A breakdown in crew integrity and other errors have been cited by NIOSH officials as factors in the death of Cincinnati Emergency Vehicle Operator Daryl Gordon.
He died of massive injuries on March 26, 2015 after falling into an open elevator shaft at a four-alarm fire in a five-story building.
Gordon became separated from his crew, and didn't see a marker written warning on an elevator door about the open shaft.
NIOSH investigators listed the following as contributing factors in the report released late Tuesday:
- Breakdown in crew integrity
- Unsecured and unguarded elevator hoistway door
- Poor visibility due to moderate smoke conditions
- Delay in getting water onto the fire burning in a second-floor apartment
- Acting officers in several key positions
- No standpipe or sprinkler system within the residential apartment building.
The investigators also studied communications and chain of command. Among the recommendations are:
- Ensure that crew integrity is properly maintained by sight, voice or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere.
- Train and empower all fire fighters to report unsafe conditions to Incident Command.
- Ensure that appropriate staffing levels are available on scene to accomplish fireground tasks and be available for unexpected emergencies.
- Review standard operating procedures used to account for all fire fighters and first responders assigned to an incident.
- Ensure that interior attack crews always enter a hazardous environment with a charged hoseline.
- Integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (UL) into operational procedures by developing or updating standard operating procedures, conducting live fire training, and revising fireground tactics.
- Consider ways to block open shafts and other fall hazards.
Authors of he department’s LODD report, released earlier this month, wrote that “proper staffing, proper training and proper equipment to safely operated at any emergency incident should be our top priority.”
Complacency also was cited as firefighters had been to the building for numerous calls over the years.
