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of the heavy acrid smoke. He reconnected his regulator to his facepiece with great difficulty
because his coordination was being affected by the smoke.
71 of 176
Firefighter Joseph Graffagnino was standing up. The Engine Company 24 Back-Up
Firefighter told him to get down low. Firefighter Joseph Graffagnino remained standing.
The Engine Company 24 Back-Up Firefighter attempted to pull Firefighter Joseph
Graffagnino to the floor, however Firefighter Joseph Graffagnino resisted this attempt.
While pulling on Firefighter Joseph Graffagnino, the Engine Company 24 Back-Up
Firefighter lost his grip and fell toward the door leading out of the stairway. His hand
landed on a garden type hose that he knew led to the elevators. Firefighter Joseph
Graffagnino fell back toward the stairs. The Engine Company 24 Back-Up Firefighter
called for Firefighter Joseph Graffagnino and Firefighter Robert Beddia to follow him. He
shouted to them that he knew the way out.
At 1650:33 the Engine Company 24 Back-Up Firefighter, while still at the 14th floor
stairway landing, transmitted the following, "MAYDAY-MAYDAY. 24 Back-Up with a
MAYDAY." Battalion 2 on the scaffold between the 14th and 15
th
floor acknowledged,
"Unit with the MAYDAY, go ahead." The Engine Company 24 Back-Up Firefighter then
transmitted, "24 Back-Up... There were two members on the 14th floor, out of air... at the
stairwell... gonna make some noise by the entrance." (THE INVESTIGATION REVEALED
THAT THIS MAYDAY TRANSMISSION WAS NOT HEARD BY ANY MEMBERS OPERATING ON THE
14TH FLOOR AND WAS GIVEN AT THE SAME TIME AS ANOTHER MISSING MEMBER WAS BEING
REMOVED TO THE Q - DECKING AREA.) After completing the MAYDAY transmission the
Engine Company 24 Back-Up Firefighter left the B stairway to get help.
At approximately 1651 hours the Engine Company 24 Officer reached the
Q - decking area. The Engine Company 24 Officer, completely exhausted, told the Rescue
Company 1 Officer and the Battalion 2 Firefighter that his members were still operating
inside.
At 1652 hours a third alarm was transmitted by Car 15. This was 75 minutes after
the alarm was transmitted.
At approximately 1653 hours the Engine Company 24 Back-Up Firefighter exited to
the Q - decking area. The Engine Company 24 Back-Up Firefighter informed the Rescue
Company 1 Officer, the Rescue Battalion Firefighter and Battalion 41 that there were still
members inside. (THE ENGINE COMPANY 24 BACK-UP FIREFIGHTER WAS PHYSICALLY
EXHAUSTED, NAUSEOUS AND VOMITING.)
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The Engine Company 3 Officer attempted to account for his two Firefighters on the
14th floor. Due to the numerous handie-talkie transmissions he was unable to contact them.
At 1653 hours he transmitted an URGENT message stating that he couldn't account for all
his members and that they were on the floor with Engine Company 24. Battalion 2
acknowledged the URGENT message. Battalion 41, on the 14th floor, exited the access
corridor to search for the missing members of Engine Company 3.
At 1654 hours Battalion 2 informed Car 15 that Battalion 2 was located on the
scaffold. He also asked Car 15 if he could confirm if members of Engine Company 24 were
missing.
At approximately 1655 hours Division 11 arrived on the 14th floor via the elevator.
After a short period of time he entered the Q - decking area. He made contact with the
Engine Company 24 Back-Up Firefighter who informed him members of Engine Company
24 were still inside.
At 1656 hours the Engine Company 3 Officer transmitted a MAYDAY because he
couldn't account for two of his members. This MAYDAY was acknowledged by Battalion
2. Thirty one seconds later Battalion 41 reported that he had the two members of Engine
Company 3 with him near the elevators on the 14th floor.
Ladder Companies 11 and 18 were assigned and designated as additional FAST
units.
THE SEARCH FOR AND REMOVAL OF }l'IREFIGHTER JOSEPH GRAFFAGNINO
At approximately 1657 hours there were no units operating above the 14th floor.
The only remaining units operating on the 14th floor were: Engine Company 24, Rescue
Company 1, Rescue Battalion, Battalion 41 and Division 11. The Engine Company 3
Officer and two of his members were also on this floor. Car 15 was still attempting to
account for all members. At 1657:52 Battalion 2, on the scaffold at the 14th floor level,
contacted Battalion 41 stating, "There's a report of Engine 24 missing members, also.
Can you confinn that?" Battalion 41 stated he was checking on it.
At 1658:44 the Rescue Battalion Firefighter made the following transmission,
"Rescue Battalion Alpha, I'm on the llh floor with 24 Back-Up. He said the rest of his
company is missing. Are they accounted for?" Car 15 replied, "That's what we're trying
to find out. "
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Rescue Company 1 had been in the fire building for approximately one hour. These
members had changed their SCBA cylinders and were staged in the Q - decking area on the
14th floor. The Rescue Company 1 Officer did not hear any of the MAYDAY transmissions
given by members of Engine Company 24 but did hear that members of Engine Company
24 were unaccounted for. Although completely exhausted the Rescue Company 1 Officer
left the Q - decking area and entered through an opening in the plywood wall to search for
the missing members of Engine Company 24. He was followed by the Rescue Battalion and
the Rescue Battalion Firefighter. The Rescue Company 1 Hook Firefighter was positioned
at the opening in the plywood wall with a thermal imaging camera. He was monitoring the
members conducting the search. Shortly after entering, the Rescue Company 1 Officer
heard a PASS Alarm sounding. He turned and informed the Rescue Battalion. The Rescue
Battalion returned to the Q - decking area and ordered the other members of Rescue
Company 1 to enter and assist their Officer. Division 11 also entered through the opening
in the plywood wall. Division 11 located Firefighter Joseph Graffagnino on the north side
of the north turnstile just across from the B stairway. Firefighter Joseph Graffagnino was
unconscious in the supine position. His facepiece was not donned. His PASS Alarm was in
full alarm (Diagram 15).
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-------
Oecootaminatior>
Area
Dollad Lines Irdicat.
Hanging Plastc Sheets
Soull1 Tumstikl
North Turnstle ---------'
\', &_w..
Hanging Piastic sn""ls'\
(25) Exhaust Fans
Access Corridor \
\ -------r-........
,
,
.
,
. -.
DrowlngnOl
fOSCJiJI.
" " Q DeC!<ing Am,.
.....
Liberty Slreet
exposure .1
..
Diagram 15
Dashed Line Indicates Firefighter Graffagnino's
Path of Removal from the 14t Floor
Division 11 transmitted the following URGENT message to Command at 1701:59,
"/ got a member down. We're trying to get him out of here on the 14h floor. His PASS
Alarm is going off, non responsive." Car 15 acknowledged the message. The Rescue
Company 1 Officer attempted to remove Firefighter Joseph Graffagnino as Division 11
made his transmission.
At 1702:33 the Rescue Company 1 Officer made the following transmission, " ...come on
in, give us a hand. We got a big guy to pull out. Hurry up." The Rescue Company 1 Hook,
Can and Forcible Entry Firefighters entered through the opening in the plywood wall and assisted
with the removal of Firefighter Joseph Graffagnino. While Firefighter Joseph Graffagnino was
being removed through the opening in the plywood wall to the Q - decking area, the Rescue
Company 1 Officer remained on the south side of the opening for about a minute. He wanted to
ensure that all members were out. He did not hear a PASS Alarm sounding from the core area.
The Rescue Company 1 Officer then exited to the Q - decking area
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After Firefighter Joseph Graffagnino was removed to the Q decking area CPR was
started by the Rescue Company 1 Roof Firefighter. The Engine Company 24 Back-Up
Firefighter emphatically stated that another member of Engine Company 24 was still inside.
The Engine Company 24 Back-Up Firefighter, with several other members, carried
Firefighter Joseph Graffagnino from the Q - decking area to the elevator. CPR continued in
the elevator while Firefighter Joseph Graffagnino was transported to street level. (FIVE
MINUTES AFTER FIREFIGHTER JOSEPH GRAFFAGNINO WAS LOCATED, HE HAD BEEN REMOVED
A DISTANCE OF APPROXIMATELY 100' TO THE ELEVATOR.)
EMS, on the scene, was ordered by Division 1 to be in position near the elevator at
street level. They were at that location when Firefighter Joseph Graffagnino was brought
down. EMS took control of Firefighter Joseph Graffagnino's care and transported him to
Beekman Downtown Hospital. The Engine Company 24 Chauffeur assisted EMS with CPR
in the ambulance in route to the hospital.
At 1707 hours a signal 10-66 was transmitted.
THE SEARCH FOR AND REMOVAL OF FIREFIGHTER ROBERT BEDDIA
The Engine Company 3 Officer believed there was another member still
unaccounted for and informed the Rescue Company I Officer. Together they moved from
the Q decking area to the opening in the plywood wall where the Rescue Company I
Officer now heard a PASS Alarm sounding. At 1707 hours the Rescue Company 1 Officer
made an URGENT handie-talkie transmission stating, "I think I'm hearing another PASS
device in there. I'm gonna bring a guy in with me and see what we can find out. We
might have another guy in there. See if we can get them to shut off all the other PASS
devices. I can hone in on it." The Engine Company 3 Officer and the Rescue Company 1
Officer left the Q - decking area and entered through the opening in the plywood wall to
initiate a search. The Rescue Company 1 Hook Firefighter monitored their search from the
opening with a thermal imaging camera. The Engine Company 3 Officer believed that the
missing member was probably in the vicinity of the hoseline. He found the hoseline and
followed it toward the B stairway. The Rescue Company 1 Officer initially followed a
search rope. As they got closer to the core area they moved toward the sound of the PASS
Alarm.
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North Turnstile ----------'
L.bGrty SIno"t
Expoa ..... '1
The Engine Company 3 Officer located Firefighter Robert Beddia in the core area
between the two turnstiles. He was on the edge of the platform that covered the original
building elevator shafts on the east side of the core area. Firefighter Robert Beddia was
unconscious in the prone position. His facepiece was not donned. His PASS Alarm was in
full alarm. (Diagram 16)
Albany Street
Expoau... ,3
Decontamination
Area
Dotted Lines Indicate
Hanging Plasuc Sheets
Sou1l1 Turnstile
;
(25) Exhaust Fans
Drawing nol
to scale
Diagram 16
Dashed Line Indicates Firefighter Robert Beddia's
Path of Removal from the 14th Floor
At 1710:12 the Engine Company 3 Officer transmitted the following message,
HMAYDAY-MAYDAY-MAYDAY. Engine ... MAYDAY, MAYDAY." Car 15 replied,
"Unit with the MAYDAY." The Engine Company 3 Officer stated, "Engine 3 with a
MAYDAY. I have an unconscious fireman." At 1710:41 the Rescue Company 1 Officer
called for members to assist with the removal of the unconscious Firefighter. Upon hearing
a MAYDAY transmission members of Squad Company 18 returned to the 14th floor. The
Rescue Company 1 Officer attached webbing to Firefighter Robert Beddia's SCBA. The
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Rescue Company 1 Hook Firefighter entered through the opening in the plywood wall and
moved towards his officer. The Rescue Company 1 Officer placed the webbing in his hand.
The Rescue Company 1 Hook Firefighter used the webbing to move Firefighter Robert
Beddia toward the opening in the plywood wall. Several other Firefighters assisted with
Firefighter Robert Beddia's removal to the Q - decking area. In the Q - decking area the
Squad Company 18 Can Firefighter, formerly a member of EMS, initiated rescue breathing.
The Squad Company 18 Roof Firefighter initiated chest compressions. The elevator was
waiting on the 14th floor when Firefighter Robert Beddia was brought to it. At 1717:16
Division 11 made a handie-talkie transmission that the unconscious Firefighter was being
placed into the elevator. (SEVEN MINUTES AFTER FIREFIGHTER ROBERT BEDDIA WAS
LOCATED, HE HAD BEEN REMOVED ADISTANCE OF APPROXIMATELY 125' TO THE ELEVATOR.)
EMS was waiting by the elevator at street level. There also was an EMS physician
at this location. Firefighter Robert Beddia was placed on a stretcher. The physician
ventilated Firefighter Robert Beddia using a Bag Valve Mask (BVM) as they moved toward
the ambulance. The physician stated that Firefighter Robert Beddia appeared hypoxic (had
not received oxygen for some time) and had no pulse. The physician assisted with CPR in
the ambulance on the way to Beekman Downtown Hospital. At the emergency room this
physician recommended to the emergency room physician that both Firefighter Joseph
Graffagnino and Firefighter Robert Beddia be treated for exposure to potential carbon
monoxide and cyanide toxicity.
Despite the efforts of the Beekman Downtown Hospital Emergency Room medical
staff, Firefighter Joseph Graffagnino and Firefighter Robert Beddia succumbed to their
lllJunes.
As noted on the Certificate of Death for Firefighter Joseph Graffagnino the date of
death was August 18, 2007. The cause of death was smoke inhalation.
As noted on the Certificate of Death for Firefighter Robert Beddia the date of death
was August 18, 2007. The cause of death was smoke inhalation.
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VII. FINDINGS
1. On August 18, 2007, 130 Liberty Street did not meet the NYC Building Code
requirements for buildings undergoing alteration or demolition. Some provisions of
the NYC Building Code not followed were:
The sprinkler system was out of service.
The standpipe system was out of service.
The means of egress were blocked.
The fire rated construction comprising the stairway enclosures was either
compromised or completely removed at many locations.
2. A demolition application for 130 Liberty Street was not filed and the New York City
Department of Buildings did not issue a demolition permit. A demolition permit for
this building would have required a working standpipe system, sprinkler system,
enclosed stairs, an unobstructed means of egress, and fire guards.
3. The New York City Department of Buildings issued alteration permits, generally
one or two floors at a time, for 130 Liberty Street. Several alteration permits were
issued for each floor that was removed. Alteration permits require building systems
to be maintained and operational, excluding the floor(s) covered by the alteration
permit. This required a standpipe system, sprinkler system, enclosed stairs and an
unobstructed means of egress.
4. The Fire Department did not conduct the inspections of 130 Liberty Street as
required by section 5.8 of the Fire Prevention Manual. This section requires
buildings undergoing construction or demolition to be inspected every 15 days.
Note: Procedures are now in place to ensure that buildings under construction or
demolition greater than 75' are inspected every 15 days as required.
5. At the time of the fire, there was no formal notification to the Fire Department when
a building was undergoing demolition or construction. The Fire Department
identified buildings undergoing demolition or construction as a result of units
discovering these buildings in their administrative areas.
Note: Section 5.8.2 of the Fire Prevention Manual states, "Notice of demolition
operations about to commence shall be forwarded by the Bureau of Fire
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I
Prevention on Form A-102 to Divisions and District Offices." It is not known why
this section of the Fire Prevention Manual was not being complied with. (THE
INVESTIGA TION TEAM DID NOT INVESTIGATE THE REASON WHY THIS WAS NOT BEING
COMPLIED WITH DUE TO THE ONGOING INVESTIGATION BY THE MANHATTAN DISTRICT
ATTORNEY'S OFFICE.)
Procedures are now III place which automatically notifies the administrative
company anytime a permit is issued for the construction or demolition of a building
greater than 75' in height. In the future automatic notification will be made to the
administrative company anytime a permit is issued for the construction or
demolition of any building.
6. At the time of the fire, there was no formal procedure for notification to the Fire
Department when a building was undergoing asbestos abatement.
7. At the time of the fire there was no written Fire Department procedure for inspecting
buildings undergoing asbestos abatement.
8. The Bureau of Fire Investigation determined that this fire was caused by careless
discard of smoking materials. There was a delayed notification of approximately
13 minutes to the Fire Department. The delayed notification to the Fire Department
and the absence of a functioning sprinkler system enabled this fire to rapidly
increase in intensity. The fire originated in the decontamination area on the south
The standpipe system had a 42 foot section of pipe missing on Sub Level A.
This prevented water from being supplied to the standpipe risers via the
siamese connections.
When water was supplied to the second floor outlet in the A stairway, the water
flowed into Sub Level A due to the missing section of pipe as well as a failed
coupling which separated during the attempt to supply the standpipe system.
The standpipe outlets in the B stairway were removed which rendered this
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of the final 130 Liberty Street Implementation Plan. Some of the provisions listed in
the 130 Liberty Street Implementation Plan were:
A dry standpipe system shall be maintained.
The two existing building stairways be maintained free of obstructions and
shall be used to provide access between floors within containment areas.
All interior stairs shall be accessible in the event of an emergency.
At work area containment boundaries, stairways shall be isolated using
minimum 2x4 studs 16" on center, sheathed with 3/8" plywood and two
layers of 6 mil polyethylene, secured with duct tape.
Kick-out panels shall be installed in containment barrier walls and within
stairwells to maintain emergency egress throughout the duration of the
project. Kick-out panels shall be clearly marked with adequate signage.
25 exhaust fans to be spaced throughout the floor being abated.
Contrary to the approved 130 Liberty Street Implementation Plan the following
conditions were found:
A functioning dry standpipe system was not maintained.
Emergency egress was not maintained within stairways.
Containment barrier walls with kick out panels were not constructed on the
14th floor. Instead there were sealed wooden platforms present in the
stairways on most of the even numbered floors in the building which blocked
access and egress.
16. Several construction workers at the site provided inaccurate information about the
building to Chief Officers and operating units. This inaccurate information delayed
operations and caused confusion on the scene. These inaccuracies included:
The standpipe system was operational.
There was water in the B stairway standpipe available for firefighting
operations.
The fire pumps were operating.
The hatches in the sealed wooden platforms in the stairways could be opened
easily by pushing them up.
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The siamese on the Albany Street side of the building would supply the
standpipe system.
17. The CIDS information was inaccurate but did correctly inform responding units that
the sprinkler system was out of service and that asbestos and hazardous materials
were present throughout the building.
18. Firefighter Joseph Graffagnino was located unconscious on the north side of the
north turnstile just opposite the B stairway on the 14th floor. When discovered by
members he was in the supine position with his facepiece removed and his PASS
Alarm in full alarm. There was 0 psi of compressed air remaining in his cylinder.
19. Firefighter Robert Beddia was located unconscious in the core area on the 14th floor
between the north and the south turnstiles on the edge of the platform that covered
the elevator shafts on the east side of the core area. When discovered by members
he was in the prone position with his facepiece removed and his PASS Alarm in full
alarm. There was no air escaping from his regulator when he was found. There was
800 psi of compressed air remaining in his cylinder.
20. The investigation was unable to determine why either Firefighter Joseph
Graffagnino or Firefighter Robert Beddia did not leave the IDLH atmosphere when
their vibralerts activated.
21. Numerous members became lost or disoriented on the 14th and 15
th
floors because of
the heavy smoke condition and the many obstacles that impeded their attempt to
leave the IDLH atmosphere. Some of these obstacles included:
Sealed wooden platforms in both stairways that prevented members from
dropping down to the safety of the 13
th
floor.
Piles of demolition debris throughout the 14th floor and 15
th
floor. This
debris was comprised of metal studs, ductwork, piping, conduit and other
materials.
Metal turnstiles located at both ends of the core area on the 14th floor.
Floor jacks located on the decking which covered the original building
elevator shafts in the core area on the 14th floor.
22. At approximately 1647 hours the smoke condition in the B stairway was so severe
that some members operating within the stairway became disoriented. There were
six members, including Firefighter Joseph Graffagnino and Firefighter Robert
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Beddia, operating in close proximity inside the B stairway between the 14th and
15
th
floors. The charged 2 lh" hoseline was stretched up the stairway from the
14th floor. There were also two uncharged lengths of 2 ]12" hose within the
stairway. The charged hoseline was entangled with the uncharged hose. One
member who attempted to follow the charged hoseline to the 14th floor became
disoriented and gave a MAYDAY transmission. Within 29 seconds, a second
member became disoriented within the same stairway and gave an URGENT
transmission. Due to the heavy smoke condition some members operating at this
location were not aware that other members were within a few feet of them in the
same stairway. The sealed wooden platform on the 14th floor prevented these
members from descending to the safety of the l3
th
floor.
23. The Safety Command impounded SCBA Engine 24-5 worn by Firefighter Joseph
Graffagnino at the scene of the fire. This SCBA was a Scott 4.5 positive pressure
breathing apparatus with an EZ flow II regulator and a 45 minute cylinder. The
SCBA was tested by the Mask Service Unit on 812012007. It was subjected to visual
and functional tests using the PosiChek3 testing procedures. The facepiece attached
to the SCBA was marked Ladder 5-5. The cylinder contained 0 psi of compressed
air when confiscated and tested. This SCBA passed both the visual inspection and
the functional tests which included the PASS Alarm. The SCBA was sent to
Intertek Testing Services for independent analysis. It was found to be compliant
with National Fire Protection Association (NFP A) standards.
24. The Safety Command impounded SCBA Engine 24-3 worn by Firefighter Robert
Beddia at the scene of the fire. This SCBA was a Scott 4.5 positive pressure
breathing apparatus with an EZ flow II regulator and a 45 minute cylinder. The
SCBA was tested by the Mask Service Unit on 812012007. It was subjected to visual
and functional tests using the PosiChek3 testing procedures. The personal facepiece
attached to SCBA Engine 24-3 was issued to a Firefighter assigned to Engine
Company 24 who was not working on the day of the fire. The cylinder contained
800 psi of compressed air when confiscated and tested. This SCBA passed both the
visual inspection and the functional tests which included the PASS Alarm. The
SCBA was sent to Intertek Testing Services for independent analysis. It was found
to be compliant with NFP A standards.
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25. SCBA policy and procedures were not strictly followed during fire operations at 130
Liberty Street in the following instances:
Some members attempting to exit to a safe area removed their facepieces in
an IDLH atmosphere.
Some members operating in an IDLH atmosphere attempted to conserve their
air supply by not keeping their facepieces continuously donned.
Some members did not notify their Officer and immediately leave the IDLH
atmosphere with another member when their vibralert alarms activated.
A member attempted to share his air supply in an IDLH atmosphere and was
nearly overcome by the toxic atmosphere.
The working and exit time that could be expected when using 45 minute
cylinders was exceeded. Members, at all levels, did not monitor the
operating time in an IDLH atmosphere.
Members operated in a building that was undergoing asbestos abatement and
did not have their facepieces continuously donned.
An important attribute found within the culture of the NYC Fire Department is the
"can do attitude". The "can do attitude" has enabled the FDNY to protect life and
property at a superior level of excellence since the Fire Department's inception.
This attitude can also cause Firefighters and Officers to ignore written policies and
procedures such as SCBA usage, in order to get the job done. When operating in an
IDLH atmosphere many Fire Department members continue to operate after their
vibralert alarm activates. Many Fire Department members also remove their
facepiece in an IDLH atmosphere exposing themselves to carbon monoxide and
Button. The members of Engine Company 24 were not equipped with hand ie-talkies
with the remote Emergency Alert Button.
Note: All MX 3500 handie-talkies have been equipped with an Emergency Alert
Button on the remote microphone.
The Command Channel was not established when the signal 10-76 was transmitted.
Later, just as the Command Channel had been ordered into use, numerous
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emergency transmissions reporting members in distress began. Chief Officers
continued to communicate with the Incident Commander on the Primary Tactical
Channel. Proper use of the Command Channel would have reduced the amount of
radio traffic on the Primary Tactical Channel possibly allowing for more effective
communications.
33. Many members demonstrated initiative and capability in several areas while
operating at this fire:
They quickly supplied the standpipe siamese.
They supplied the standpipe outlet on the second floor in an attempt to get
water up to the fire floor after it became known that the building siamese
would not supply the standpipe system.
They sought out and consulted building construction personnel in an effort to
resolve the water supply problem with the standpipe system.
They performed the arduous task of pulling additional 2 112" hose up to the
14th floor via the exterior of the building.
Engine Company Chauffeurs repositioned two ladder apparatus and raised
'. the aerial ladders to the scaffold providing emergency egress for members.
Engine Company Chauffeurs utilized a hoseline and multiversal appliances
to extinguish fires that had ignited at ground level on the south side of the
building.
Units operated for an extended period of time due to the numerous
emergency situations.
Although the members were physically exhausted, they removed the two
unconscious members from the IDLH in a timely manner.
34. Several members immediately transmitted MAYDAY and URGENT messages as
soon as they realized that they were in a potential life threatening situation. This
allowed adequate time for nearby members to assist them to safety. The response to
the training members have received on transmitting MAYDAY and URGENT
messages had a positive effect on the safety of these members.
35. Several messages were transmitted reporting that fire had extended to the 14th floor.
Some of these messages were intermixed with other emergency handie-talkie
transmissions. Due to numerous reports of missing members and the advanced fire
condition on the 15
th
floor, the escalating fire problem on the 14th floor was not fully
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realized by members. As a result, the fire on the 14th floor was not immediately
addressed.
36. The scaffold was used by members as a means of egress. The distance from the
building to the scaffold was approximately 4 feet. There was a platform on the
15
th
floor that allowed for safe egress from the building to the scaffolding. There
was no such platform on the 14th floor. When the conditions deteriorated rapidly
some members were forced to evacuate the 14th floor to the scaffold. Some
members exiting the building to the scaffold were secured with the PSS or a Life
Saving Rope. Other members were unsecured by any safety device as they moved
onto the scaffold.
37. Members vented windows on the 15
th
floor contrary to Section 6.3.8. of Firefighting
Procedures High-Rise Office Building Fires which states, "Ventilation of high-rise
office buildings shall be supervised and implemented by the Incident Commander. ..
Horizontal ventilation should be the last consideration as its effects are least likely to
be beneficial."
38. Carbon Monoxide (CO) Monitors (GasAlert Extreme) have a retrievable memory.
One of Ladder Company 1's CO monitors reached the maximum recordable level of
999 ppm at approximately 1614 hours when the conditions changed drastically on
the 15
th
floor.
39. A member performed a dangerous action when he climbed on top of the elevator
while it was positioned at the 14th floor. He rode on top of the moving elevator as
the exterior hoseline was lowered to street level. This was an unsafe act because the
member could have received an electrical shock, been struck by the ties that secured
the elevator to the building, or fallen off the descending elevator.
40. Both elevators on the north side of the building were not always staffed with a
Firefighter.
41. There are no set Fire Department guidelines or training for operating construction
hoists/elevators in buildings under construction or demolition.
42. Some members were given an assignment which they were unable to complete.
They did not inform their Officer or the Incident Commander that they were unable
to complete their assignment.
90 of 176
43. Unit integrity was not maintained due to rapidly changing fire conditions which
forced an emergency evacuation. This further complicated the Incident
Commander's attempt to account for all members.
44. Member accountability was extremely difficult because numerous members became
separated from their units. The Resource Unit Leader and the Field
Communications Unit Officer did not team up to work effectively to account for all
members in a timely manner. The use of the Primary Tactical Channel to complete a
roll call was ineffective because it was overwhelmed with numerous transmissions.
45. The communications systems required in high-rise office buildings (Fire Command
Station, In-House Phones, Class E System, Standpipe Phones, etc.) were not
available at this fire.
46. Three Engine Companies were teamed up to stretch the hoseline via the exterior of
the building. There was confusion on the 14th floor as to which unit was in overall
control of this hoseline. A Battalion Chief and the Engine Company Officers ,
involved in the stretch never established which unit would take control and initiate
the advance to extinguish the fire.
15
th
47. The Engine Company 24 Officer was forced to leave the floor when his
vibralert activated. He had entered the 15
th
floor alone from the B stairway to search
for the location of the fire. Shortly after commencing the search, the Engine
Company 24 Officer's vibralert activated. He returned to the B stairway where the
Engine Company 24 Nozzle Team was located with a charged hoseline. The Engine
Company 24 Officer informed Firefighter Robert Beddia (the Nozzle Firefighter)
that he was low on air and that he was dropping down. While attempting to exit, the
Engine Company 24 Officer became disoriented in the heavy smoke within the
B stairway and transmitted a MAYDAY. Eventually he was able to follow the
hoseline out of the stairway and make his way to the Q decking area on the
14th floor. He immediately notified several Officers and Firefighters that his unit
was still operating inside.
48. Progress Reports from the scene of the fire were not in accordance with section
10.3.2 of the Communications Manual. Progress Reports provide a continuing
history of the development, control and extinguishment of a fire or emergency.
Oftentimes, as operations become more complex and conditions deteriorate, Chief
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Officers have less time to focus on the transmission of the required progress reports.
As a result the progress reports are not always transmitted within the required
frequency. It is at these times that the transmission of a detailed progress report is
even more critical to convey a clear and accurate picture of the conditions existing at
the fire or emergency.
49. The first due Deputy Chief was a Battalion Chief acting Out of Title. The second
arriving Battalion Chief was a Captain acting Out of Title and was the Company
Commander of Engine Company 24.
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VIII. CAUSES
DIRECT CAUSE
1. Smoke Inhalation
INDIRECT CAUSES
1. Construction of combustible structures on numerous floors within a fireproof
structure with a non-functioning sprinkler system.
2. Careless discard of smoking material.
3. Failure to maintain an operational sprinkler system as required by the New York
City Building Code.
4. Failure to maintain an operational standpipe system as required by the New York
City Building Code.
5. Failure to maintain emergency fire exits as required by the New York City Building
Code. The sealed wooden platforms on the 14th floor prevented egress to the safety
of the 13
th
floor.
6. SCBA Policies and Procedures not followed regarding:
Immediately leaving the IDLH atmosphere on activation of the vibralert alarm.
Removal of SCBA facepiece in an IDLH atmosphere.
BASIC CAUSES
1. Delayed notification to the Fire Department.
2. Failure of the contractor(s) to ensure that fire protection systems remained
operational.
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IX. RECOMMENDATIONS
1. Ensure that Firefighters are trained annually by the Division of Training and
demonstrate competence in the following five areas:
All Scott 4.5 SCBA Policies and Emergency Procedures (reduced profile,
quick release, use of the purge valve, etc.).
All Personal Safety System (P.S.S.) Evolutions.
How to properly transmit your own MAYDAY or URGENT handie-talkie
transmissions. Emphasis shall be placed on the procedures outlined in
Communications Manual Chapter 9.
How to react when a MAYDAY or URGENT transmission is given by
another member. Emphasis shall be placed on procedures outlined in the
Communications Manual Chapter 9. Proper handie-talkie discipline on the
fire ground must be included III this training. Reinforce that only
emergency transmissions should be made when the Incident Commander
orders all handie-talkie traffic to cease.
All Life Saving Rope Evolutions.
These five areas are so vital to personal survival on the fireground, that they must
be repeated annually by an fuB duty members.
2. Ensure that Chief Officers are trained annually by the Division of Training and
demonstrate competence in the following areas:
All Unit Circular 320 (Procedures For Managing Lost, Trapped or
Seriously Injured Members Requiring Extrication).
Communications Manual Chapter 9, Section 9.4 (Emergency Handie-
Talkie Communications).
These topics are so vital for the effective management of operations when
members are in distress, that they must be repeated annually by all Chief Officers.
3. Strictly enforce policies and procedures of All Unit Circular 220, Self-Contained
Breathing Apparatus (SCBA) Policy, and All Unit Circular 329 FDNY
Policy/OSHA Respiratory Standards as they relate to the use of the Scott 4.5
SCBA, including the following:
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When the vibralert alarm activates the member must notify their Officer
and immediately leave the contaminated area. This member MUST be
accompanied to a safe area by another member using an SCBA.
The SCBA facepiece must be continuously donned when in an IDLH
atmosphere. Removal of the facepiece to conserve air, to increase visibility, or
to improve communication is dangerous and this practice must not be allowed
to continue. As per Training Bulletin SCBA, Addendum 3, "Exposure to 1.3%
of carbon monoxide will cause unconsciousness in two or three breaths and
wi1l cause death in a few minutes. Exposure to small concentrations for only a
few seconds inhibits one's ability to think clearly, rapidly causes disorientation,
and gives a feeling of euphoria compounding the risk hazard."
All members must be teamed-up when entering, leaving or operating within
an IDLH atmosphere as per All Unit Circular 329, FDNY Policy/OSHA
Respiratory Standards.
Facepiece sharing with other members and/or civilians is PROHIBITED.
Facepiece sharing hampers the search for an exit, increases the exposure to
airborne contaminates such as carbon monoxide, and depletes the limited
air supply in less time, thus posing risk to both victim and rescuer.
Therefore, victims should be removed from the contaminated area as soon
require the entire Nozzle Team (Engine) or the entire Inside Team (Ladder) exiting
together when the Officer is forced to leave the IDLH area.
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5. Re-emphasize to all members that the actual working and exit time achieved from an
SCBA will vary considerably depending upon physical conditioning, type of work
load, physical characteristics, training and a number of other factors. Each member
must be aware of their individual consumption rate when using an SCBA and how this
effects their work and exit times. The Fire Department should establish the means for
members to determine their personal air consumption rates when using an SCBA.
6. Research new technologies which would allow the air supply of operating members to
be monitored from a remote location. This technology should be utilized and
procedures should be established to ensure compliance with existing SCBA policies.
7. Reinforce to all members the importance of immediately transmitting a MAYDAY
message when faced with a potentially life threatening situation.
8. Equip all handie-talkies with an Emergency Alert Button on the remote
microphone. The Emergency Alert Button on the body of the handie-talkie is
difficult to access when properly wearing PPE.
Note: All MX 3500 handie-talkies have been equipped with an Emergency Alert
Button on the remote microphone.
9. Re-emphasize the use of the handie-talkie Emergency Alert Button for any
MAYDAY or URGENT transmission. The use of this button will boost the
wattage of the transmitted message from two to five watts. The use of the
Emergency Alert Button will cause the Emergency Alert Tone to sound signaling
the Incident Commander and other members at the scene that there is a MAYDAY
or URGENT situation in progress. If a member transmitting a MAYDAY or
URGENT message does not use the Emergency Alert Button, then the Incident
Commander should use hislher Emergency Alert Button to gain control of the
handie-talkie network and alert members on the scene of the emergency situation.
10. 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 notification must be made because incoming units
and different levels of command must be made aware that a life threatening
situation has developed. An announcement shall also be made on both radios when
the MAYDAY situation has been resolved.
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11. Re-emphasize to all members that a message transmitted on the handie-talkie
network must be directed to a specific member by unit number and position.
Names should not be used during routine transmissions. Members transmitting a
message must identify themselves by unit number and position. Any message not
acknowledged must be considered as not having been received. This message
must be transmitted again until it is acknowledged.
12, Develop a system to track the inspections by units of buildings undergoing
construction or demolition as required by section 5.8 of the Fire Prevention
Manual.
Note: Procedures are now in place to ensure that buildings under construction or
demolition greater than 75' are inspected every 15 days as required.
13. Develop a system of notification between the Fire Department and the Department
of Buildings which will ensure that timely notification is made when a permit is
issued for the construction or demolition of a building.
Note: Implementation of this recommendation is being addressed in the
"Strengthening the Safety, Oversight and Coordination of Construction,
Demolition and Abatement Operations" report by Mayor Michael R. Bloomberg.
This report was developed by the Construction, Demolition & Abatement Working
Group which included the Fire Department of New York.
14. Develop a system of notification between the Fire Department and the Department
of Environmental Protection which will ensure that timely notification is made
when a pennit is issued for asbestos abatement within a building.
Note: Implementation of this recommendation is being addressed in the
"Strengthening the Safety, Oversight and Coordination of Construction, Demolition
and Abatement Operations" report by Mayor Michael R. Bloomberg. This report
was developed by the Construction, Demolition, & Abatement Working Group
which included the Fire Department of New York.
15. Establish written guidelines to be followed by units when required to conduct
inspections in buildings undergoing asbestos abatement.
16. Incorporate and develop where necessary all pertinent information and procedures
into a single guide pertaining to buildings under construction and demolition with
emphasis on high-rise buildings. Numerous Fire Department documents currently
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address different areas relating to this subject. This guide would provide for all
related information to be incorporated into an inclusive publication for reference.
This guide should include but not be limited to the following:
Construction hoists/elevators.
Scaffolds: types, dangers and the use of.
Temporary shoring for recently poured concrete.
Common hazards found at construction sites. (Open shafts, cranes, wind,
tar kettles, propane use etc.)
17. Train FDNY members to become familiar with and safely operate construction
hoists/elevators at construction sites. Drills should be conducted at construction
sites to familiarize members with the safe operation of hoists/elevators. The
hoists/elevators would still be available for Fire Department use even if civilian
workers were not present to operate them.
18. Ensure that a handie-talkie equipped member is always assigned to any fireman
service or manually operated elevator being used for firefighting operations.
19. Analyze alternate means of providing water to the upper floors of a high-rise
building when the standpipe system is out of service. This should include:
Procedures to provide an emergency repair to a damaged standpipe system.
Guidelines and limitations of using FDNY hose as an exterior standpipe
system.
20. Re-emphasize to all members the importance of communicating to their Officer or
the Incident Commander that an assigned duty has not been completed. This may
be more critical than communicating the results of a completed assignment.
21. Reinforce the importance of not venting windows in a high-rise building unless
approval is given by the Incident Commander.
22. Reinforce the importance of maintaining unit integrity during high-rise operations.
23. Emphasize the importance of units verifying CrDS information at least on an
annual basis and updating as necessary.
NOTE: Administrative units can access this information on the intranet.
24. Reinforce to all Chief Officers that there are alternative means of broadcasting
emergency transmissions to gain control of the handie-talkie network:
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Use of the emergency alert button on the handie-talkie to boost power to five
watts
Use of the 40 Watt UHF Mobile Radio in the Battalion and Division
vehicles.
Use of the Post Radio on the Primary Tactical Channel to broadcast a
message at 45 watts.
25. Re-emphasize to all Chief Officers the importance of transmitting preliminary and
progress reports particularly when conditions are deteriorating.
26. Reinforce that Battalion vehicles must remain on with the motor running during
operations so that the Battalion Handie-Talkie Recorder will continue to record for
the duration of the incident. Presently, the Battalion Handie-Talkie Recorder stops
recording handie-talkie messages approximately 30 minutes after the vehicle's
motor is turned off.
27. Analyze the feasibility of eliminating Acting Out of Title for the ranks of Deputy
Chief and Battalion Chief except on an emergency basis after the start of a tour.
This analysis should include the effect this situation creates at fire operations. It
should also analyze the effect on administrative efficiency when the Company
Commander or the Battalion Chief is not working in their assigned unit.
28. Research the feasibility that an handie-talkie radios be equipped with a short term