledge,” according to the report. “The immediate dangers include falling through the floor and working in the exhaust portion of a flow path.”

According to Alston, firefighters have developed a relationship with the New Haven Police Department that allows for the police drone to get an aerial look at a structure fire.

The investigation also recommended fire officers and firefighters be trained in mayday operations, which was another bone of contention for Alston who maintains that all firefighters receive mayday training.

“Firefighters should be trained and have confidence in how to call a mayday when in danger,” investigators wrote. “Any delay in calling a mayday reduces the chance of survival and increases the risk to other firefighters trying to rescue the ‘downed’ firefighter.”

“A mayday tactical worksheet can serve as a tailored guide to any fire department’s mayday procedures such as a reminder to prompt the firefighter to activate their emergency alert button for priority radio transmissions and other important items such as personal alert safety system activation, air status, and location information,” NIOSH officials said in the report.

“This process is too important to operate from memory and risk missing a vital step that could jeopardize the outcome of the rescue of a firefighter who is missing, trapped, or injured.”

NIOSH officials also recommended having a rapid intervention team or crew (RIC) dedicated, assigned and in place before interior firefighting operations begin and throughout the incident.

“During the 360-degree survey, the RIC officer and members should look for ways in and out of the structure, including window configurations, fire escapes and construction features,” the report said. “The RIC officer should note the feasibility for placement of ground ladders for rescue or escape purposes. The RIC officer has a responsibility to set up and secure a suitable secondary egress for interior crews.”

Since the fire, Alston said fire officials have worked to ensure such an intervention team has “better accountability.”

Officials also recommended having a dedicated and trained incident safety officer, separate from the incident commander, whose responsibilities would include determining hazardous incident conditions, advising the commander to “modify control zones or tactics to address corresponding hazards, communicate fire behavior and forecast growth, and estimate building/structural collapse hazards” the report said.

“This also includes the authority to stop or suspend incident operations based on imminent threats posed to firefighter safety,” investigators wrote.

Another recommendation would include having an incident command technician whose responsibilities would include assisting with “logistical, tactical, and accountability functions at an emergency incident,” the report said.

Alston said the department’s administration is working with city officials in contract negotiations to potentially add an ICT to fire scenes.

The ninth and final recommendation involved implementing a training, education and professional development program that is based on each rank.

“Fire departments should make sure that training and professional development are offered to any personnel who may be expected to perform outside of their normal functional area but within their experience level,” the report said. “In this specific incident, the lack of experience and knowledge prevented critical task level information from being shared with the (incident commander) as it relates to the rapidly changing fire conditions and environment.”

According to Alston, firefighters are offered a number of different training opportunities once they join the department and as they rise through the ranks. He said more in-house training is an option city officials could look into.

NIOSH investigators noted that, since the incident, the fire department has already taken steps to address some of the recommendations that were made, including those dealing with crew integrity, basement/below grade fires, air management/firefighter survival and size-ups/risk assessments.

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