CINCINNATI -- The line-of-duty death of Cincinnati firefighter Daryl Gordon was the result of, among other factors, mistakes made by fire crew members on the scene, according to a federal investigation.
In a report released Tuesday , the National Institute of Occupational Safety and Health, a wing of the Centers for Disease Control and Prevention, concluded a “breakdown in crew integrity” and “acting officers in several key positions” were among six contributing factors that led to FAO Gordon’s 24-foot fall into an unsecured elevator shaft March 26, 2015.
Similar to a report released by the Cincinnati Fire Department nearly a month earlier, the federal report concluded that communications among officers in command as well as between firefighters on scene could have been improved. The report attributed miscommunication to Gordon’s separation from the rest of the crew just prior to falling down the elevator shaft.
The report also found that, while a firefighter had marked the shaft door with the words, “DO NOT ENTER OPEN SHAFT,” that information was never relayed to incident command or the shift safety officer.
“This information could have allowed the incident commander and/or the shift safety officer to take action to prevent exposure to this hazard,” the report stated.
Echoing current concerns voiced by CFD Chief Richard Braun, the report also found that staffing levels and response capacity were insufficient at the time of the deadly fire, resulting “in a delay in establishing fireground accountability and crews operating without a dedicated Rapid Assistance Team in place.”
"It's extremely valuable to us because it validates our report," Braun said.
Also like the CFD’s own report, the NIOSH investigation recommended the creation of new positions within the department, specifically what it called a “staff assistant” or “chief’s aide” role. Without having someone in this position during the fire that killed Gordon, 40 minutes passed before the first personnel accountability check was made.
The investigation also found firefighters entered the structure without a properly charged hoseline, which created the smokey conditions with less than 5-foot visibility at the time Gordon fell into the elevator shaft.
The report listed seven key recommendations:
- 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.
Firefighters Local #48 President Matt Alter said officials would use both reports and implement the recommendations.
"We're going to ... do everything in our power to make sure that this sort of incident doesn't happen again," he said.
Tom McKee contributed reporting.