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FIRE DEPARTMENT CITY OF NEW YORK

SAFETY AND INSPECTION SERVICES COMMAND


INVESTIGATIVE REPORT
BROOKLYN BOX 2-21770
577 JEROME STREET
JANUARY 23, 2005
CASE NUMBER 09-05
FATAL INJURY
FIREFIGHTER RICHARD T . SCLAFANI
LADDER COMPANY 103
VOLUME I
THE INVESTIGATION

I. SUMMARY


On Sunday, January 23, 2005, at 1337 hours, the Brooklyn Communications
Office of the New York City Fire Department received a telephone alarm reporting a fire
in a private dwelling at 577 Jerome Street. The dispatcher assigned a full fIrst alarm
assignment due to the number of phone calls received. Engine 290 transmitted a 10-75
on arrival for fIre in a two story private dwelling at 1340 hours. Fire Department
"
standard operating procedures for a fIre in a private dwelling were initiated.

The fire building. located at 577 Jerome Street was a two story detached, peaked

roof, private dwelling. The building was approximately 25 feet wide by 50 feet deep.
The fIre was in the cellar of this bUilding. FirefIghter Richard T. Sclafani of Ladder
Company 103 was discovered unconscious on the half landing of the stairway leading up
from the cellar approximately eight minutes after his arrival on the scene. When he was
found, his helmet was not on his head and his Self Contained Breathing Apparatus
(SCBA) facepiece was not on his face. It has not been determined why Firefighter

Sclafani's facepiece was off his face. FirefIghter Sclafani was in the process of exiting

the building directly behind the Ladder Company 103 Officer when he inhaled toxic and
highly heated gases, which caused him to lose consciousness.
On exiting the building, the Ladder Company 103 OffIcer noticed FirefIghter
Sclafani was missing and transmitted a MAYDAY. The Ladder Company 103 OffIcer
and Forcible Entry FirefIghter re-entered the building to search for him. They found
Firefighter Sclafani unconscious on the stairway landing within one minute after he was

fIrst noticed missing. The Ladder Company 103 OffIcer then transmitted a second

MA YDA Y for a member down on the stairs.
The Ladder Company 103 OffIcer and Forcible Entry FirefIghter attempted to
remove Firefighter Sclafani but were unable to do so. The removal operation continued
for approximately 22 minutes until FirefIghter Sclafani wa.s removed to the street at
approximately 1410 hours. A high heat and heavy smoke condition as well as the
absence of a hose line between the fIre and the rescue operation hindered the removal

operation of FirefIghter Sclafani.

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Firefighter Sclafani was transported by FDNY Emergency Medical Service
(EMS) to Brookdale Hospital. The results of the autopsy revealed that Firefighter
Sclafani had a carboxyhemoglobin (COHb) level of 24 percent as well as third degree
burns to his head, torso and upper extremities.
As a result of the investigation into this fatality, Safety and Inspection Services
Command makes the following recommendations:

1. Develop a procedural guide to assist Chief Officers in formulating a strategy to
"
manage a MAYDAY for distressed members.

2. Develop and implement training for Chief Officers that will focus on the
procedures and the active management of a MAYDA Y operation.
3. Re-emphasize the importance of using the proper format when transmitting a

MAYDAY as per Communications Manual Chapter 9, Section 9.4.
4. Amend the Communications Manual Chapter 9, section 9.4 to include: The

emergency alert button must be used during any MAYDAY or URGENT


transmission.
5. Amend the Communications Manual and other appropriate documents to require

that every time a MAYDAY is transmitted, the Incident Commander must
announce the MAYDAY on the handie-talkie and on the appropriate Department
borough radio frequency.

6. Incorporate all pertinent information and procedures pertaining to distressed
members into a single guide.

7. Re-evaluate Firefighting Procedures Volume 1, Book 6, Private Dwellings,
Chapter 3, section 2 pertaining to fIrst due Engine and Ladder Company
operations at cellar fIres in private dwellings having an exterior cellar entrance.

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8. Amend Firefighting Procedures Volume 1, Book 6, Private Dwellings Chapter 5
section 1.2.B, by adding the following: "Type and location of interior stairs."
9. Re-emphasize that the first due Ladder Company Outside Team must perform a
quick exterior survey and notify their Officer and Incident Commander of the

conditions found, coordinate VES with the Inside Team, and vent the fire
area/room when ordered.

10. Equip each Ladder, Rescue and Squad Company with an additional SCBA to be
taken by the unit assigned or designated as the FAST Unit.
11. Amend AVC 320, FIREFIGHTER ASSIST AND SEARCH TEAM - FAST

UNIT, to specify member assignments.

12. Re-emphasize the importance of the FAST Unit bringing the full complement of
FAST tools and equipment to the Command Post or Operations Post.
13. Reinforce to all members the need to maintain building entrances and stairways
unimpeded.

14. Re-emphasize that handie-talkie transmissions must be concise and directed to
specific members or units.

15. Re-emphasize to all Chief Officers the importance of transmitting preliminary and
progress reports as required by the Communications Manual.

16. Battalion and Division Commanders must ensure that units in their command are
staffed with an appropriate number of Firefighters trained to work as Battalion
and Division Firefighters.

17. Re-emphasize the importance of notifying the dispatcher when the FAST Unit is
put to work.

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18. Develop and issue documentation regarding the proper use and maintenance of
the frrefighting helmet and the proper use of the chinstrap.
19. Research and/or develop a drag rescue device that can be incorporated into the
present PPE to assist in the removal of incapacitated members.
20. Amend Safety Bulletin 84, Window Bars, section 4, to include the following
sentence: "An Engine on the scene or a special called Engine could provide an
exterior hoseline to protect civilians or members trapped behind the window bars

inside the building or members removing the window bars. "


21. Amend All Unit Circular 314, Incident Command and Safety Investigations, to
incorporate appropriate subsections of sections 5, 6, 7, and 9 of All Unit Circular

317, Crime Scene Operations to ensure the fire scene is immediately secured and
properly documented.

22. Expand the training program titled, "CellarlUnconscious Firefighter Removal"


that is currently being piloted by Division 13 to all Divisions. This program
provides hands-on training in the removal of an unconscious member.

23. Reinforce to all members of the Department the dangers of carbon monoxide.
Removing the SCBA facepiece in a contaminated atmosphere is extremely
hazardous.

24. The Bureau of Fire Prevention should work with the Department of Buildings to
implement an effective procedure to ensure the administrative company is notified
when a building is constructed or renovated using lightweight wood I beam

construction. Units notified of such conditions must evaluate the hazard and
submit a CIDS card.

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DIAGRAM #2 - CELLAR LAYOUT
Coat Rack
Sub Water
Box Breakers Meter
Drawing not to scale
Play
Area
0
~ Vent Pipe
D-waSher
D-Dryer
o-water
Heater
D-BOiler
Umbrella
Stroller
I Circuit t
Iron
___r--- Gate
Note: Overhead
Awning, See
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Bedroom
Boxes
Half - Landing
Car
I_Seat-----,
o [ Desk
D I
Living
ROOnl
D
D
D
D

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v. OPERATIONS

On Sunday, January 23, 2005 at 1337 hours, the Fire Communications Office of

the New York City Fire Department in the Borough of Brooklyn received a telephone
alarm, reporting a fIre at 577 Jerome Street. Engine Company 290, Ladder Company
103, Engine Company 332, Ladder Company 175, Engine Company 236, Battalion 44,
Rescue Company 2 and Squad Company 252 were assigned to respond. Ladder Company
107 became available and no tilled the Brooklyn dispatcher. Ladder Company 107 was
then assigned by the dispatcher and arrived second due.

On the morning of January 23,2005, New York City had received accumulations
of approximately twelve to eighteen inches of snow. The temperature on this day only
reached a high of 20 degrees with a wind chill factor near zero degrees. The wind was

from the north with an average wind speed of 24 miles per hour and gusting winds of up

to 48 miles per hour. Although response was slowed due to the snowstorm, no units
reported a significant delay in their response. Engine Companies were all staffed with
five fIrefIghters for this tour due to the adverse weather conditions.
The fire building, 577 Jerome Street, was a detached two-story, peaked roof,
wood frame (Group lID construction), private dwelling. The dimensions were
approximately 25 feet wide by 50 feet deep. The building had floor joists constructed

with lightweight laminated wood I-beams protected by 5/8 inch sheetrock. One family

occupied the entire second floor, while another family used the fIrst floor and the cellar as
their living space. Two exterior doors on the front stoop provided access to the fIrst and
second floors respectively. A wooden interior return type stair, located just inside the
front entrance, connected the cellar and the frrst floor. The upper stair section was 3 feet
5 inches wide and had six steps that led down to the half landing. The half landing was
approximately 6 feet 9 inches by 3 feet 6 inches. (See diagram # 1) The lower stair

section was 2 feet 10 inches wide and had six steps that led to the cellar floor. The

following items were stored on the half landing: A 70 pound metal coat rack with four
winter coats, an umbrella baby stroller and storage boxes. There was an exterior cellar
entrance in the rear. (See diagram # 2)

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The exposures were as follows:
Exposure #1 - Front yard

Exposure #2 - Similar detached private dwelling separated by a nine foot


driveway. The driveway contained four parked cars that impeded access to the
rear of the fIre building.
Exposure #3 - Rear Yard

Exposure #4 - Vacant lot with a chain link fence located approximately fIve feet
from the fIre building.
The Bureau of Fire Investigation determined that the fIre was started accidentally

by combustible material in close proximity to a portable electrical heater in the rear of the
cellar. (See Diagram # 2) There was a delay in the notifIcation to 911. Occupants spent
some time searching the first floor for the source of smoke before realizing that the fIre
was in the cellar.

Initial Operations
Engine Company 290 transmitted a 10-75 for a fIfe in a two-story private

dwelling at 1340 hours. Engine Company 290 back stretched a P4-inch hose line to the
front of the fIfe building. The Engine Company 290 Officer reached the fIfe building
first and an occupant told him that the fIfe was in the cellar. The Engine Company 290
OffIcer opened the interior cellar door, located just inside the front entrance, and heavy

black smoke pushed out. He immediately closed the door and waited for the hose line to
be placed in position and charged.
Ladder Company 103, the fIfst due Ladder Company, arrived at approximately

1341 hours. The Ladder Company 103 Officer, the Ladder Company 103 Forcible Entry
FirefIghter, and Firefighter Sclafani, the Ladder Company 103 Can Firefighter (the Inside
Team) proceeded to the front stoop and donned their facepieces while waiting for Engine
Company 290's hose line to be charged.

The Ladder Company 103 Chauffeur Firefighter began to remove the cellar
window bars on the exposure #1 side. The Ladder Company 103 Roof Firefighter placed
a portable ladder on the exposure #4 side adjacent to the fIfst floor windows. He then

worked on removing the window bars on two rear cellar windows on the exposure #4
side before proceeding to the rear. Neither member completely removed these cellar
Page 13 of 62



window bars. The Ladder 103 Outside Vent Firefighter went to the rear and began
forcing the exterior rear cellar entrance door.
When Ladder Company 107 arrived, the Officer thought that the fire was on the
first floor due to heavy smoke venting out the front door. The Ladder Company 107
Inside Team went to the second floor and conducted a primary search. There was a light

smoke condition on the second floor with no fIre extension. The primary search on the
second floor was negative.
The Ladder Company 107 Chauffeur, Roof and Outside Ventilation Firefighters

began to remove the cellar and fIrst floor window bars on the exposure #1 side.
Initially, Engine Company 332 assisted Engine Company 290 in stretching their
hose line. Engine Company 332 then stretched a 1 %-inch hose line from the apparatus of
Engine Company 290 and charged it in front of the fIre building.

Engine Company 236 arrived as the third due Engine Company and teamed up

with Engine Company 290.
At approximately 1344 hours, the Ladder Company 103 Inside Team encountered
a heavy smoke condition as they opened the door leading to the cellar. Firefighter
Sclafani, the Ladder Company 103 Can Firefighter, began to descend the upper cellar
stair followed by the Ladder Company 103 Officer. Both members were able to walk
down the stairs upright; the heat condition was not severe at this time. The Ladder

Company 103 Forcible Entry Firefighter descended the upper cellar stair behind the

Ladder Company 103 Officer. When Firefighter Sclafani reached the half landing he
called out that there was a door. Firefighter Sclafani was at the wall on the half landing
that was straight ahead from the upper stair. The lower stair leading down to the cellar

from the half landing was behind Firefighter Sclafani and to his left. Firefighter Sclafani
said, "It's to the left", and then continued down the lower stair to the cellar followed by
the Ladder Company 103 Officer.
The Ladder Company 103 Forcible Entry Firefighter and the Engine Company
290 Officer descended the upper cellar stair followed by the hose line to the half landing.
The Ladder Company 103 Forcible Entry Firefighter was unable to descend the lower

stair to the cellar due to the conditions on the half landing.
While the Engine Company 290 Nozzle Firefighter advanced the hose line down
the upper cellar stair to the half landing, the Engine Company 290 Back Up Firefighter

Page 140f62

made a large loop in the hose line at the top of the upper cellar stair to assist in hose line
advancement. The large loop fell onto the Engine Company 290 Officer dislodging his
helmet. He did not have the protection of his helmet for the remainder of this ftre. The

Engine Company 290 Officer became entangled with the items stored on the half landing.
The heat condition increased signiftcantly. The Engine Company 290 Officer received
ftrst and second degree bums to his forehead at this time.

As the Ladder Company 103 Inside Team descended the interior cellar stairs, the
Ladder Company 103 Outside Ventilation Fireftghter forced open the exterior rear cellar
door. At approximately 1345 hours the Ladder Company 103 Outside Ventilation and

Roof Fireftghters teamed up and entered the door to conduct a primary search. They
encountered a heavy smoke condition. They were able to proceed into the cellar
approximately 10 feet before they were forced to withdraw to the rear yard due to the
expanding ftre condition. When they exited to the rear yard, ftre vented out of the rear

cellar window and exterior rear cellar door. Fire also vented out of the cellar windows on
the exposure #2 and exposure #4 sides of the ftre building. No handie-talkie
transmissions were made regarding the change in ftre conditions in the cellar at this time.

After completing a primary search on the second floor, the Ladder 107 Inside
Team proceeded to the rear via the alleyway on the exposure #4 side. The Ladder
Company 107 Forcible Entry Firefighter and the Ladder Company 107 Can Fireftghter
stopped to remove the cellar window bars on the exposure #4 side while the Officer

continued to the rear yard. The Ladder Company 107 Can Fireftghter attempted to
remove the middle cellar window bars and accidentally vented this window. The Ladder
Company 107 Forcible Entry Firefighter vented the rear cellar window. They were both

unable to remove the window bars, and immediately joined their Officer in the rear.
The extremely heavy smoke and swirling winds periodically obscured the rear of
the ftre building. The Ladder Company 107 Officer located the rear entrance to the cellar
and transmitted this information to Battalion 44. He also requested a hose line to this

location.
At approximately 1345 hours, the Engine Company 290 Officer ordered the
Engine 290 Nozzle Fireftghter, who was now on the half landing, to open the hose line

due to the high heat condition. The member operated the hose line for approximately ten
seconds and then shut the hose line down in order to reposition himself on the half
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landing. The Engine Company 290 Officer felt that the heat condition increased
significantly and ordered the hose line opened again. There was no visible fire on the
cellar stairs. The Ladder Company 103 Officer and Firefighter Sclafani were in the cellar
approximately eight to ten feet from the base of the stairs.
While operating in the cellar, the Ladder Company 103 Officer was unable to see

the screen of the thermal imaging camera due to the unusually heavy smoke condition.

The Ladder Company 103 Officer decided to leave the cellar when he heard Engine
Company 290's hose line operating. He told Firefighter Sclafani, "Let's go." Firefighter
Sclafani replied, "Okay." When they reached the base of the cellar stair, the Ladder
Company 103 Officer as well as the other members operating on the stairs then heard the
Engine Company 290 Officer call for everyone to get out.
At approximately 1346 hours, Battalion 44 arrived in front of the fire building and

noticed the window bars covering the cellar and fITst floor windows. Battalion 44

requested an additional Engine Company and Ladder Company due to the presence of
window bars. Battalion 44 observed fITe venting from the exposure #2 side cellar
window.
Battalion 44 ordered Engine Company 332 to reposition their hose line to the rear.
As Engine Company 332 was repositioning their hose line via the alleyway on the
exposure #4 side; they observed fITe venting from the two rear cellar windows on the

exposure #4 side.

At approximately 1346 hours, the Ladder Company 103 Officer and Firefighter
Sclafani were craw ling up the lower stair from the cellar. The Ladder Company 103
Officer stated that Firefighter Sclafani was right behind him, at his feet, as they craw led
up to the half landing. Engine Company 290's hose line was being directed toward the
exposure #2 wall on the half landing. As the Ladder Company 103 Officer reached the
half landing, there was congestion with other members who were exiting. At that time,

the Ladder Company 103 Officer heard Firefighter Sclafani who was behind him state in

a muffled tone, "Let's go, Let's go."
There was no visibility due to the heavy black smoke. The Engine Company 290
Nozzle Firefighter operated the hose line from the half landing to protect the members
who were exiting the cellar. The Engine Company 290 Nozzle Firefighter stated that
after one member passed by him, another member then passed him in a more frantic state

Page 16 of62
and a third member collided with him. The force of the collision caused the Engine
Company 290 Nozzle Firefighter to be knocked down onto his back. His helmet and

facepiece were dislodged. The use of the chinstrap prevented his helmet and facepiece
from becoming completely dislodged. He shut down the nozzle, placed it on the stair,
and exited the building via the front entrance.
After reaching the front stoop, the Ladder Company 103 Officer and the Ladder

Company 103 Forcible Entry Firefighter immediately realized that Firefighter Sclafani
did not exit the building with them. The Ladder Company 103 Officer returned to the top
of the cellar stairs and heard a Personal Alert Safety System (PASS) alarm sounding. He

stated that he heard air escaping under pressure from a SCBA. The Ladder Company 103
Officer stated that the airflow had a high-pitched sound. He stated that this sound
differed from the sound of an undonned SCBA facepiece without the manual shut off
button depressed. On hearing the PASS alarm and high-pitched airflow, the Ladder

Company 103 Officer transmitted a MAYDAY via his handie-talkie. The time was
approximately 1348 hours.
Battalion 44 did not hear the Ladder Company 103 Officer transmit a MAYDAY.

Immediately after this MA YDA Y was transmitted, Battalion 44 ordered via handie-talkie
for all "Trucks" to get off the fIrst floor until a hose line was in position. Battalion 44's
strategy was to extinguish this fire via the exterior rear cellar entrance. His tactics were
to have Engine Company 290 maintain their position of protecting the fIrst floor with

their hose line while Engine Company 332 attacked the fIre via the exterior rear cellar
entrance.
The heat venting up the interior cellar stairs had intensified. Visibility on the stairs

was zero. The Engine Company 290 Officer located at the top of the stairs also heard the
sound of pressurized air at the half landing. He stated that it sounded like the airflow
from the SCBA was "quicker" than when the manual shut off of the SCBA is not
depressed.

The Ladder Company 103 Officer called for Engine Company 290's hose line.
The Engine Company 290 Officer pulled the hose line up the stairs. The Engine
Company 290 Officer then gave the nozzle to the Engine Company 290 Back Up

Firefighter who operated the hose line down the stairs from the fIrst floor. The Ladder
Company 103 Officer was on the fIrst floor when his helmet was dislodged after being
Page 17 of 62



struck by the stream. He did not have the protection of his helmet for the remainder of
the fire.
The Ladder Company 103 Officer and the Ladder Company 103 Forcible Entry
Firefighter descended the upper cellar stair to locate and remove Firefighter Sclafani
under the protection of Engine Company 290's hose line. The Ladder Company 103

Officer immediately found Firefighter Sclafani unconscious, in a prone position, with his

upper torso on the half landing and his waist and legs on the lower stair. (See diagram #
1) The Ladder Company 103 Officer immediately transmitted a second MA YDA Y via
the handie-talkie stating that the member was on the stairs. Several members believed
that the member in distress made this transmission. The two MA YDAYS transmitted by
the Ladder Company 103 Officer were approximately one minute apart. The time of the
second MAYDA Y was approximately 1349 hours.

The second MAYDAY was acknowledged and Battalion 44 ordered a second

alarm transmitted. The Battalion 44 Firefighter transmitted a second alarm at 1349 hours
and stated, "We have a MAYDAY for a member on the first floor." Battalion 44 ordered
Engine Company 236 to stretch a second hose line to the front of the fire building.
The Engine Company 290 Officer decided to have his hose line continue to
operate from the first floor down into the half landing area to protect the removal
operation. He believed that Firefighter Sclafani would be removed quickly and did not

want to block the stairs impeding Firefighter Sclafani's removal.

The Ladder Company 103 Officer stated that when he reached Firefighter
Sclafani on the half landing, Firefighter Sclafani's helmet and facepiece were not on.
The Ladder Company 103 Officer stated that Firefighter Sclafani's PASS Alarm was

sounding at this time. The Ladder Company 103 Officer and Ladder Company 103
Forcible Entry Firefighter were unable to remove Firefighter Sclafani. The Ladder
Company 103 Officer and the Ladder Company 103 Forcible Entry Firefighter continued
to operate on the half landing in a high heat and heavy smoke condition for

approximately five to six minutes. Their air supply was nearly depleted. They were
physically exhausted and left the building via the front entrance. The time was
approximately 1354 hours.
Ladder Company 120 arrived as the Firefighter Assist and Search Team (FAST
Unit) and heard the second MAYDAY transmission. They reported in to Battalion 44 in

Page 18 of62
front of the fire building and were assigned to the MAYDA Y operation. Ladder
Company 120 attempted to enter the ftre building via the front stoop. They were unable
to enter due to numerous members positioned on the exterior front stoop.

On arrival, Rescue Company 2 heard the second MAYDAY transmission. The
Rescue Company 2 Officer arrived in front of the fire building after Ladder Company
120 was assigned to the rescue effort and split his company into two teams to locate the

downed member. One team went to the rear while his team attempted to gain access
through the front door. The Rescue Company 2 Officer and the Ladder Company 120
Officer were both now on the front stoop attempting to gain access. Battalion 44 ordered

the Rescue Company 2 Officer to address the MAYDAY.


Battalion 44 then redirected Ladder Company 120 to search the stairway between
the ftrst and second floor to ensure that the member was not located on this stair. Ladder
Company 120 proceeded to the second floor via the interior stair and performed vent,

entry and search (VES) of the stairway and second floor. The results of this search were
negative and Ladder Company 120 reported these results to Battalion 44.
Squad Company 252 also heard the second MAYDAY transmission as they

arrived on the scene. They reported into Battalion 44 and were ordered to fmd another
point of entry into the cellar to address the MAYDAY. Squad Company 252 proceeded
to the rear.
Battalion 58 reported into Battalion 44 and was ordered to supervise operations in

the rear at approximately 1351 hours.
Division 15 arrived in front of the ftre building and assumed command after a
brief exchange of information with Battalion 44. Division 15 ordered Battalion 44 to

supervise the rescue operation. The time was approximately 1353 hours.
Initial Operations in the Rear
As the operations were being conducted in the front, members converged near the

rear entrance stair. Engine Company 332's charged hose line was standing fast in the
rear yard at the exposure #2 - #3 comer. The Engine Company 332 Officer attempted to
contact both Battalion 44 and Engine Company 290 several times via hand ie-talkie to

request permission to advance the hose line into the cellar. The Engine Company 332
Officer wanted to ensure that his hose line would not be in opposition to Engine
Page 19 of62



Company 290' s hose line. While theEngine Company 332 Officer was trying to contact
Battalion 44, he observed fire venting out of the cellar window on the exposure #2 side,
extending up the exterior of the fire building to the underside of the eaves. Engine
Company 332 extinguished this fITe on the exterior without the stream entering the cellar
window. The Engine Company 332 Officer was then mistakenly informed by a member

in the rear yard that Engine Company 290 was out of the cellar and in front of the fITe

building. The Engine Company 332 Officer then ordered his hose line advanced through
the exterior rear cellar door to extinguish the fITe in the cellar. The time was
approximately 1353 hours.
Initial Operations in the Front
As Engine Company 332 was knocking down the fITe on the exposure #2 side,

Engine Company 290 operated their hose line from the top of the upper cellar stairs just

inside the front entrance. When the Engine Company 290 Back Up Firefighter's vibralert
alarm activated, he handed the nozzle to the Engine Company 290 Door Firefighter
directly behind him. The Engine Company 290 Back Up Firefighter then left the fITe
building via the front door to replace his SCBA cylinder. The Engine Company 290
Door Firefighter operated the hose line at this location for approximately two minutes
and then began to advance the hose line down the upper cellar stair. During this time, the

Ladder Company 103 Officer and the Ladder Company 103 Forcible Entry Firefighter

ascended the upper stair and exited the fire building via the front door.
The Engine Company 290 Door Firefighter was unaware of Firefighter Sclafani's
location as he advanced the nozzle down the upper stair unassisted. On reaching the half
landing, he discovered Firefighter Sclafani. The Engine Company 290 Door Firefighter
shut the nozzle down and laid it on the half landing. Engine Company 290's hose line did
not operate again until after Firefighter Sclafani was removed from the fITe building.

The Engine Company 290 Door Firefighter attempted to pull Firefighter Sclafani

up the stairs, but was unable to do so. The Engine Company 290 Door Firefighter stated
that there was a heavy object (coat rack) on top of Firefighter Sclafani that he was unable
to remove. The Engine Company 290 Door Firefighter re-positioned himself on the half
landing at the lower stair but was still unsuccessful in his attempt to remove him. The
time was now approximately 1356 hours.

Page 20 of62

When the Ladder Company J03 Officer was exiting the front door, he informed
the Rescue Company 2 Officer that Firefighter Sclafani was right there on the stairs. The

Rescue Company 2 Officer and the Rescue Company 2 Can Firefighter proceeded down
the upper cellar stair to the half landing and operated with the Engine Company 290 Door
Firefighter. The Rescue Company 2 Officer stated that he heard the PASS alarm
sounding at this time. There was an extremely high heat condition and zero visibility.

With great difficulty, the Rescue Company 2 Officer removed the 70-pound metal
coat rack that was on top of Firefighter Sclafani. The Rescue Company 2 Officer stated
that he then verbally called for a Life Saving Rope to assist in the removal of Firefighter

Sclafani. While operating with Rescue Company 2, the Engine Company 290 Door
Firefighter's vibralert alarm activated. The Engine Company 290 Door Firefighter then
exited the fire building via the front entrance at approximately 1358 hours.
The Rescue Company 2 Officer attempted several times to get Firefighter

Sclafani's body into a position for removal. He stated that he made a handie-talkie
transmission requesting assistance. This handie-talkie transmission was never
acknowledged. After a short period of time, he was handed some nylon tubular webbing

by the Rescue Company Can Firefighter and was unsuccessful in his attempt to attach the
webbing to Firefighter Sclafani. The heat condition on the half landing was becoming
untenable.
The Rescue Company 2 Officer was aware that there was a hose line on the half

landing. The Rescue Company 2 Officer ordered the Rescue Company 2 Can Firefighter
to find the nozzle, and get the hose line into operation. The Rescue Company 2 Can
Firefighter located the nozzle but was unable to move it because the hose line was

entangled in the items on the half landing. At approximately 1402 hours, the intense heat
forced these members of Rescue Company 2 to exit the building via the front entrance.
When the Rescue Company 2 Officer reached the front entranceway, he
transmitted the following message via handie-talkie:

"Rescue 2 to 1-5 Urgent. We have to have a line at this front door."
Division 15 replied, " Repeat Rescue."
Rescue 2 Officer replied, "We have to have another hose line at this front door to make it

down the stairs." The time was 1403 hours.


Page 21 of62



Division 15 then ordered Engine Company 236, who was standing fast in the front
yard with a charged hose line, to bring their hose line into the frre building via the front
entrance.
Operations in the Rear

Engine Company 332 encountered a heavy frre condition as they advanced their

hose line into the cellar from the rear exterior cellar entrance. The Ladder 107 Inside
Team entered the cellar behind Engine Company 332. The Ladder Company 103 Outside
Ventilation Firefighter, Chauffeur and Roof Firefighters also entered the cellar followed
by the Rescue Company 2 Chauffeur, Roof 1, Roof 2, and Forcible Entry Firefighters.
The Squad Company 252 Officer entered the cellar, but exited immediately due to the
numerous members already at this location. While extinguishing the frre in the cellar,

Engine Company 332 had difficulty maneuvering their hose line due to the numerous

members operating at this location. Two members had their helmets dislodged by the
stream.
After Engine Company 332 entered the cellar, Battalion 58 arrived in the rear
yard to supervise operations. Battalion 58 ordered Engine Company 231 to stretch a back
up hose line to the rear yard. Engine Company 231 stretched a 1% inch hose line from
Engine Company's 236 apparatus via the vacant lot on the exposure #4 side.

After searching in the cellar for approximately seven minutes, the Ladder

Company 103 Roof Firefighter's vibralert alarm activated. The Ladder Company 103
Roof Firefighter was now in the rear cellar bedroom. He saw light from the bedroom
window on the exposure #4 side and decided to exit via this window. He had to
completely remove his SCBA and facepiece in order to fit through the window.
The Ladder Company 175 Roof Firefighter and the Ladder Company 120 Outside
Ventilation Firefighter, operating in the exposure #4 alleyway, assisted the Ladder

Company 103 Roof Firefighter out of the window. The Ladder Company 170 Officer

witnessed the removal and transmitted a handie-talkie message to Division 15 stating that
a member was being removed from the cellar window on the exposure #4 side. He
requested EMS to this location. The Ladder Company 103 Roof Firefighter was removed
at approximately 1402 hours.

Page 22 of62

The Ladder Company 103 Roof Firefighter made it very clear to the members
assisting him that he was not the MAYDAY in the cellar. This information was relayed

to Division 15. Ladder Company 120 went to the exposure #4 alleyway and assisted
carrying the Ladder Company 103 Roof Firefighter to the front yard. The Ladder
Company 103 Roof Firefighter was then turned over to EMS. The Ladder Company 103
Roof Firefighter was transported to Brookdale Hospital by EMS where he was treated

and released.
The Ladder Company 103 Outside Ventilation Fireftghter was also searching in
the cellar. His vibralert alarm activated. While attempting to locate the rear cellar door,

the Ladder Company 103 Outside Ventilation Fireftghter saw the cellar window on the
exposure #2 side and exited through this window. The Ladder Company 170 Chauffeur,
who was in the driveway on the exposure #2 side, assisted him out the cellar window.
The time was approximately 1403 hours.

Engine Company 332 operated in the cellar for approximately 10 minutes and
extinguished most of the fire in the cellar before their hose line developed a hole.
Battalion 58 ordered Engine Company 231 to bring their hose line into the cellar to

replace Engine Company 332's hose line. Battalion 58 notifted Division 15 that he was
switching the hose lines in the cellar.
Operations in the Front

Several members of Squad Company 252, Ladder Company 120 and Ladder
Company 107 were operating together on the ftrst floor. They searched the first floor,
and then removed the sheetrock around the cellar stairway enclosure on the first floor in

an attempt to ventilate the cellar stair.


While Engine Company 236 was repositioning their hose line to the front
entrance, Engine Company 225 Nozzle Fireftghter attempted to pull Engine Company
290' s hose line up the cellar stairs from the ftrst floor landing, but he was unable to move

the hose line. The Engine Company 225 Officer and Engine Company 225 Nozzle
Firefighter descended the upper cellar stair in an attempt to locate the nozzle of Engine
Company 290's hose line and found Fireftghter Sclafani on the half landing. No other

members were with Fireftghter Sclafani when they found him. The heat condition on the
half landing made it impossible to operate without the protection of a hose line. The
Page 23 of62



Engine Company 225 Officer and Engine Company 225 Nozzle Firefighter ascended the
upper stair to the front door. As the members of Engine Company 236 donned their face
pieces near the front entrance, the Engine Company 225 Officer told them to bring their
hose line down the stairs and to the left.
As the Engine Company 225 Officer exited the fire building, the Squad Company

252 Hook Firefighter descended the upper stair to the half landing and found Firefighter

Sclafani. Squad 252 Hook Firefighter was alone with Firefighter Sclafani at this time.
He realized that a hose line was needed and went back up the stairs to get a hose line.
Engine Company 236 entered the first floor of the fire building via the front entrance and
began to advance the hose line down the upper cellar stair at approximately 1404 hours.
The Squad Company 252 Hook Firefighter met the Engine Company 236 Nozzle
Firefighter at the top of the upper stair and guided him past Firefighter Sclafani to the

lower stair. As Engine Company 236 slowly descended the lower stair to the cellar floor

they opened their hose line and extinguished visible fire. They continued to operate the
hose line, advancing approximately ten feet into the cellar. Conditions on the half
landing improved significantly once this hose line was in operation between the fire and
Firefighter Sclafani. The time was now approximately 1406 hours.
As Engine Company 236 advanced their hose line in the front of the cellar, the
Engine Company 236 Officer stated the unusual heat conditions indicated there could be

an opposing hose line. He notified Battalion 44 via handie-talkie. Battalion 44 directed

Battalion 58 to have Engine Company 231' s hose line shut down and have them back out
of the rear of the cellar.
The Rescue Company 2 Officer, and the Rescue Company 2 Can and Hook
Firefighters followed Engine Company 236's hoseline down the upper cellar stair to the
half landing. They joined with the Squad Company 252 Hook Firefighter, who was
already operating at this location. The Rescue Company 2 Officer was handed one end of

a life saving rope and attempted to wrap it around Firefighter Sclafani's torso. Before

this could be accomplished, members operating outside the fire building prematurely
pulled the rope out of the Rescue Company 2 Officer's hand. The Rescue Company 2's
Hook Firefighter, who was operating on the upper stair, maintained a hold on the rope
and was able to pass the end of the rope back down to the half landing. The Rescue
Company 2 Officer and the Squad Company 252 Hook Firefighter then attached the rope

Page 24 of62

to Firefighter Sclafani's SCBA shoulder strap. Numerous members outside the fire
building were then directed to pull on the rope and Firefighter Sclafani moved slightly.

The Rescue Company 2 Officer and the Squad Company 252 Hook Firefighter
were able to partially descend the lower cellar stair to pivot Firefighter Sclafani's legs up
onto the half landing. Members on the outside, utilizing the attached life saving rope,
were then able to pull Firefighter Sclafani from the half landing to the front stoop.

Firefighter Sclafani was face down as he was moved up the stairs. The Rescue Company
2 Can and Rescue Company 2 Hook Firefighters located on the upper cellar stair kept
Firefighter Sclafani's face and head off the steps as he was moved out of the frre

building. The time was now 1410 hours.


Firefighter Sclafani was placed on a stretcher and immediately carried to a FDNY
EMS ambulance located at Livonia Avenue and Jerome Street, and transported to
Brookdale Hospital. As noted on the certificate of death, the date and time of death was

January 23, 2005 at 2:50 P.M. The immediate cause of death was smoke inhalation and
third degree burns of the head, torso and upper extremities.





Page 25 of 62


VI. FINDINGS

1. Firefighter Sclafani was found unconscious on the half landing leading up from the
cellar in a two story private dwelling. He had been operating in the frre building for
approximately four to five minutes. Firefighter Sclafani and his Officer were in the

process of exiting the cellar via the interior stairs when they became separated.

Approximately one minute after they became separated, his Officer transmitted a
MAYDAY when he became aware that Firefighter Sclafani did not exit the cellar
with him. Less than one minute after the initial MAYDAY was transmitted,
Firefighter Sclafani was found unconscious on the half landing. When he was found
his:
Facepiece was not on his face.

Helmet was removed.
Protective hood was in a down position around his neck.
Personal Alert Safety System (PASS) was in full alarm.


2. The investigation was unable to determine how Firefighter Sclafani's face piece
became dislodged or removed. He inhaled toxic and highly heated gases causing him
to lose consciousness. The investigative team has put together several theories as to
why his facepiece was dislodged or removed. They are as follows:
Firefighter Sclafani may have had his facepiece dislodged in a collision
with the Engine Company 290 Nozzle Firefighter on the half landing

while trying to exit.
Firefighter Sclafani may have had his facepiece dislodged by being hit
with the hose stream that was operating on the half landing.

Firefighter Sclafani's SCBA may have become entangled in a coat rack
or other items on the half landing causing his facepiece to become
dislodged or he may have intentionally removed it.
The low-pressure hose on Firefighter Sclafani's facepiece was found
separated between the quick connect coupling and the pressure reducer
assembly_ This may have caused him to remove his facepiece.

Page 26 of 62

Firefighter Sclafani may have removed his facepiece for other unknown
reasons.

3. Firefighter Sclafani's SCBA # 103-3 was confiscated by the Safety Command at
Brookdale Hospital. This SCBA was a Scott 4.5 positive pressure breathing
apparatus with an EZ flow II regulator and a 45-minute luxfer cylinder. The

facepiece belonged to another member of Ladder Company 103. This SCBA was
tested on January 24, 2005 at the Mask Service Unit (MSU). The cylinder was
found to be empty at the time of testing. The manual shut off switch was found in

the open position. The low-pressure hose was separated between the quick
connect and the pressure reducer assembly. If the facepiece was removed without
the manual shut off button depressed or if the low-pressure hose was severed, then
the air supply in the cylinder would deplete at a minimum rate of 400 liters per

minute. A full 45-minute cylinder has approximately 1835 liters of air and would
be depleted in approximately four to five minutes. The SCBA, facepiece and
cylinder were sent to Intertek Testing Services for analysis

4. The low-pressure hose on Firefighter Sclafani's SCBA was found separated
between the quick connect coupling and the pressure reducer assembly. The
damaged SCBA was sent to Intertek Testing Services for analysis. The low

pressure hose was evaluated for resistance to splitting during an applied heat load
and flex. A pristine sample of a low-pressure hose was subjected to multiple
energy types and then flexed approximately 135 degrees in an effort to replicate

the exposure conditions present to cause deterioration and subsequent separation


of the hose. It was found that when the low-pressure hose was subjected to
radiant heat energy of one calorie per square centimeter per second, for a 30
second period and then flexed, the low-pressure hose exhibited similar damage of

blistering, flaking and split similar to the low-pressure hose of Firefighter
Sclafani's SCBA. The investigative team could not determine at exactly what
moment the low-pressure hose of Firefighter Sclafani's SCBA became damaged.

Page 27 of62



5. Two members positioned at the top of the interior cellar stairs reported hearing air
leak under pressure from a SCBA immediately after Firefighter Sclafani was
noticed missing. The Ladder Company 103 Officer reported hearing airflow with
a high-pitched sound coming from the half landing. The Engine Company 290
Officer reported hearing an air leak from the half landing that was "quicker" than

when the SCBA manual shut-off button is not depressed.

6. On December 30,2004, SCBA # LI03-3 was placed out of service and sent to
MSU for an air leak where the low-pressure hose connects to the regulator. The
low-pressure hose, regulator, and PASS alarm were replaced. The SCBA was
subjected to a visual and functional test using the Scott Posichek3 testing
procedures. The SCBA passed both the visual inspection and the function tests

and placed back in service on January 5, 2005.

7. Firefighter Sclafani's PASS alarm was heard sounding by the Ladder Company
103 Officer from the half landing immediately after it was discovered that
Firefighter Sclafani was missing. Numerous other members also reported
hearing the PASS alarm sounding during the operations.

8. After Firefighter Sclafani was found unconscious on the half landing, a hose line

operated from the top of the cellar stairs to protect the members attempting to
remove Firefighter Sclafani. After approximately five minutes, this hose line
advanced to the half landing. This hose line was shut down and the nozzle was
placed on the half landing when the member operating the hose line attempted to
remove Firefighter Sclafani. This hose line became entangled on the half landing
and was unable to be put back into operation. Removal operations continued on

the half landing for approximately ten minutes without the protection of a hose

line. Both the Incident Commander and Chief Officer assigned to the rescue
effort were unaware that this hose line was not operating during this time. The
absence of an operating hose line between the fIfe and the distressed member
severely hampered the removal operation.

Page 28 of62

9. Firefighter Sclafani was removed from the fire building approximately 22 minutes
after the frrst MAYDAY was transmitted. Difficulties encountered on the half
landing included:

Extreme high heat
Unusually heavy dense smoke condition
Small working area, which was further reduced by numerous items

stored on the half landing
Firefighter Sclafani's position on the half landing and lower cellar
stair.

10. When Firefighter Sclafani was found unconscious without his facepiece on his
face, there was no attempt to establish an air supply for him, even though he was
in an atmosphere that was Immediately Dangerous to Life and Health (IDLH).

Providing the unconscious Firefighter with an air supply is not adequately
addressed in AUC 320 FIREFIGHTER ASSIST AND SEARCH TEAM - FAST
UNIT, and Training Bulletin Unconscious Firefighter Removal

(
11. Numerous members were crowded together at both the front entrance and the
exterior rear cellar entrance. These members impeded access and egress at these
locations.

12. The MAYDA YS were not transmitted via handie talkie in the proper format as
per Chapter 9 of the Communications Manual. The initial MAYDAY transmitted

was never acknowledged. These initial and subsequent MAYDAY transmissions
were not clear as to who gave the MAYDAY, what the MAYDAY was for, and
where the MAYDAY was located. Many incoming members and members
operating at the scene were not aware of the status of the removal operations and
when the member was actually removed from the building. The member
transmitting the MA YDA Y s did not activate the emergency alert button on the

({Ce <rCa c{ac f[({(8IC mc [{CC( o(cacc acc CCCE
bandie-talkie.


13. After the MAYDAY was acknowledged on scene, Battalion 44 immediately
transmitted a second alarm.
14. Preliminary and progress reports were not transmitted until approximately 32
minutes into the operation. Communication between the Brooklyn

Communication Office and the Incident Commander were not according to
Department guidelines as outlined in the Communication Manual. The dispatcher
prompted both the Battalion and Division for preliminary and progress reports.

Both the fIrst arriving Battalion and the Division did not have regularly assigned
..-- - -..---. ..--r
Firefighters working this tour.
15. As the FAST Unit arrived on the scene, a MAYDAY was transmitted via hand ie

talkie. The FAST Unit did not take the full complement of FAST tools/equipment
to the Command Post.

16. Once the FAST Unit was deployed at this operation, they were not replaced as
required by Department procedures. The Incident Commander did not notify the
dispatcher that the FAST Unit was being put to work.

17. During fire operations at this incident, at least seven members reported that their

helmets were dislodged while performing fIre related tasks. Six of the members
had their helmets completely dislodged and were not wearing the helmet
chinstrap. One member, because his chinstrap was properly used, did not have his
helmet completely dislodged.
18. Battalion 44 special called an additional Engine Company and Ladder Company

when the presence of window bars was reported. Early removal of the window

bars played a key role in the ability for two members, disorientep and low on air,
to exit the cellar through two separate cellar windows (31" X 16 W'). The special
called Ladder Company assisted in the complete removal.
Page 30 of 62
I

19. Engine Companies were all staffed with five fIrefighters for this tour due to the
weather conditions. The additional members helped in the rapid positioning of
initial hose lines and back up hose lines at this operation. The Engine Company

290 Control Firefighter located and cleared the hydrant of snow. He also assisted
hooking up to the hydrant. Engine Company 332 was able to stretch numerous
lengths of hose from Engine Company 290' s apparatus through the heavy snow to

the front of the fIre building. They were then able to reposition this hose line to
the rear in a "timely fashion." Engine Company 231 also was able to stretch a
back-up hose line through the heavy snow to the rear ofthe fIre building without a

delay.
20. The adverse weather conditions played a key role in the operations at this fIre.
The fire took place in the aftermath of a bfuz;a-with accumulations between 12

and 18 inches of snow. The temperature on this day only reached a high of 20
degrees with a wind chill factor near zero degrees. The average wind speed was
24 miles per hour with gusting winds of up to 48 mph. Although response was

slowed due to the snowstorm, no units reported a significant delay in their


response.
21. The hand ie-talkie communications at the scene did not provide a clear and concise

picture to the Incident Commander of fIre conditions and the status of the rescue
effort, i.e.:
Changing fire conditions in the cellar were not reported to the

Incident Commander.
Information transmitted via handi-talkie was at times incomplete.
The exact location and nature of injuries were not transmitted to the
Incident Commander.

The fIrst MAYDAY transmitted was not acknowledged.
The Incident Commander ordered all Ladder Company members off
the fIrst floor. This order was not directed to specific units, was not

Page 31 of62



acknowledged, and no further action was taken to ensure
compliance.
22. Procedures outlined in AVC 314, Incident Command and Safety Investigations,
were not fully implemented by the Incident Commander to secure the scene.
-
-


23. The frre building, 577 Jerome Street, was found to have lightweight, laminated
wood I-beam floor joists throughout the building. The wood I-beams in the cellar
ceiling were protected by 5/8 inch sheetrock. The sheetrock in the cellar ceiling
was compromised in one small area near a pipe recess. Three wood I-beams
adjacent to the pipe recess sustained frre damage. Platform construction
prevented frre extension to the floors above even though there was a heavy frre

condition in the cellar.

24. There was no cms card on record for this building, which was constructed in
1999. The Bureau of Fire Prevention did not receive the required notification as
per Department of Buildings Technical Policy Procedure Notice 8/92 for
buildings with lightweight wood I beam construction. The administrative unit
was not aware of this use of lightweight wood I beam construction.


25. The "Smart Mic" (Model # RMN5023 SP01) was being field tested by the
members of Rescue Company 2 on their handie-talkie model XTS3500. Two
members reported that they were unable to transmit or receive messages after

their "Smart Mic" became wet while operating in the cellar. The "Smart Mics"
being field tested by Rescue Company 2 were removed from service following
this frre.

26. The Ladder Company 103 Officer attempted to use the thermal imaging camera in
the cellar. He was unable to see the screen because of the heavy dense smoke
condition.

Page 32 of 62

27. Members vented cellar windows on the exposure #4 side, and other members
performed YES via the rear exterior cellar entrance door, without the approval of
I

the first due Ladder Company Officer.










Page 33 of62


VUe CAUSES

DIRECT CAUSES
1) Inhalation of toxic levels of carbon monoxide and other gases.

2) Inhalation of heated products of combustion.
3) Third degree burns to head and torso and upper extremities.

INDIRECT CAUSES

1) Dislodgement or removal of the SCBA facepiece in a toxic and heated environment.
2) Physical conditions of the interior stairway half landing leading to the cellar. This
narrow landing had numerous boxes, a coat rack and an umbrella stroller on it that
further reduced the width of the landing.

3) Combustibles in close proximity to a portable electric heater.
4) Absence of an operating hose line between the fire and the removal effort in a timely
manner.

5) Failure to provide an air supply with an SCBA to the unconscious firefighter.
BASIC CAUSES

1) Sustained winds of 24 miles per hour (mph) with wind gusts up to 48 mph.
2) Heavy fire load in the cellar area, including foam rubber furnishings.
3) Unusual interior cellar stairway configuration.

4) Delayed notification to the Fire Department.


Page 34 of 62


VIII. RECOMMENDATIONS

1. Develop a procedural guide to assist Chief Officers in formulating a strategy to
manage a MAYDAY for distressed members. These procedures should address
an overall rescue plan for the Incident Commander while continuing to address
the developing emergency operations. These procedures shall be incorporated
into department publications where appropriate.

2. Develop and implement training for Chief Officers that will focus on the

procedures and the active management of a MA YDA Y operation. This training
could include tabletop, functional, and full-scale exercises. This training could be
conducted at the Bureau of Training, during multi unit drill, during Command
Chief and Division conferences.
3. Re-emphasize the importance of using the proper format when transmitting a

MAYDAY as per Communications Manual Chapter 9, section 9.4. The
emergency alert button shall be used, and all handie-talkie messages must be
acknow ledged.
4. Amend the Communications Manual Chapter 9, section 9.4 to include: The
emergency alert button must be used during any MAYDAY or URGENT
transmission. If the member transmitting the MAYDAY or URGENT is unable

to activate the emergency alert button, then the Incident Commander must use
this button to gain control of the handie-talkie network.

5. Amend the Communications Manual and other appropriate documents to require
that every time a MAYDAY is transmitted, the Incident Commander must
announce the MAYDAY on the handie-talkie and on the appropriate Department
borough radio frequency. This will aid in alerting all members on the scene a

well as incoming units of the emergency situation. An announcement shall also
be made on both radios when the MAYDAY situation has been resolved.

Page 35 of62

6. Incorporate all pertinent in(ormation and procedures pertaining to distressed
members into a single guide. Numerous department documents currently address

different areas relating to this subject. This guide would provide that all related
information is incorporated into an inclusive publication for reference.
7. Re-evaluate Firefighting Procedures Volume 1, Book 6, Private Dwellings,

Chapter 3, section 2, pertaining to first due Engine and Ladder Company
operations at cellar fires in private dwellings having an exterior cellar entrance.

8. Amend Firefighting Procedures Volume 1, Book 6, Private Dwellings, Chapter 5


section 1.2.B, by adding the following: "Type and location of interior stairs."
This added information would provide the Incident Commander with a
description of the layout and unusual configurations that may hinder operations.

9. Re-emphasize that the first due Ladder Company Outside Team must perform a
quick exterior survey and notify their Officer and Incident Commander of the

conditions found, coordinate VES with the Inside Team, and vent the fire
area/room when ordered. This information is contained in Firefighting Procedures
Private Dwellings.

10. Equip each Ladder, Rescue and Squad Company with an additional SCBA to be
taken by the unit assigned or designated as the FAST Unit. This will provide a
dedicated and readily available air supply for the distressed member.

11. Amend AUC 320, FIREFIGHTER ASSIST AND SEARCH TEAM - FAST
UNIT, to specify member assignments. This should include designating a
member to ensure that the distressed member has an adequate air supply.

12. Re-emphasize the importance of the FAST Unit bringing the full complement of
FAST tools and equipment to the Command Post or Operations Post.

Page 36 of62



13. Reinforce to all members the need to maintain building entrances and stairways
unimpeded. Stairway Management must be conducted at all operations for the
safety of members and effective operations. Every level of command has a
responsibility to ensure that the stairs are not overcrowded and can be rapidly
used as either a means of egress or access in case of an emergency. They are not

to be used as staging areas.
To alleviate overcrowding on stairways:

Chief Officers should assign only the units or members necessary to
accomplish a task. They shall ensure that companies maintain operational
discipline.

Company Officers must control members to ensure that they do not
impede access or egress on a stairway or at a building entrance. They

shall ensure that members maintain operational discipline.

Firefighters on a stairway must be conducting active operations. Standing
fast on a stairway is dangerous and unacceptable.


14. Re-emphasize that handie-talkie transmissions must be concise and directed to
specific members or units. Unacknowledged transmissions must be regarded as
not being received, and will need to be retransmitted. If handie-talkie
communications cannot be established, consider using alternate means such as
sending a member with the message.

15. Re-emphasize to all Chief Officers the importance of transmitting preliminary and

progress reports as required by the Communications Manual. When a Battalion
or Division is not staffed with a regularly assigned or trained Firefighter, the
Chief Officer must ensure these vital communications are transmitted.
16. Battalion and Division Commanders must ensure that units in their command are
staffed with an appropriate number of Firefighters trained to work as Battalion

and Division Firefighters.

Page 37 of62

17. Re-emphasize the importance of notifying the dispatcher when the FAST Unit is
put to work. This notification will ensure that the dispatcher immediately assigns

another FAST Unit.


18. Develop and issue documentation regarding the proper use and maintenance of
the frrefighting helmet and the proper use of the chinstrap. The use of the helmet

chins trap should be mandatory during operations. Failure to properly utilize all
PPE can result in serious consequences affecting operations as well as a members'
personal safety. It is the Officer's responsibility to ensure that a member wears

PPE, but it is the member's responsibility to wear the PPE correctly.


19. Research and/or develop a drag rescue device that can be incorporated into the
present PPE to assist in the removal of incapacitated members.

20. Amend Safety Bulletin 84, Window Bars, section 4, to include the following
sentence: "An Engine on the scene or a special called Engine could provide an

exterior hose line to protect civilians or members trapped behind the window bars
inside the building or members removing the window bars. "
21. All Unit Circular 314, Incident Command and Safety Investigations, to

incorporate appropriate subsections of sections 5, 6, 7, and 9 of All Unit Circular
317, Ciime Scene Operations,.to ensure the frre scene is immediately secured and
properly documented. The proper safeguarding of the fire scene and equipment is

essential to a thorough investigation of serious firefighter injuries or fatalities.


22. Expand the training program titled, "CellarlUnconscious Firefighter Removal"
that is currently being piloted by Division 13 to all Divisions. This program

provides hands-on training in the removal of an unconscious member. This drill
is conducted in quarters for on duty members in full frrefighting gear. During the
course of this drill, members stretch hose lines, utilize the thermal imaging

camera to locate the simulated frre and search for a downed member. The
member is then packaged and removed.
Page 38 of 62



23. Reinforce to all members of the Department the dangers of carbon monoxide.
Removing the SCBA facepiece in a contaminated atmosphere is extremely
hazardous. Emphasis should be placed on the extremely short exposure time
necessary to receive an incapacitating or lethal dose.

24. The Bureau of Fire Prevention should work with the Department of Buildings to
implement an effective procedure to ensure the administrative company is notified
when a building is constructed or renovated using lightweight wood I beam

construction. Units notified of such conditions must evaluate the hazard and
submit a cms card.






Page 39 of 62