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FIRE DEPARTMENT OF CITY OF NEW YORK

SAFETY AND INSPECTION SERVICES COMMAND


INVESTIGATIVE REPORT
BROOKLYN BOX 22-3762
1700 BEDFORD AVENUE
JANUARY 3, 2008 CASE NUMBER SB 01108 FATAL INJURY LIEUTENANT JOHN H. MARTINSON
ENGINE COMPANY 249

VOLUME I
THE INVESTIGATION

I.

SUMMARY

On Thursday, January 3, 2008, at 1914 hours, the New York City Fire Department's Brooklyn Communications Office received a telephone alarm reporting a fire in apartment 14M at 1700 Bedford Avenue. Brooklyn Box 3762 was transmitted at 1915 hours. The initial Engine

response was three Engine Companies, two Ladder Companies and one Battalion.

Company 249 and Ladder Company 113 arrived at 1918 hours and proceeded to the 14th floor. The Engine Company 249 Officer, Lieutenant John H. Martinson, requested Battalion 38 to transmit a 10-75 signal after observing a heavy smoke condition in the 14th floor hallway. Battalion 38 transmitted a 10-75 signal at 1921 hours followed by a 10-77 signal at 1923 hours. Standard firefighting operations were initiated for a fire in a high-rise, fireproof, multiple dwelling. The fire building was a 25 story, fireproof (Class 1), multiple dwelling that was part of a seven building complex known as the Ebbets Field Apartments. The building complex was constructed in 1962 and occupied one city block. The dimensions of the building complex were feet by 637 feet. The fire originated in the bedroom of apartment 14M. The occupants left apartment door open when they exited the apartment. The fire caused the bedroom windows fail. These factors in conjunction with a northwest wind created a heavy smoke condition in

Lieutenant John H. Martinson of Engine Company 249 was found unconscious in 14M at 1943 hours. He was removed from the building and transported by Fire of New York (FDNY) Emergency Medical Service (EMS) to Kings County Hospital

that Lieutenant John Martinson's cause of death was smoke As a result of the investigation into this fatality, the Safety and Services Command makes the following recommendations:

Strictly enforce proper Self Contained Breathing Apparatus (SCBA) usage.


All members should be aware of the location and well being of other team members,
including their Officer.
Re-emphasize the importance of the proper use of the firefighting helmet chinstrap.
Page 1 of 88

4.

Re-emphasize the need for Engine Companies to team up for the duration of the operation.

5.

Continue to evaluate the implementation of positive pressure ventilation and use of wind control devices as initial operational tactics for fires in high-rise fireproof multiple dwellings.

6.

Revise and issue Firefighting Procedures "Multiple Dwelling Fires", section 6, Class A Fireproof Multiple Dwelling Fires as a separate volume.

7.

Implement a fire safety education campaign to educate the public on the importance of closing the fire room door and not obstructing self-closing doors.

8.

The Command Channel and the Post Radio should be utilized at high-rise multiple dwelling fires whenever a 10-77 signal has been transmitted.

9.

Emphasize the importance of maintaining radio discipline during MAYDA YIURGENT situations.

10.

Re-emphasize that handie-talkie transmissions should be concise and direct. Handie talkie transmissions should be made using the unit designation and assigned position.

11.

Train all members to be proficient in roll call procedures as per Communications Manual Chapter 9, Addendum 2, "Emergency Roll Call Procedures."

SECTIONB

Although the following did not have an impact on this incident, the Department should consider these recommendations to improve safety and efficiency at future operations: 12. Hard copies of important information, such as numerous apartments with occupants in distress, should be sent via Mobile Data Terminal (MDT) in addition to notification on the Department radio. 13. Emphasize the importance of reacting to a Personal Alert Safety System (PASS) Alarm signal sounding during operations. 14. 15. The CADS should reflect when a Division or Battalion is staffed by an Acting Chief. Ensure scissor stairs are properly labeled whenever inspecting or operating in buildings serviced by scissor stairs. 16. Establish an education and training program to present units in the field with the findings and recommendations found in Fatal Fire Investigations.

Page 2 of 88

IV. FDNY OPERATIONS

On Thursday, January 3, 2008 at 1914 hours, the New York City Fire Department's Brooklyn Communications Office received a telephone alarm reporting a fire in apartment 14M at 1700 Bedford Avenue, the Ebbets Field Apartments. transmitted and the following units were assigned to respond: At 1915 hours Box 3762 was

Engine Company 249 Ladder Company 113 Engine Company 280 Ladder Company 132 Engine Company 234 Battalion 38

Engine Company 234 was assigned on the initial alarm as per the Critical Information Dispatch System (CmS). The CIDS information was as follows: MD 25STY 200X150 CLI- 4 LENGTHS HOSE NEEDED-STAIR A HAS STDP-OS&Y VALVE 16 FL APTS A,B,E,F,N&O HAVE BALCONIES- LONG DEAD END HALLS- MINRESP 32 On the evening of January 3,2008 at 1900 hours the National Weather Service at John F. Kennedy International Airport reported a temperature of 18 degrees Fahrenheit and wind from the north-northwest at 15 miles per hour. At the time of the fire, Brooklyn Poly-Tech University was conducting tests on the roof of Fire Department headquarters, 9 MetroTech Center in Brooklyn. From 1920 hours to 1945

hours they reported a temperature of 18 degrees Fahrenheit with an average wind speed of 11
miles per hour from the northwest, with gusts up to 20 miles per hour.

Page 19 of 88

Photo 11 Ebbets Field Apartments


The Ebbets Field Apartments were a seven building complex arranged in an H shape. The buildings were attached but were not interconnected. The complex contained a total of 1,321 apartments. The fire was located in 1700 Bedford Avenue, the center building of the complex. The fire building was a 25 story multiple dwelling of Class I fireproof construction consisting of steel, brick, concrete, gypsum board and plaster. This building contained 16

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apartments on each floor. There were six 2-bedroom apartments, six I-bedroom apartments and four studio apartments on each floor. The fire apartment (14M) was a one-bedroom apartment on the 14th floor. The building had four elevators that served all floors. Windows in the fire apartment were doubled paned glass and faced west. The public hallway was in the shape of a cross, which measured 131 feet by 53 feet and was 4 feet wide except for the elevator lobby, which was approximately 8Yz feet wide. The distance from stairway A (attack stairway) to the fire apartment door was approximately 60 feet (See Diagram 3). Page 20 of88

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FII

Diagram 3
Floor Plan of Center Building, 1700 Bedford A venue
All floors in the fire building were served by three stairways. The stairway doors were Stairway A was a return type stairway that contained the only standpipe The other two stairways were scissor type stairs. The scissor type stairs labeled incorrectly. The stairway door lettering of the scissor type stairs did not alternate floor to floor properly (See Diagram 4).
(TI-lROUGHOUT TI-lIS REPORT STAIRWAYS BAND C

REFERRED TO AS TI-lEY WERE LABELED ON TI-lE DOOR TO EACH STAIRWAY AT THE TIME OF THE

Page 21 of 88

4th

floor

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B
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4th floor

3rd floor

====.

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.+

.. B

2nd floor

==== ..

B.

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.... B

3rd floor

1st floor

====..

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~. C B 2nd floor ====.. .~e==== \;

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1st floor

Scissor Stairs labeled correctly

Scissor Stairs as labeled


at 1700 Bedford Avenue

Diagram 4 Scissor Stairs


The exposures of the complex were designated as follows: Exposure #1 Bedford Avenue Exposure #2 Sullivan Place Exposure #3 McKeever Place Exposure #4 Montgomery Street

The lobby entrance to 1700 Bedford Avenue was located on the concourse level. The concourse was an area one story above grade level from Bedford Avenue. The Bureau of Fire Investigation determined the cause of the fire to be accidental. The fire was started by a six-year-old child igniting combustible packaging material on the open flame of the kitchen stove. The child took the flaming material into the bathroom where he tried to extinguish the fire. He was unable to extinguish the fire and the bathroom rug ignited. The child then brought the flaming material to the bedroom and placed it under the bed nearest the window (See Diagram 5). He left the bedroom and closed the door but did not tell his mother what had occurred. The burning material ignited the bed. When the mother became aware of the Page 22 of 88

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fire she attempted to extinguish the fire, but was unable to. The occupants fled the apartment leaving the door partially opened. A piece of cloth used as a draft stop at the bottom of the door, in combination with the carpeting in the room prevented the door from self closing.

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DiagramS Apartment 14M


INITIAL OPERATIONS

The first units on the initial alarm arrived in two minutes and 41 seconds. All Engine Companies on the initial alarm were staffed with five Firefighters. While responding, Battalion 38 was notified by the Brooklyn Dispatcher of additional phone calls reporting smoke on the 14th floor and in apartment 14A. Engine Company 249 and Ladder Company 113 arrived at 1918 hours and proceeded to the concourse level of 1700 Bedford Avenue. When the Engine Company 249 Officer,

Lieutenant John Martinson, arrived in the lobby, he used Firemen Service to recall the elevators. the first elevator arrived in the lobby, the Engine Company 249 members smelled smoke. John Martinson and the members of Engine Company 249, exclusive of the Page 23 of88

Chauffeur, entered that elevator.

The members of Ladder Company 113, exclusive of the

Chauffeur, entered the lobby and conferred face-to-face with the members of Engine Company 249. The Engine Company 249 members then took the first elevator to the Ith floor. The Ladder Company 113 members took the second elevator to the 12th floor. The Ladder Company 113 Outside Ventilation Firefighter operated this elevator in Firemen Service for the duration of the fire. The 2nd due units, Engine Company 280 and Ladder Company 132, arrived at 1700 Bedford Avenue at 1919 hours. Squad Company 1 was at the quarters of Engine Company 280 and Ladder Company 132 when the Box was transmitted. Squad Company 1 was not part of the initial response assignment, but proceeded in the direction of 1700 Bedford Avenue when the Brooklyn Dispatcher reported receiving additional phone calls for smoke on the 14th floor. Squad Company 1 arrived at 1700 Bedford Avenue at approximately 1920 hours, just behind Engine Company 234 and Battalion 38. Lieutenant John Martinson and the members of Engine Company 249 exited the elevator on the 12th floor. They then ascended stairway A to the 13th floor. Lieutenant John Martinson placed the standpipe kit on the 13th floor by the standpipe outlet and proceeded to the 14th floor. The members of Engine Company 249 prepared to connect their four lengths of 2Y2" hose to the 13 th floor standpipe outlet in stairway A. When Lieutenant John Martinson opened the 14th floor stairway door he encountered a heavy smoke condition. Lieutenant John Martinson called

Battalion 38 at 1921:05, and transmitted via handie-talkie, "You can give a 10-75; we've got a

heavy smoke condition on the 11h floor."


The Engine Company 249 Nozzle Firefighter verbally informed Lieutenant John Martinson that the M apartment was three doors down on the left. Lieutenant John Martinson acknowledged, donned the facepiece of his SCBA and entered the public hallway on the 14th floor at approximately 1922 hours. (mIS WAS mE LAST TIME LIEUTENANT JOHN MARTINSON WAS
SEEN OR HEARD FROM, ornER mAN VIA HANDlE-TALKIE, UNTIL HE WAS FOUND UNCONSCIOUS IN THE FIRE APARTMENT, TWENTY ONE MINUTES LATER AT 1943 HOURS.)

The Ladder Company 113 Inside Team and Roof Firefighter heard Lieutenant John Martinson transmit the 10-75 via handie-talkie after they exited the elevator on the Ith floor. The Battalion 38 Firefighter transmitted a 10-75 to the Brooklyn Dispatcher at 1921:38. On receipt of the 10-75 signal, the Brooklyn Dispatcher assigned the following units:

Page 24 of88

Squad Company 1 (already at the scene and operating as ordered by Battalion 38) Engine Company 248 Ladder Company 123 - Firefighter Assist and Search Team (FAST Unit). Rescue Company 2 Battalion 41

Division 15 was notified of the 10-75 and directed the Brooklyn Dispatcher to assign Division 15 to the Box. Battalion 38 called Lieutenant John Martinson via handie-talkie in order to verify the CIDS information on the response ticket and to determine the attack stairway. Lieutenant John Martinson replied, "10-4 Chief." Battalion 38 made a handie-talkie transmission to all units that the hallways are in the shape of a cross and not a T (See Diagram 3). While on the concourse level, prior to entering the building, the Ladder Company 132 Officer notified Battalion 38 via handie-talkie of a heavy wind condition. The Ladder Company 132 Inside Team and Outside Ventilation Firefighter then entered the lobby. At 1922 hours Battalion 38 ordered Ladder Company 132's Officer to check the compactor shaft for possible fire.
(THE EBBETS FIELD APARTMENTS HAD A HISTORY OF COMPACTOR FIRES.)

The initial call reported a fire in apartment 14M. As the Ladder Company 113 Inside Team passed the 13 th floor, the Ladder Company 113 Officer ordered the Ladder Company 113

Can Firefighter to check the l3 th floor for the M line of apartments. The Ladder Company 113
Officer recalled hearing that the fire apartment was one door down and to the left. There was a heavy smoke condition when the Ladder Company 113 Inside Team arrived on the 14th floor landing. At approximately 1923 hours, the Ladder Company 113 Inside Team donned their SeBA facepieces and entered the public hallway. Engine Company 249 members continued to connect their hoseline to the 13th floor standpipe outlet and flake out the hoseline in the 13th floor public hallway. Engine Company 280 members arrived on the 13th floor at approximately 1923 hours and began assisting Engine Company 249 with their hoseline. Engine Company 280 helped flake the hoseline in the public hallway on the 13 th floor and up stairway A to the 14th floor. The Engine Company 280 Control Firefighter flushed out the standpipe outlet on the 1t h floor in preparation for a second hoseline. As Engine Company 234 made their way to the 12th floor, the Officer received a transmission via handie-talkie from Battalion 38 to ensure the first hoseline was in operation and then to check the layout of the floor below. Page 25 of88

At 1923 hours Battalion 38 transmitted a 10-77 to the Brooklyn Dispatcher and reported stairway A as the attack stairway. The following units were dispatched: Ladder Company 105 Ladder Company 111 Engine Company 219 - Certified First Responder-Defibrillator (CFR-D) Battalion 48 Battalion 37 - Safety Officer Safety Battalion 1 Field Communications Unit Rescue Battalion
(

At 1924 hours, Engine Company 249' s 2W' hoseline was connected to the standpipe outlet on the 13 th floor. The hoseline was flaked out in the 13th floor public hallway and up stairway A to the 14th floor stairway door. At 1924:12 Lieutenant John Martinson transmitted,

"249, charge the line in the ... "


AS,

(NUMEROUS MEMBERS REPORTED HEARING TIllS TRANSMISSION

"249, CHARGE TIlE

LINE IN TIlE STAIRWAY.")

The Engine Company 249 Control Firefighter

acknow ledged that the hose line was being charged. After Engine Company 249's hoseline was charged in the stairway, the Engine Company 280 Officer anticipated that there might be a need for a second hoseline on the fire floor. He directed a member of Engine Company 280 to start a second hoseline. Two members of Engine Company 280 connected their hoseline to the Ith floor standpipe outlet. Other members of Engine Company 280 remained with the first hoseline. The Ladder Company 113 Inside Team, after entering the 14th floor public hallway, proceeded left toward the hallway intersection. The Ladder Company 113 Forcible Entry

Firefighter continued past the intersection to the stairway door labeled B. The Ladder Company 113 Officer and Ladder Company 113 Can Firefighter made a left at the intersection and continued down the short public hallway to apartments 14J and 14K (See Diagram 3). The Ladder Company 113 Officer knocked on both apartment doors. apartments answered the door, opening it only slightly. A tenant in one of the

The tenant informed the Ladder

Company 113 Officer that the M apartment was down the public hallway and to the left. They proceeded back to the intersection to search for the M apartment. The visibility in the public hallway was zero and the heat condition was intensifying. The Ladder Company 113 Officer and Ladder Company 113 Can Firefighter met up with the Ladder Company 113 Forcible Entry Page 26 of 88

Firefighter at the stairway door labeled B.


APPROXIMATEL Y 1924 TO

(TIlE PRECEDING EVENTS OCCURRED FROM

1927 HOURS.)

At approximately 1924 hours the Ladder Company 113 Chauffeur took an elevator to the
12th floor with members of Ladder Company 132.

The Ladder Company 132 Outside

Ventilation Firefighter operated this elevator in Firemen Service. The Ladder Company 113 Chauffeur then entered the stairway door labeled B to ascend to the roof. The Ladder Company 132 Officer was informed by a member of Engine Company 249 that members of Ladder Company 113 were searching to the left. The Ladder Company 132 Inside Team entered the 14th floor public hallway from stairway A and began to search to the right. The Squad Company 1 Inside Team arrived on the 12th floor at approximately
1924 hours and made their way up stairway A to the 14th floor.

The Squad Company 1

Chauffeur observed flaming debris at the concourse level on the exposure #3 side of the building.
(THE INVESTIGATION REVEALED TIlAT TIlE DEBRIS WAS AN AIR CONDmONER WHICH HAD FALLEN FROM TIlE BEDROOM OF TIlE FIRE APARTMENT.)

The Squad Company 1 Chauffeur observed fire venting out two windows on the 14th floor. He then entered the building carrying a Fire Window Blanket. The Squad Company 1 Chauffeur left the Fire Window Blanket in the lobby and took an elevator to the 1i h floor. After Engine Company 249' s hoseline was charged, the Engine Company 249 Nozzle and Back-Up Firefighters prepared to advance into the public hallway. The smoke condition in stairway A made it difficult to find the closed stairway door. When the stairway door was located and opened, the Engine Company 249 Nozzle Firefighter was in a position behind the door and was unable to enter the public hallway. In order to advance the hose line the Engine Company 249 Back-Up Firefighter took the nozzle and moved into the public hallway.
THIS POINT ON, ENGINE COMPANY AND TIlE ENGINE COMPANY (FROM

249 BACK-UP FIREFIGHTER OPERATED IN TIlE NOZZLE PosmON


NOZZLE FIREFIGHTER OPERATED IN TIlE BACK-UP POSITION.

249

THROUGHOUT TIllS REPORT BOTII MEMBERS ARE REFERRED TO BY THEIR INmALLY ASSIGNED

At 1925:49 Lieutenant John Martinson transmitted via handie-talkie, "249 to Nozzle." The Engine Company 249 Nozzle and 249 Back-Up Firefighters were in the process of switching
vv.",uv"

and advancing the charged 2W' hoseline into the public hallway and did not respond.

Engine Company 249 Control Firefighter made two attempts to respond to Lieutenant John These hand ie-talkie transmissions were not acknowledged by Lieutenant John Page 27 of88

Martinson. At 1926:27, Battalion 38 contacted Lieutenant John Martinson via handie-talkie and asked, "John, did we find the fire apartment yet?" Lieutenant John Martinson replied,

"Negative." Battalion 38 informed Lieutenant John Martinson that the M apartment should be to
the left of the stairway. Lieutenant John Martinson responded, "10-4 Chief." At 1926 hours, Engine Company 234 was on the 13 th floor assisting Engine Company 249 with their hoseline. The following additional companies arrived on the scene: Rescue Company 2 Ladder Company 123 - FAST Unit Engine Company 248 Battalion 41

At approximately 1927 hours the Engine Company 249 Back-Up and Nozzle Firefighters advanced the charged 2Y2" hoseline to the intersection of the public hallway. The Engine

II p

Company 249 Back-Up Firefighter called via handie-talkie for members to lighten up on the line. They were having difficulty advancing the charged hoseline. The Ladder Company 113 Inside Team and the Engine Company 249 Back-Up and Nozzle Firefighters met at the intersection of the public hallway. The Ladder Company 113 Officer used the thermal imaging camera to locate the direction of the fire apartment. The Ladder Company 113 Officer led the members down the public hallway towards the fire apartment. The Ladder Company 113 Officer notified

to

Cc

Battalion 38 via handie-talkie that they were making their way down the public hallway but had not found the fire apartment. The Engine Company 249 Chauffeur notified Lieutenant John Martinson and Battalion 38 via handie-talkie that the standpipe siamese was now being supplied. Battalion 38 acknowledged this transmission. Lieutenant John Martinson did not.
JOHN MARTINSON'S LOCATION WAS NOT KNOWN AT THIS TIME.) (LIEUTENANT

At 1927 hours Battalion 38 was on the Concourse level and made a general handie-talkie transmission to all units warning them of the wind condition.
(THE INVESTIGATION REVEALED

THAT THE FIRE INTENSITY VARIED DUE TO THE WIND CONDITIONS. AT TIMES FIRE WAS VENTING OUT THE WINDOWS OF THE FIRE ROOM AND AT OTHER TIMES FIRE WAS BEING BLOWN INTO THE APARTMENT. THE CONDITIONS IN THE PUBLIC HALLWAY ALSO VARIED. SOME MEMBERS REPORTED A MODERATE HEAT CONDmON, OTHER MEMBERS REPORTED A SEVERE HEAT CONDmON. THE

Page 28 of88

INVESTIGA TION TEAM DETERMINED THIS TO BE A WIND IMPACTED FIRE, AS OPPOSED TO A WIND DRIVEN FIRE. I)

The Squad Company 1 Roof Firefighter proceeded up stairway A to the floor above the fire. The Ladder Company 113 and Ladder Company 132 Inside Teams had not yet located the fire apartment. At 1927:51 the Squad Company 1 Officer tried to contact Engine Company 249 and tell them to hold up on bringing their hoseline down the public hallway until the fire apartment was located. At 1927:58 the handie-talkie recordings indicate that Lieutenant John Martinson's hand ie-talkie was keyed, however there was no recorded transmission.
(THE

INVESTIGATION TEAM BELIEVES LIEUTENANT JOHN MARTINSON WAS IN THE FIRE APARTMENT AND WAS ATrEMPTING TO RESPOND TO THE TRANSMISSION FROM THE SQUAD COMPANY 1 OFFICER. THERE WERE OTHER HANDIE-TALKIE TRANSMISSIONS OCCURRING AT THIS TIME. IT IS NOT KNOWN IF THESE TRANSMISSIONS PREVENTED LIEUTENANT JOHN MARTINSON FROM RESPONDING, OR PREVENTED HIS TRANSMISSION FROM BEING HEARD OR RECORDED.)

At 1928 hours the Engine Company 234 Officer contacted his members via handie-talkie and directed them to bring the second line to the 14th floor. He then descended to the 13 th floor to try to identify the fire apartment. The Officer was unaware at this time that Engine

Company 280 had already started stretching a second hoseline. While advancing the hoseline, the Engine Company 249 Back-Up Firefighter observed fIre rolling across the public hallway ceiling in the area between apartments Land M. The Engine Company 249 Back-Up Firefighter opened the nozzle, knocked down the fire and advanced the hoseline toward the fire apartment door. The Ladder Company 113 Inside Team advanced to apartment 14M and found the door open approximately one to two feet. The Engine Company 249 Back-Up and Nozzle Firefighters operated the hoseline from the public hallway into the fire apartment. At 1929: 18 the Ladder Company 113 Officer transmitted to Battalion 38 that they found
the fire apartment. Battalion 38 notified the Ladder Company 113 Officer that the fire was out the windows on the 14th floor in the rear of.the building.

wind driven fire implies a constant wind condition pressurizing the fire area. A wind impacted fire describes a condition that does not constantly pressurize the fire area. The variable wind conditions cause the heat, smoke fire to fluctuate in direction and intensity in the fire apartment and public hallway.

Page 29 of88

c
Diagram 6 Apartment 14 M Note: Red Lines in the Bedroom Indicate the Fire Area.
(OVER TIlE NEXT SEVERAL MINUTES,

OJ

th

1929 TO 1931 HOURS, TIlERE WERE SEVERAL ATTEMPTS TO

VERIFY TIlE FIRE APARTMENT DESIGNATION.)

At 1930 hours, the Engine Company 234 Officer was in apartment 13K and transmitted that the fire was in apartment 14K directly above him. At this time, the Squad Company 1 Chauffeur was in apartment 13L. He looked out the window and believed the fire was directly above him in apartment 14L. Due to the conflicting reports about the location of the fire

as

ap

La

apartment, the Squad Company 1 Chauffeur did not want to add to the confusion by reporting this to Command. At 1931 hours, the Squad Company 1 Roof Firefighter in apartment 15M, reported to Command that the fire was right below him in apartment 14M. Command acknowledged this transmission and indicated the fire location would still have to be verified due to the conflicting reports he had received. (THE INFORMATION FROM TIlE SQUAD COMPANY 1 ROOF FIREFIGHTER
PROVED TO BE ACCURATE.)

Page 30 of 88

The Ladder Company 132 Inside Team continued to search the public hallway to the right of stairway A. extremely hot. Some of the members of Engine Company 280 stood fast in stairway A on the 13 th floor with an uncharged hose line while the other members continued to assist with the first hoseline. They were not sure if the second hose line would be required on the fire floor or the floor above. Members of Engine Company 234 were dispersed between the 13 th and 14th floors in stairway A assisting Engine Company 249 with the first hoseline. Engine Company 248, the 4th due Engine Company, entered an elevator in the lobby and proceeded to the 1th floor. The Ladder Company 113 and 132 Chauffeurs entered the stairway door labeled B on the 12th floor and ascended to the roof. When they arrived on the roof, they found the bulkhead door of the attack stairway, stairway A, already opened. There were approximately 10 civilians who had self evacuated to the roof. The bulkhead doors to the evacuation stairways, labeled B and C, were closed. There was a heavy smoke condition in both the Band C stairways. The Ladder Company 113 and 132 Chauffeurs vented the bulkhead doors of stairways labeled Band C. Battalion 41 made his way up to the fire floor to assume command of fire floor operations. Battalion 38 informed Battalion 41 via handie-talkie of the identity of the units that were operating in the building, and that he had ordered Ladder Company 123, the FAST Unit, to the 13th floor. Battalion 41 arrived on the 14th floor at approximately 1931 hours. He reported from stairway A that the hose line was advancing. The FAST Unit, Ladder Company 123, had taken an elevator to the 11th floor, then ascended stairway A to the 13 th floor. They familiarized themselves with the building layout and apartment locations on the 13 th floor. There was a heavy smoke condition on the 15 th floor. While searching this floor, the Ladder Company 132 Roof Firefighter entered an open smoke filled apartment and found an nine year old girl. She was having difficulty breathing so he placed his SCBA
lacc~pH~ce

The Ladder Company 132 Officer stated that the public hallway was

on her face and removed her from the apartment. He brought her down to the lobby an elevator from the 15th floor. At 1932 hours the Squad Company 1 Roof Firefighter reported to Command that fire threatening to extend to apartment 15M. He requested a fire extinguisher or a hoseline be to apartment 15M. The Squad Company 1 Chauffeur was in the public hallway at the to apartment 14L, which he believed was the fire apartment. Members operating on the fire Page 31 of 88

floor and in the fire apartment were not able to determine and verify the fire apartment designation due to the severe conditions on the fire floor. The Engine Company 249 Back-Up Firefighter had been operating the nozzle from the entrance to the fire apartment. The Ladder Company 113 Officer entered the fire apartment followed by the Engine Company 249 Back-Up Firefighter with the nozzle. There was no visibility and a high heat condition. The Engine Company 249 Back-Up Firefighter was

directing the stream into the living room area. The Engine Company 249 Nozzle Firefighter assisted on the hoseline just outside the fire apartment. The Ladder Company 113 Forcible Entry and Can Firefighters were in the public hallway just outside the fire apartment door. The Engine Company 249 Control Firefighter was in the public hallway on the 14th floor assisting with the hoseline advance. The Engine Company 249 Door Firefighter had lost his helmet in the public hallway while advancing the hoseline. He was unable to locate his helmet. His head was exposed to the high heat and hot water forcing him to evacuate into the stairway door labeled B
I

on the 14th floor. At 1933 hours Division 15 arrived on the scene and assumed command. Battalion 38 called Lieutenant John Martinson on the handie-talkie at 1933:04. The Battalion Handie-Talkie Recorder indicated that Lieutenant John Martinson's handie-talkie was keyed at 1933:09, but there was no recorded transmission.
(THE INVESTIGATION TEAM BELIEVES LIEUTENANT JOHN

MARTINSON WAS IN THE FIRE APARTMENT AND WAS ATTEMPTING TO RESPOND TO BATTALION

38.

THERE WERE OTHER HANDlE-TALKIE TRANSMISSIONS OCCURRING AT THIS TIME. IT IS NOT KNOWN IF THESE TRANSMISSIONS PREVENTED LIEUTENANT JOHN MARTINSON FROM RESPONDING, OR PREVENTED HIS TRANSMISSION FROM BEING HEARD OR RECORDED.)

At approximately 1934 hours Ladder Companies 105 and 111 were assigned to search the floors above the fire due to multiple phone calls reporting smoke throughout the building. The Ladder Company 132 Roof Firefighter arrived in the lobby with the civilian he removed from the 15 th floor. Engine Company 219, the CFR-D Engine, was just entering the lobby and treated the civilian. When EMS Unit 31C arrived in the lobby, the patient was transferred to their care. At 1934 hours the Squad Company 1 Roof Firefighter was still in apartment 15M on the floor above the fire. The fire caused the outer panes of the windows to crack and flames were visible at the air conditioner sleeve. He called Command a second time and requested a hoseline because the fire was threatening to extend to apartment 15M. Page 32 of 88

By approximately 1934 hours the Engine Company 249 Back-Up Firefighter had advanced the hoseline four to six feet inside the apartment. The Ladder Company 113 Officer was located immediately to the right of the nozzle. The Ladder Company 113 Officer

repositioned to the left of nozzle. He realized the fire was to the left and ordered the hose stream operated in that direction. The Engine Company 249 Nozzle Firefighter moved up on the

hose line to a position about three feet inside the fire apartment door. The Ladder Company 113 Forcible Entry Firefighter was just inside the apartment door. The Ladder Company 113 Can Firefighter was located just outside the fire apartment door (See Diagram 7). The Squad Company 1 Chauffeur and Hook Firefighters were operating under the belief that the fire was in apartment 14L. They were unaware of the fire conditions in apartment 14M. Before forcing the door to apartment 14L they wanted the protection of a charged hose line. The Squad Company 1 Hook Firefighter went to apartment 14M to get Engine Company 249 to reposition the hoseline to apartment 14L. This hoseline was already operating in apartment 14M, so he returned to the L apartment without the hoseline.

Page 33 of88

t1

--------

---t

. - L-113 Officer . - L-l13 Forcible Entry Firefighter

e-

L-113 Can Firefighter E-249 Back-Up Firefighter

. - E-249 Nozzle Firefighter


~ Arrows

indicate hoseline

Diagram 7 Approxinlate Location of Members in Apartment 14M at 1935 Hours. At This Time Lieutenant John Martinson's Location Within the Apartment Was Unknown
Due to the size of the building, the multiple phone calls reporting smoke throughout the building, and the report of possible fire extension to the floor above, Battalion 38 ordered the transmission of a 2nd alarm. The 2nd alarm was transmitted to the Brooklyn Dispatcher at 1935 hours. The following units were assigned: Page 34 of88

Engine Company 235 Engine Company 220 Engine Company 214 Engine Company 207 - Satellite 6 Rehabilitation and Care Unit 2 Tactical Support Unit 2 Engine Company 240 Battalion 57

At 1938 hours the following Ladder Companies were manually selected and assigned by the Dispatcher: Ladder Company 157 Ladder Company 120

(DURING THE NEXT SEVERAL MINUTES NUMEROUS HANDlE-TALKIE TRANSMISSIONS WERE MADE. 1WO OF THESE HANDlE-TALKIE MESSAGES PERTAINED TO MEMBERS RUNNING OUT OF AIR. THERE WERE ALSO VERBAL REPORTS BY MEMBERS ON THE AIR. BATTALION

14TH FLOOR OF A MEMBER RUNNING OUT OF

41 TRANSMITTED AN URGENT MESSAGE VIA HANDlE-TALKIE TO BATTALION 38 2 TO LOCATE THE

THAT A MEMBER WAS OUT AIR AND THAT HE DIRECTED RESCUE COMPANY MEMBER.)

Battalion 38 transmitted to Engine Company 234, "Do you have the second line up on

fifteen?" Engine Company 234 Officer answered, "Negative." Battalion 38 was unaware that
Engine Company 280 had stretched a second hose line and Engine Company 234 was now backing up Engine Company 249. At 1935:26 the Ladder Company 113 Officer called the Ladder Company 113 Forcible Entry Firefighter on the handie-talkie and asked, "Are you OK?" The Ladder Company 113 Forcible Entry Firefighter transmitted, "Yeah, I'm running out ofair, (unintelligible) up here." The Ladder Company 113 Officer transmitted at 1935:51, "113 to Irons and Can, back out

we're running out of ... "

(THE FORCIDLE ENTRY FIREFIGHTER IS ALSO KNOWN AS THE IRONS

At approximately 1936 hours, the Ladder Company 113 Forcible Entry Firefighter was just inside the fire apartment door when his air supply was depleted. As he exited the fire apartment he removed his SCBA facepiece and yelled he was out of air. The smoke and heat
...v ..'......." .."

in the public hallway were severe. The Ladder Company 113 Can Firefighter was just Page 35 of88

outside of the fire apartment and assisted the Ladder Company 113 Forcible Entry Firefighter down the public hallway toward the stairway. The Engine Company 249 Back-Up Firefighter was unable to direct the stream onto the main body of fire in the bedroom or advance in that direction. The immediate area inside the fire apartment was now becoming extremely hot. The Engine Company 249 Back-Up Firefighter described the conditions in the fire apartment as sudden waves of intense heat and bright white orange light coming from the bedroom fire area. The vibralert of the Engine Company 249 Back-Up Firefighter activated and the Ladder Company 113 Officer directed the Engine 249 Back-Up Firefighter to exit the fire apartment with him. The Ladder Company 113 Officer started to leave and was hit in the face with the hose stream. The hose stream displaced his facepiece and dislodged his helmet. He dropped the thermal imaging camera and hand light and moved behind the Engine Company 249 Back-Up Firefighter to readjust his facepiece and put his helmet back on. After the blast of heat subsided, the Engine Company 249 Back-Up

Firefighter shut down the nozzle and turned to his right. He reported placing the nozzle against the left shoulder of a member as he quickly exited the apartment. He was unable to identify this member.
(NO MEMBER INTERVIEWED BY THE INVESTIGATION TEAM REPORTED RECEIVING THE

NOZZLE. LIEUTENANT JOHN MARTINSON'S LOCATION WITHIN TIlE FIRE APARTMENT WAS UNKNOWN AT THIS TIME.)

As the Engine Company 249 Back-Up Firefighter and the Ladder Company 113 Officer rapidly exited the fire apartment, they each collided with the Engine Company 249 Nozzle Firefighter. The Engine Company 249 Nozzle Firefighter reported one member striking him on the right side and then another member striking him on the left side. He was knocked over and pushed into the public hallway with his helmet and SCBA facepiece becoming dislodged. As the Ladder Company 113 Officer exited the fire apartment he observed the nozzle in a closed position on the floor. The Engine Company 249 Nozzle Firefighter moved to the area between the fire apartment door and the dead end of the public hallway between the M and N apartments. He adjusted his SCBA facepiece and helmet and began to exit toward the stairs. As he passed the fire apartment door he heard water flowing from the hose line inside the apartment but was unaware if anyone was in the apartment. His vibralert had activated, so he continued to exit by following the hoseline toward the stairway A.

Page 36 of88

- L-113 Officer - L-l13 Forcible Entry Firefighter - L-l13 Can Firefighter - E-249 Back-Up Firefighter - E-249 Nozzle Firefighter

Diagram 8
14th Floor Hallway at 1937 Hours
Approximate Location ofL-113 Inside Team and
E-249 Back-Up and Nozzle Firefighters

(OllIER MEMBERS WERE IN THE PUBLIC HALLWAY AT THIS TIME BUT ARE NOT SHOWN IN THIS

DIAGRAM.)

As the Engine Company 249 Back-Up Firefighter exited toward stairway A, he collided with other members in the public hallway. He was completely exhausted, lost his balance, and fell several times as he followed the hoseline back to stairway A. The Ladder Company 113 exited behind the Engine Company 249 Back-Up Firefighter. Page 37 of88

The Ladder Company 113 Forcible Entry Firefighter was out of air and in distress in the public hallway when the Ladder Company 113 Can Firefighter assisted him through the stairway door labeled B on the 14th floor. They descended to the 13 th floor stairway landing. At 1937:28 the Ladder Company 113 Can Firefighter transmitted a request via handie-talkie for EMS on the 13 th floor. Members in the public hallway on the fire floor were unaware that the member who was out of air had reached the safety of the 13 th floor. They were shouting through their donned facepieces about a member who was out of air. These shouts were heard by Battalion 41 who was in stairway A. At 1937:37 Battalion 41 transmitted a message via handie-talkie to Battalion

38, "I got a guy screaming he's got no air. Ijust sent Rescue in to find him." At this time, the
high heat, heavy smoke and flue like conditions in the public hallway hampered operations severely. Members in stairway A were not aware of who was exiting the fire floor via the other stairways. This complicated the process of accounting for members. The Engine Company 249 Door Firefighter was unaware of the location of the other members of his unit. Without his helmet he re-entered the public hallway from the stairway door labeled B on the 14th floor to rejoin his unit. When he reached the fire apartment door he heard
(

the hose line operating inside. He was not able to discern if anyone was operating the hoseline. Due to the heat condition in the public hallway and the activation of his vibralert, he exited toward stairway A. Engine Company 219, the CFR-D Engine Company, arrived on the 13th floor with their CFR-D equipment and several folded lengths of 2Y2" hose. Engine Company 280 moved their uncharged hoseline to the stairway door labeled B on the 13th floor. Engine Company 234 stood fast in stairway A awaiting orders to relieve Engine Company 249. The Ladder Company 105 Inside Team continued to search stairway A from the 15th floor to the roof. The Ladder Company 105 Outside Team continued to search the evacuation stairways from the 15 th floor to the roof. Ladder Company 111 began a search of the 15 th floor. Ladder Company 123, the FAST Unit, assisted members exiting the fire floor. Battalion 38 directed Engine Company 248 to stretch a hoseline to the 15th floor. This was in response to the Squad Company 1 Roof Firefighter's report of fire threatening apartment 15M. Engine Company 248 members began stretching a hoseline from the 11th floor standpipe outlet up stairway A to the 13th floor. The hoseline then crossed over to the stairway door labeled C on the 13 th floor and continued to the 15th floor. Two members from Engine

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Page 38 of88

Company 219 added three lengths of their hose and assisted Engine Company 248 with the hoseline stretch. At 1937 hours Division 15 contacted Battalion 41 via handie-talkie to determine the location of the member who was running out of air. This transmission was not acknowledged by Battalion 41. The Squad Company 1 Hook Firefighter moved to apartment 14M for a second time to get the hose line. The Squad Company 1 Chauffeur completed forcible entry into apartment 14L. When he discovered there was no fire in apartment 14L, the Squad Company 1 Chauffeur proceeded toward apartment 14M to rejoin the Squad Company 1 Hook Firefighter. At 1938:08 Lieutenant John Martinson transmitted, "249's out of air, 249's out of air." This transmission was given rapidly and was barely audible on the Battalion Handie-Talkie Recorder. There was noticeable distress in Lieutenant John Martinson's voice. This

transmission was not heard or acknowledged by any member.

It occurred in the midst of

numerous handie-talkie transmissions that were of an urgent nature and focused on the member of Ladder Company 113 who was known to be out of air and in need of assistance.
JOHN MARTINSON HAD BEEN OPERATING L'lDEPENDENTLY SL'lCE (LIEUTENANT

1922

HOURS WHEN HE ENTERED

THE PUBLIC HALLWAY. HIS LOCATION WAS NOT KNOWN TO OPERATING MEMBERS UNTIL HE WAS FOUND UNCONSCIOUS JUST L'lSIDE THE FIRE APARTMENT AT

1943 HOURS.)

The Ladder Company 113 Officer exited the public hallway into stairway A. He was unaware of the location of his Forcible Entry and Can Firefighters who had already exited the public hallway via the stairway door labeled B on the 14th floor. The Ladder Company 113 Officer called the Ladder Company 113 Forcible Entry and Can Firefighters numerous times via handie-talkie to come to the stairway. At 1938:34 Battalion 41 who was in stairway A transmitted, "1131nside Team come on

out to the stairwell." There was no response to this transmission. At 1938:52 Battalion 41
transmitted, "41 to 1131nside Team. 1 want you outside the apartment." Ladder Company 113 Officer answered, "10-4, 1 just made it to the stairway."
(THE ATTACK AND EVACUATION

STAIRWAYS WERE CONGESTED Wfrn MEMBERS. DUE TO MEMBERS EXITING THE FIRE FLOOR FROM DIFFERENT STAIRWAYS THERE WAS A GREAT DEAL OF CONFUSION CONCERNL'lG THE LOCATION OF TIlE MEMBERS FROM LADDER COMPANY

113.)

At 1939 hours Division 15 attempted to gain control of the handie-talkie traffic. He did this in order to verify if the member who was running out of air had been located. Page 39 of 88 He

transmitted, "Command, Command to all units. Hold your messages. Command to all units,

hold your messages. Command to the 41. Do you have the guy who was running out of air? Command to the 41. Do you have the guy that was running out of air K?" At the same time
Battalion 41 and the Ladder Company 113 Officer were also trying to verify the same information. At 1940 hours Division 15 continued his efforts to contact Battalion 41 without success. Battalion 41 transmitted, "All members stay off the radio. This is the 41 Battalion. 41 to 113

Irons." The Ladder Company 113 Forcible Entry Firefighter transmitted, "113 Irons is OK in the stairway." Ladder Company 113 Can Firefighter who had returned to the fire floor
transmitted, "113 Can, I'm OK. I'm doing a search ofthe hallway." The Squad Company 1 Hook Firefighter returned to the fire apartment door and heard water flowing. He picked up the hoseline; the nozzle was open enough to cause it to start

whipping around. He pulled approximately three feet of hoseline toward him until he could hold the nozzle. He briefly operated the nozzle from the fire apartment doorway into apartment 14M and then shut down the nozzle. He started to bring the hoseline back to apartment 14L. The Squad Company 1 Chauffeur met him about five feet from apartment 14M and told him that there was no fire in apartment 14L. The Squad Company 1 Hook Firefighter felt a blast of heat on his back and then turned the hoseline toward apartment 14M. The Squad Company 1

Chauffeur backed him up as he advanced the nozzle back to the fire apartment and operated the hose line from the apartment door. At 1941 hours Battalion 41 contacted Division 15 and stated, "I got all members

accounted for at this time. All members of 113 Truck are accounted for."
Battalion 37, the Safety Officer, arrived on the 13 th floor and was advised by members of Engine Company 249 that their Officer and Control Firefighter were still on the fire floor. Battalion 37 attempted to contact the Engine Company 249 Officer via handie-talkie at 1941:43. There was no recorded response from Lieutenant John Martinson. The Engine Company 249 Control Firefighter was still in the public hallway assisting on the hoseline between apartment 14L and the fire apartment. Many members passed him in the public hallway in both directions. He was unsure of their identity. The hoseline was bowed at the end of the public hallway near apartment 14N. The Engine Company 249 Control Firefighter followed the hoseline to the end of the public hallway. He heard a handie-talkie transmission that Engine Company 249 was being relieved by Engine Company 234. His vibralert activated Page 40 of88

and he began to exit the public hallway by following the hoseline. He exited into the stairway door labeled B on the 14th floor. Engine Company 234 was assigned by Battalion 41 to relieve Engine Company 249 on the hoseline. Engine Company 234 members began to advance into the public hallway from stairway A toward the fire apartment. As the Engine Company 249 Control Firefighter was exiting the public hallway he passed the members of Engine Company 234 following the hoseline toward the fire apartment. The Squad Company 1 Chauffeur relieved the Squad Company 1 Hook Firefighter and assumed control of the nozzle. The Squad Company 1 Hook Firefighter was exhausted, low on air and proceeded to exit. The Squad Company 1 Chauffeur remained on the hoseline in the doorway of the fire apartment with his back against the door jamb. From this position he was able to direct the hose stream toward the bedroom. The Squad Company 1 Roof Firefighter had set up for a possible life saving rope rescue while in the living room of apartment 15M. He was located directly above the fire apartment and could hear water hitting the living room windows of apartment 14M. These windows were still intact; he could see water from the hose stream being forced out of the window jambs and the air conditioner sleeve. At 1942 hours the Squad Company 1 Roof Firefighter gave direction to the members operating the hoseline in the fire apartment by transmitting, "Alright, whoever was just operating that line you were in the right apartment. You got to go to the bedroom to your left, right when you come through the door." Engine Company 248, with the assistance of two members of Engine Company 219, the CFR-D Unit, continued to stretch their hoseline to the 15 th floor. Engine Company 280 members stood fast with a dry hoseline. At 1942:19 Battalion 41 attempted to contact Lieutenant John Martinson via handie talkie, "41 to 249." At 1942:21 Battalion 41 transmitted via handie-talkie, "/ got 234 coming in to take over your line." There was no recorded response to either transmission from Lieutenant John Martinson. Ladder Company 132 Officer, who had been searching the opposite end of the public hallway advanced toward the fire apartment. Command contacted the Squad Company 1 Roof Firefighter in apartment 15M to determine if fire had extended into that apartment and if a hoseline was in position. The Squad Company 1 Roof Firefighter responded that one pane of the double pane bedroom window in Page 41 of 88

apartment 15M was failing. Engine Company 248's hose line was still in the process of being stretched. The Squad Company I Chauffeur started advancing the nozzle into the fire apartment when he noticed the reflective stripes of a bunker coat on the floor in front of him. Squad Company I Chauffeur shut down the nozzle and at 1943:12 transmitted, "member down." Lieutenant John Martinson was found approximately three feet inside the apartment lying on his right side with his head toward the kitchen and his feet toward the bedroom. Lieutenant John Martinson was unconscious with his helmet and SCBA facepiece off. There was no air escaping from his SCBA. The Squad Company I Chauffeur rolled Lieutenant John Martinson to a supine position. Battalion 41 transmitted at 1943:18, "Is there a MAYDAY in there?" At

1943:23 Battalion 41 transmitted, "Did anyone give a MAYDAY?"

Lieutenant John Martinson Squad Company 1 Chauffeur Engine Company 234 Back-Up Ladder Company 132 Officer

Red lines indicates fire area

o o

Diagram 9 Location of Lieutenant John Martinson When Found in the Fire Apartment
Page 42 of88

The Engine Company 234 Back-Up Firefighter followed the hoseline through the heavy smoke condition into the fire apartment. He physically bumped into the Squad Company 1 Chauffeur just after the "member down" message was transmitted. The Engine Company 234 Back-Up Firefighter began to assist with the removal of Lieutenant John Martinson from the apartment. At 1943:31 he transmitted, "MAYDAY, MAYDAY, MAYDAY, Engine 234 Back-Up

to Command, MAYDAY. We got a member down."

(NONE OF THE MEMBERS INTERVIEWED

REPORTED BEING AWARE OF THE ACTIVATION OF LIEUTENANT JOHN MARTINSON'S PASS ALARM. HOWEVER, THE BATTALION HANDlE-TALKIE RECORDINGS REVEALED A PASS ALARM SOUNDING IN THE BACKGROUND DURING THIS MAYDAY TRANSMISSION.)

The Engine Company 234 Back-Up Firefighter moved to the other side of Lieutenant John Martinson and grabbed his legs. He noticed that Lieutenant John Martinson did not have a helmet, SCBA facepiece or gloves on. The Squad Company 1 Chauffeur and the Engine

Company 234 Back-Up Firefighter moved Lieutenant John Martinson to a seated position, pivoted him so that his back was toward the apartment doorway and lowered his upper body out of the door into the public hallway. The Ladder Company 132 Officer was in the public hallway at the apartment door when he heard the Engine Company 234 Back-Up Firefighter give the MAYDAY transmission. The Ladder Company 132 Officer assisted in removing Lieutenant John Martinson from the fire apartment into the public hallway. There continued to be a high heat condition at the fire apartment door. As Lieutenant John Martinson was being removed, the Engine Company 234 Back-Up Firefighter took control of the nozzle and protected the members removing Lieutenant John Martinson by operating the hoseline in the fire apartment. The Ladder Company 123 Can and the Squad Company 1 Forcible Entry Firefighters quickly moved to this location and assisted with the removal of Lieutenant John Martinson. Battalion 41 activated the FAST Unit, Ladder Company 123. The members of Ladder Company 123 had already moved to the 14th floor and were assisting the distressed members. Ladder Company 111 members left the 15th floor and proceeded to the 14th floor when they heard the MA YDA Y transmission. At 1944 hours the Ladder Company 113 Officer contacted the Ladder Company 113 Can Firefighter and asked if he gave a MAYDAY. responded that he did not give a MAYDAY. The Ladder Company 113 Can Firefighter At 1944:39 the Safety Officer, Battalion 37
(THIS IS THE FIRST

transmitted to Command, "We're missing the Officer of 249... " Page 43 of88

TRANSMISSION INDICATING TIIAT LIEUTENANT JOHN MARTINSON WAS UNACCOUNTED FOR.)

A few

seconds later Battalion 37 transmitted via handie-talkie that the Engine Company 249 Control Firefighter was also missing. At approximately 1945 hours the Ladder Company 132 Officer, the Squad Company 1 Chauffeur, the Squad Company 1 Forcible Entry Firefighter and the Ladder Company 123 Can Firefighter continued to work on the removal of Lieutenant John Martinson. Lieutenant John Martinson's SCBA and bunker coat were loose which interfered with his removal. They

removed his SCBA and left it in the public hallway near the fire apartment. In the attempt to carry Lieutenant John Martinson his bunker coat was unintentionally pulled off. The Ladder Company III Officer and Forcible Entry Firefighter advanced down the public hallway and encountered the members working on the removal of Lieutenant John Martinson. The Ladder Company 123 Can Firefighter grabbed Lieutenant John Martinson's feet. The Squad Company I Chauffeur and the Squad Company 1 Forcible Entry Firefighter had Lieutenant John Martinson by the arms. They carried him face-down toward the stairway door labeled B on the 14th floor. Several other members assisted in the removal by clearing the public hallway. The Engine Company 234 Back-Up Firefighter operated the hoseline during the removal of Lieutenant John Martinson. He was unable to advance the hoseline toward the bedroom fire area so he backed the hoseline out into the public hallway and closed the apartment door. Lieutenant John Martinson was carried through the stairway door labeled B on the 14th floor. The Squad Company 1 Officer made a rapid evaluation of Lieutenant John Martinson's condition and determined that he was unconscious and not breathing. At 1945:41 Battalion 37 transmitted, "MAYDAY is out on the B staircase on the l,fh floor." Battalion 37 was unable to identify the unconscious member. At 1946:45 the Squad Company 1 Officer transmitted, "Squad 1 to the 15. Unconscious

Firefighter coming down the stairs now, we need ALS on the 1ih floor now." Division 15
replied, "Command 10-4, ALS is on the way up..." Lieutenant John Martinson was moved to the l3 th floor where Engine Company 219, the CFR-D Unit, was staged. The Engine Company 219 Control and Nozzle Firefighters immediately provided oxygen and started performing patient assessment as Paramedics from EMS Unit 38S3 arrived on the 13 th floor. EMS Paramedics performed their initial assessment on Lieutenant John Martinson and determined that he was not breathing and had no pulse. The defibrillator could not be employed due to water Page 44 of88

---~--~~----

conditions in the public hallway. Lieutenant John Martinson was placed in the stokes basket and chest compressions were initiated. At 1948:52 the Rescue Battalion transmitted, "One member is being worked on, in full

cardiac arrest on 13th floor. EMS is with him now."

(THE IDENTITY OF THE UNCONSCIOUS

MEMBER WAS NOT KNOWN TO MANY OF THE OPERATING MEMBERS.)

Lieutenant John Martinson, in the stokes basket, was moved to an elevator. Due to the small dimensions of the elevator, the stokes basket had to be placed on an angle with one end of it resting on the elevator wall. Chest compressions were continued in the elevator en-route to the lobby. On arrival at the concourse level at approximately 1952 hours, additional EMS members and Firefighters assisted with the care of Lieutenant John Martinson. Lieutenant John Martinson was moved to an FDNY ambulance staged on Bedford A venue. Lieutenant John Martinson was transported to Kings County Hospital where he was pronounced dead at 2021 hours. The cause of death was smoke inhalation and thennal bums. While Lieutenant John Martinson was being taken out of the 14th floor public hallway, Engine Company 234 members maintained the fire apartment door in the closed position. After Lieutenant John Martinson was removed they opened the door and advanced into the fire apartment. The Engine Company 234 Nozzle Firefighter was now in control of the hoseline. The Ladder Company 111 Inside Team, Rescue Company 2 Chauffeur, Roof, and Can Firefighters were in the public hallway behind Engine Company 234. The members from Ladder Company 111 and Rescue Company 2 entered the apartment behind Engine Company 234 and proceeded to search the kitchen and living room. Ladder Company 105 continued to search the floor above and assisted Engine Company 248 and Squad Company 1 Roof in apartment 15M. At 1947 hours the Engine Company 234 Nozzle Firefighter advanced the hoseline toward the bedroom and directed the stream at the main body of fire. The Squad Company 1 Roof Firefighter transmitted a handie-talkie message to Command from the apartment above the fire, " .. they're getting water on the fire now ... " Ladder Company III and Rescue Company 2 members continued their primary search of the fire apartment. Lieutenant John Martinson's helmet was found behind the fire apartment door by the Rescue Company 2 Can Firefighter. Division 15 requested an additional FAST Unit to replace Ladder Company 123. At 1948 hours Ladder Company 122 was designated the additional FAST Unit.

Page 45 of88

The use of the three stairways continued to add to the confusion. During the next several minutes there were many handie-talkie transmissions attempting to account for members. At 1949 hours and at 1951 hours Battalion 41 transmitted MA YDA Y messages in an attempt to identify the missing member from Engine Company 249 (Lieutenant John Martinson). Lieutenant John Martinson had already been removed. At 1952:21 Battalion 38 transmitted via handie-talkie that all members from Engine Company 249 were accounted for. He also stated that the Engine Company 249 Officer was under the care of EMS. At approximately 1954 hours Car 13A arrived on the scene and assumed command. At 1956 hours the Engine Company 234 Officer reported that the main body of fire in the fire apartment had been extinguished. At 1957 hours Battalion 41 reported that the primary search in the fire apartment was negative.

1.

2.

Page 46 of88

v.
1.

FINDINGS

The Investigation Team was unable to account for Lieutenant John Martinson's actions from the time he entered the public hallway on the 14th floor at approximately 1922 hours until he lost consciousness immediately after his last transmission at 1938 hours. When Lieutenant John Martinson was found unconscious in the fire apartment at 1943 hours his: Facepiece was not on his face Helmet was not on his head Protective hood was in a down position around his neck Gloves were not on his hands SCBA cylinder was depleted

The Investigation Team believes that Lieutenant John Martinson entered the fire apartment to search prior to the flue like condition developing. He remained in the apartment either trapped by these conditions or unaware of them. The kitchen, dining area, and living room were not in the flue path and therefore not subject to the wind intensified conditions. Lieutenant John Martinson remained in the apartment until his air supply was depleted. Then he removed his facepiece, made a handie-talkie transmission and inhaled highly heated gases. These highly heated gases closed down his airway which prevented him from breathing causing him to immediately lose consciousness. 2. SCBA # 249-1 worn by Lieutenant John Martinson was impounded by Safety Command at the scene. This SCBA was a Scott 4.5 positive pressure breathing apparatus with a CBRN EZ flow II regulator and a 45-minute cylinder. The facepiece belonged to another Officer assigned to Engine Company 249. MSU records indicate that both members were fitted for the same size facepiece. This SCBA was tested on January 10,2008 at MSU. The cylinder was empty at the time of testing. The high pressure coupling was found loose. The manual shut off switch was in the off position. The HEADS-UP DISPLAY (HUD) wire was broken at the coupling. The facepiece was found with the nose cup right inhalation valve missing. The SCBA and facepiece passed Scott Posicheck 3 testing at MSU. The HUD was not able to be

Page 47 of 88

tested due to the broken wire and therefore, considered "Failed" during the preliminary visual inspection.
It is not known when the high pressure coupling became loose or when the HUD wire

broke. The Investigation Team believes that the high pressure coupling was not loose when it was used by Lieutenant John Martinson. This conclusion is based on the fact that the SCBA lasted for approximately 17 minutes which would be unlikely if the high pressure coupling was loose during use. The 17 minute duration is estimated from the time Lieutenant John Martinson donned the SCBA facepiece to his handie-talkie transmission stating he was out of air. The SCBA, facepiece and cylinder were sent to Intertek Testing Services for independent analysis. This independent testing corroborated the results obtained at MSU. On January 3,2008 at 1800 hours this mask was inspected as per roll call procedure. No defects were noted. This inspection and the results are reflected in the 1800 hours

Company Journal entry made by Lieutenant John Martinson. The Investigation Team concluded that Lieutenant John Martinson's SCBA, PASS, and End of Service Time Indicators were all working properly while used at this fire.

3.

The Investigation Team examined the possibility that this may have been a wind driven fire. The fire apartment door remained partially open when the occupants fled. Windows in the bedroom of the fire apartment faced west and failed due to the heat prior to or shortly after Fire Department arrival. A northwest wind caused the products of

combustion to be driven through the fire apartment and into the public hallway. The stairway doors were self closing which initially kept most of the smoke and heat in the public hallway. The attack stairway bulkhead door was opened by civilians who fled to the roof. The only element preventing a flue like situation at this point in the fire was the closed attack stairway door on the 14th floor. The advance of the first hoseline into the public hallway completed the path from the bedroom of the fire apartment to the public hallway into the attack stairs and to the attack stair bulkhead. This allowed the wind gusts to intensify conditions at the apartment entrance and in the public hallway. Members reported that conditions in the hallway varied from moderate heat to blistering heat. Although the conditions in the hallway were severe at times, many effects that would be expected at a wind driven fire were not found at this fire: Page 48 of88
6.

Numerous members were able to operate in the public hallway for the duration of the fire

Plastic light fixtures and plastic covered wire raceways at the ceiling level were intact in most of the public hallway

There was a lack of spalling in the public hallway At times fire auto exposed the windows on the floor above cracking the outer pane

The wind was not constant; at times it gusted and swirled throughout the H-shaped configuration of the building. The fire at times was issuing out the windows with force. At other times it was blowing into the windows. These facts led the Investigation Team to conclude that this fire was impacted by the wind but not wind driven.
Note: The Department along with Brooklyn Polytechnic University and the National Institute of

Standards and Technology (NIST) is currently researching wind driven fires.

The

Department is currently conducting an ongoing pilot program, "Wind Driven Fires" using Positive Pressure Fans, Fire Window Blankets and High-Rise Nozzles. 4. Members did not recall hearing a PASS Alarm signal when Lieutenant John Martinson was found. A review of the handie-talkie recordings indicates that a PASS Alarm was sounding in the background when the MA YDA Y transmission was being made. PASS Alarm signals are common occurrences on the fireground and are sometimes purposely or subconsciously ignored by members.

5.

The working and exit time of the SCBA depends on many factors. Cylinders rated to provide 30, 45 or 60 minutes do not provide this amount of time. The 45 minute rated cylinders used at this fire lasted approximately 15 to 20 minutes

6.

The first available elevator was used by Engine Company members only. The elevator was small and only able to accommodate a maximum of five members. This prevented the 1st Engine Company and Ladder Company from complying with Firefighting Procedures Multiple Dwelling Fires section 6. L3F, which states that the elevator should be shared by both the Engine and Ladder Company members.

Page 49 of 88

7.

A Firemen Service elevator was brought to the fire floor and floor above during fire operations. An elevator that serviced the fire floor was used during fire operations to transport a civilian from the floor above the fire. These actions placed members and the civilian in jeopardy.

8.

The 1st and 2nd Ladder Companies operated elevators in Firemen Service for the duration of the fire. A Firemen Service elevator was ordered to the 13 th floor to assist members evacuating. This expedited the removal of Lieutenant John Martinson.

9.

Some members operated contrary to Department polices and procedures: Members entered an IDLH area to conduct a search without being teamed up with another member (All Unit Circular 329) Members entered the smoke filled public hallway without a charged hoseline (Fire fighting Procedures Multiple Dwelling Fires 6.2.1.A.2) Some members exiting the IDLH were not accompanied to a safe area by another SCBA equipped member (Training Bulletin SCBA 2.1.7, 3.6.2, All Unit Circular 220) At least two members continued to operate in an IDLH atmosphere after their SCBA End of Service Indicators (HUD and vibralert) were activated. continued to operate until their cylinders were depleted Two members removed their SCBA facepieces when their cylinders where depleted instead of removing the regulator from the facepiece. The facepiece with the regulator removed still provides physical protection to the member's face and allows for rapid application of the FAST Pak regulator A member shared his SCBA facepiece with a civilian during removal from the floor above the fire. Facepiece sharing hampers the search for an exit, increases the exposure to airborne contaminants such as carbon monoxide, and depletes the limited air supply in less time, thus posing risk to both victim and rescuer They

10.

The CFR-D Engine Company did not maintain unit integrity. ordered by their Officer to assist another unit stretching a hose line.

Two members were

Page 50 of 88

11.

The 2 nd due Engine Company initially assisted the 1st due Engine Company but did not tearn up with them for the duration of the fire. Some members of the 2nd Engine

Company stretched a second hoseline. According to Firefighting Procedures Multiple Dwelling Fires, the 3rd to arrive Engine is responsible for stretching the second hoseline. 12. There were delays and confusion accounting for members operating on the fire floor. Officers must account for their members at all times. However, it was not

addressed in Department publications that Firefighters should also account for their Officer Roll call procedures were not conducted in a timely fashion. Chief Officers were unable to determine which members were reported being out of air The presence of the three stairways in conjunction with the heavy smoke conditions added to the difficulty in accountability. Members operating in one stairway were not aware of members entering and exiting the other stairways Members were not aware Lieutenant John Martinson was out of air; their focus was drawn to another member known to be out of air and in need of assistance There was difficulty in identifying Lieutenant John Martinson after he was removed from the fire floor because he did not have on his helmet, bunker coat, SCBA or Officer's shirt 13. A member on the floor above the fire prepared for a life saving rope rescue. The life saving rope was tied off to a substantial object and in position for deployment if necessary. This member also gave clear and accurate reports from the apartment above the fire. 14. After Lieutenant John Martinson was found, the Engine Company 234 Back-Up Firefighter transmitted a clear and concise MAYDAY for a member down. He located the nozzle and operated the hoseline to protect the members removing Lieutenant John Martinson. After Lieutenant John Martinson was removed from the fire apartment the Engine Company 234 Back-Up Firefighter backed the hoseline out of the apartment and closed the door. This improved the conditions in the hallway and allowed the other members of Engine Company 234 to regroup and make an effective attack on the fire.

Page 51 of 88

Engine Company 234 remained focused on their extinguishment duties which expedited the removal of Lieutenant John Martinson.

15.

After being discovered in apartment 14M Lieutenant John Martinson was quickly removed from the IDLH. It took approximately four minutes to remove him from the fire apartment to the floor below. According to a December 2003 Fire Engineering article, "Rapid Intervention Isn't Rapid," by Steve Kreis, the average removal time of a downed Firefighter is approximately 22 minutes. Even with the rapid removal, the Medical Examiner stated that if Lieutenant John Martinson had been intubated within one to two minutes after losing consciousness, he still would have had significant complications and his survival would have been doubtfuL Nine minutes transpired from the time Lieutenant John Martinson lost consciousness until he was removed to the 13th floor. The Medical Examiner indicated this time frame allowed no chance for survival.

16.

During the fire operations at this incident, at least seven members reported that their helmets were dislodged while operating. None of these members were wearing the helmet chinstrap and their helmets were completely dislodged.

17.

Ventilation procedures at high-rise fireproof multiple dwelling fires need to be further studied and evaluated. Fire Window Blankets may have had a positive effect on the outcome of this fire. Fire Window Blankets were brought into the building but were not in position to be deployed. At the time of the fire, Department procedures did not require Fire Window Blankets to be brought above the fire at high-rise fires.
Note: The Department is currently conducting an ongoing pilot program, "Wind Driven

Fires" using Positive Pressure Fans, Fire Window Blankets and High-Rise Nozzles.

18.

The bulkhead door of the attack stairway was left open by civilians exiting to the roof. This information was not relayed to the Incident Commander by members arriving at the roof.

19.

Hoselines were stretched via the evacuation stairway.

Once the attack stairway

IS

designated, all hoselines should be stretched and operated from this stairway. Page 52 of88

20.

The in-line pressure gauge was placed on the standpipe outlet. It was not used to set hoseline pressure or monitored during operations to ensure that proper pressure was maintained.

21.

Handie-talkie communications at the scene did not give a clear and concise picture of fire conditions or the actions taken by units. Lieutenant John Martinson failed to maintain frequent handie-talkie

communication with Command and other members operating. He did not make an emergency notification until his air supply was depleted. Many Firefighters, who are trapped, lost or out of air do not call for help in a timely manner. They tend to try to resolve problems themselves until it is too late to be rescued without serious consequences Conditions that existed in the hallways, stairways, floor above and fire floor were not communicated to Command. Knowledge of these conditions would have

given the Incident Commander better situational awareness and may have prompted him to reevaluate his strategy and tactics The status of searches on the fire floor and floors above were not communicated to Command until later in the operation The designation of the attack stairway was not transmitted on the handie-talkie to units on the scene Notification of the self evacuation of civilians to the roof and the additional venting of the bulkhead doors by members were not communicated to Command First names were used by some members in handie-talkie transmissions instead of unit designation with assigned positions. Situational awareness will not be

conveyed to other members when communications are conducted in this manner A civilian was found and removed from the floor above without notifying Command 22. Many members operating at this fire were not equipped with an Emergency Alert Button on the remote handie-talkie microphone.

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Note: All MX 3500 handie-talkies have been equipped with an Emergency Alert Button

on the remote microphone as of July 2008. Members transmitting MAYDAY or URGENT messages did not activate the Emergency Alert Button Chief Officers attempting to gain control of the handie-talkie network did not use the Emergency Alert Button 23. Progress reports were not transmitted to the Brooklyn Dispatcher in accordance with the Communications ManuaL 24. The incident duration times were not transmitted by the Brooklyn Dispatcher until late in the operation. 25. During critical stages of the fire the Primary Tactical Channel became overwhelmed by numerous transmissions. The Command Channel was not established until after the removal of Lieutenant John Martinson The Post Radio was not utilized until later in the operation

Note: Neither the Post Radio nor the Command Channel are required at operations in

high-rise fireproof multiple dwellings. 26. Ladder Companies assigned on the 2nd alarm after a 10-77 signal are not automatically selected and dispatched by the CADS. The Dispatcher must manually select these units. This resulted in a delay of more than three minutes from the transmission of the 2nd alarm to the assignment of the Ladder Companies. Although this had no impact on the outcome of this incident this delay could be critical at future incidents. 27. The Brooklyn Dispatcher notified Battalion 38 of phone calls from approximately 20 apartments throughout the building. Although no problems were reported at this incident, the potential for error is great when attempting to manually transcribe this amount of information. 28. The Battalion Handie-Talkie Recorder is a valuable investigative and educational tool. Present technology only allows for a maximum of six handie-talkie identifiers to be recorded for each recorded segment. Specific transmissions are not definitively identified. Page 54 of88

29.

The early arrival of a Department photographer greatly assisted in the documentation of unit operations and the subsequent investigation of this fire. The photographs provided time stamped pictures of interior and exterior operations during the fire.

30.

The Daily Chief Officer Schedule at the start of the 6x9 tour was incorrect. This led the 1st arriving Battalion Chief to be unaware that an Acting Battalion Chief (ABC) was the All-Hands Chief.

31.

Stairways Band C were scissor type stairs. These stairways were mislabeled; the stairway door labeling should have alternated from floor to floor. The stairways should be designated, not stairway doors.
In this building, the stairway doors were labeled

vertically with the same letter above one another and did not reflect the proper stairway designation.

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VI. CAUSES
DIRECT CAUSES
1. Smoke inhalation and thermal burns.

INDIRECT CAUSES
1. 2. 3. 4. Child playing with fire on kitchen stove. Failure of occupant to fully close the apartment door when exiting the apartment. Failure to team up with another member when entering an IDLH. Failure to leave the IDLH when the End of Service Time Indicators, HEADS-UP DISPLAY (HUD) and vibralert activated.

BASIC CAUSES
1. Winds of 11 to 15 miles per hour with gusts up to 20 miles per hour.

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VII. RECOMMENDATIONS

SECTION A

1.

Proper SCBA usage must be strictly enforced. All Chief and Company Officers shall take any and all measures to ensure that the Department's SCBA policy (AUC 220) is followed. Leave the IDLH when the End of Service Time Indicators, (HUD and vibralert) activate Team up with other members when entering, operating in and leaving an IDLH Prohibit facepiece sharing Keeping the facepiece in place and removing the regulator when the SCBA air supply has been exhausted and the member is unable to exit the IDLH

2.

All members shall maintain an awareness of other team members during operations. It is inherent of the Company Officer's responsibility to be aware of the location and status of their members during fire operations. Members must also maintain awareness of the location and status of their Officer.

3.

Re-emphasize the importance of the proper use of the firefighting helmet chin strap. Failure to utilize the chin strap can result in serious consequences which affects operations as well as members' personal safety. When a helmet is lost or dislodged, the member is at risk of serious injury and is no longer effective in conducting assigned tasks. No member should enter or operate in an IDLH without a helmet.

4.

Re-emphasize the need for Engine Companies to team up for the duration of the operation. This is needed for rapid placement of the hoseline, advancement of the

hose line, and to ensure that members are readily available for relief.

The Fire Department should continue to evaluate the implementation of positive pressure ventilation and the use of wind control devices as initial operational tactics for fires in high-rise fireproof multiple dwellings.

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6.

Firefighting Procedures Multiple Dwelling Fires, section 6, "Class A Fireproof Multiple Dwelling Fires" should be revised and issued as a separate volume. A workgroup should be formed to revise the document. The revision of this document should emphasize and expand on the following: Controlling the fire apartment door Control of ventilation by the Incident Commander Strategies and tactics of ventilation procedures Elevator operations Standpipe operations

7.

A fire safety education campaign should be implemented to inform the public of the importance of closing the fire room door, as well as apartment doors, in case of fire. The fire safety education campaign should also emphasize the importance of not disabling or obstructing the self closing devices on apartment doors. This information could be

provided to the public through the Fire Safety Education Unit as well as the FDNY public website. The FDNY should encourage other public and private agencies, such as the New York City Housing Authority and Con Edison, to participate in this fire safety education campaign.

8.

Establish a Command Channel whenever a 10-77 signal is transmitted.

This will

alleviate handie-talkie traffic on the Primary Tactical Channel and will improve overall communications. The Post Radio should be utilized as soon as possible to provide an improved communications link between the Command Post and the Operations Post.

9.

Emphasize the importance of maintaining radio discipline during MAYDAY/URGENT situations. All hand ie-talkie transmissions should cease, except those related to the

MA YDA Y/URGENT or critical information related to the fire.

10.

Re-emphasize to all members that handie-talkie transmissions should be concise and direct. Transmissions must be made using unit designation and assigned position, not the member's name

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11.

Train all members to be proficient in roll call procedures as per Communications Manual Chapter 9, Addendum 2, "Emergency Roll Call Procedures."

SECTIONB

Although the following did not have an impact on this incident, the Department should consider these recommendations to improve safety and efficiency at future operations: 12. The Dispatcher should relay important information such as numerous apartments with occupants in distress to the Incident Commander via the MDT as well as the Department radio. The printed copy from the MDT will ensure the accuracy of this information. 13. Emphasize the importance of reacting to a PASS Alarm signal sounding during operations. When a PASS Alarm is activated in the full cycle for ten seconds, the An

member hearing the alarm should immediately notify the Incident Commander.

immediate investigation of the alarm must be made to determine the cause. The results of the investigation must be transmitted to the Incident Commander as soon as possible. PASS Alarm signals have become so common during routine operations on the fireground that many members have a tendency not to hear them and/or disregard them. Research the feasibility of developing other PASS Alarm signals such as using verbal unit designations.

14.

The CADS should reflect when a Division or Battalion is staffed by an Acting Chief. For example, the Acting Battalion Chief, Battalion 99, could be indicated on the response ticket as ABC99 instead of BC99.

15.

Ensure scissor stairs are properly labeled whenever inspecting or operating in buildings serviced by scissor stairs. Mislabeled scissor stairs can cause confusion during fire

operations. This information should be relayed to the Incident Commander as soon as it is discovered. Detailed information on scissor stairs should be incorporated into Firefighting
Procedures "Fireproof Multiple Dwellings"

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The labeling of scissor stairs should be included on the Multiple Dwelling Building Inspection Fonn A-291 and Inspection Guide 3 for Fireproof Multiple Dwellings

16.

Corrective action must be taken whenever scissor stairs are improperly labeled Scissor stairs should be included in the CIDS infonnation

Establish a training program to visit field units to review and discuss the findings and recommendations found in Fatal Fire Investigations.

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