By Dale Lezon and Dane Schiller
The Houston Chronicle

HOUSTON — Houston firefighters failed to follow proper procedures when battling an office blaze that killed three people earlier this year, according to a Houston Fire Department report released Tuesday.

The 24-page report also said 911 emergency operators did not pinpoint the exact location of victims in the building, including one of the three who perished in the fire.

The Quality Assurance Report noted that firefighters rescued several people trapped by fire on the upper floors of a six-story, atrium-style office building at 9343 North Loop East on March 28, but faulted the firefighters for poor communications and failure to adhere to department guidelines.

"We're mapping out a management plan to address those issues," Executive Assistant Chief Rick Flanagan said Tuesday night. "We're not out to punish anyone. We want to use this as a learning tool."

Nothing in the report indicates that any missteps directly led to the deaths.

Killed in the blaze were Jeanette Hargrove, 52, of Friendswood; and Marvin Wells Sr., 46, and Shana Ellis, 38, both of Houston.

Investigators say Misty Ann Weaver, who worked at the building for a cosmetic surgeon, admitted to setting the fire to delay the deadline on an audit. Weaver, 33, is charged with three counts of felony murder and one case of arson.

The report includes a desperate 911 phone call that offered a glimpse into the final moments of the lives of two victims trapped inside.

Hargrove and Ellis were together on the fifth floor.

Hargrove called 911 and was connected for as long as 23 minutes, but the emergency operator failed to determine a precise location, other than finding out she was on the fifth floor.

An abridged timeline released as part of the report does not include the actual dialogue between Hargrove and the operator, but seems to indicate that she was overcome by smoke.

Three minutes after Hargrove called 911, the operator asked Hargrove if she could hear fire engines heading to the scene. It is unclear from the report if she could.

Two to three minutes later, the operator asks Hargrove how she is doing. Her voice is "decidedly weaker.''

Approximately four minutes later, Hargrove is barely able to speak to the call taker. Two minutes later, the operator attempts to speak to Hargrove, but gets no answer. The operator continued to try to speak to Hargrove to let her know firefighters are pulling people out of the building.

The operator tries to get Hargrove to tell her what room number she is in so that she could perhaps be rescued. Weak coughing is heard over the line. Hargrove says nothing.

Approximately one minute later — 19 minutes after she first called 911 — snoring is heard over the phone line.

That is the last contact noted.

The report lists 26 "areas of concern," some of which criticized firefighters.

That included a fire captain who neglected to "maintain crew integrity" and had to be rescued after he become lost in the pitch-black smoke inside the building.

The captain and two other firefighters ascended to the fifth floor to look for possible victims or survivors. After sending two crewmen to get a nozzle, he searched the area around him and became lost. He radioed for help, and other firefighters rescued him.

The report also stated that not all firefighting crews were equipped with "tag lines," safety devices that clip on firefighter uniforms and link them together as they move through burning buildings. The report also cited the "freelancing" of firefighters who completed tasks they hadn't been assigned. The report said that undermined safety and accountability.

Poor communications between the command post and firefighters created confusion, the report stated. Some units responding did not report directly to the command post or failed to report at all, undermining the leadership's ability to keep track of what resources were available to fight the fire.

Also, some fire crews left their assigned response areas before they were officially dispatched to the fire, placing burdens on other crews to handle emergency calls in the undermanned neighborhoods.

The report also said the building did not have a complete sprinkler system or a central alarm to alert people inside the building to smoke.

The building met city code requirements when it was built in 1980. In 1981, the city changed its code to require fire-suppressing technology in all rooms of new office buildings.

But as many as 40 atrium structures did not have to make the improvements under a grandfather clause.

The victims' relatives had different views about the report.

"If this stuff is confirmed, it is amazing," said Jerome Ellis Jr., brother of Shana Ellis. "What I'd like to see is whoever is responsible for overseeing these issues be held responsible so nothing else slips through the cracks. We need to address it so other people's family members won't be in harm's way.

"Nothing is perfect, but if there is something that was left undone, there needs to be a change."

Willie Hargrove, whose wife died in the blaze, said the firefighters did their best.

"I have nothing against the Houston Fire Department," he said. "They did a terrific job in my eyes. I'm not even looking at the report. To me, I think they did everything humanly possible to rescue people. It was just a bad situation."

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