By Mike Hendricks and Matt Campbell
The Kansas City Star
KANSAS CITY, Mo. — A new federal report cites a series of operational failures that contributed to the deaths of two Kansas City firefighters at a blaze on the city’s old Northeast side nearly two years ago.
The report released Thursday said the two men should not have been in an alley next to the three-story brick building after all personnel were directed to pull back because of fears the walls would collapse.
Six minutes after that order was given, they died in an avalanche of bricks.
Poor communication and commanders’ failure to follow safety procedures were among the key failings contributing to the men’s deaths noted in the report from the National Institute of Occupational Safety and Health.
None of its conclusions are surprising. Instead, the document underscores conclusions reported by The Kansas City Star two months after the deaths of John Mesh and Larry Leggio, as well as the Kansas City Fire Department’s own internal investigative report published in the spring of 2016.
While not assigning blame — NIOSH reports never do — federal investigators said commanders did not keep track of where all firefighters were operating the night of the fire, did not have a designated safety officer on duty until after the wall collapse, and did not act quickly to evacuate the perimeter of the building after ordering the establishment of a collapse zone.
Fire Chief Paul Berardi has acknowledged previously that his department did not have a collapse zone policy at the time of the tragedy, but adopted one several months later during a review of all department policies.
In an investigation spurred by the deaths, the Star found that the Kansas City department was not unusual among fire departments. In case after case, departments across the country often fail to heed the lessons they should have learned from others’ fatal mistakes.
The new report notes that a communication breakdown was also partly to blame for the fact that Mesh, 39, and Leggio, 43, were still working within a few feet of the burning building several minutes after the evacuation order was issued.
One of their superiors had ordered them to pour water on the flames through a window.
The report also cites a failure to have a system in place at the time of the fire for commanders to keep track of where firefighters were operating at any particular time.
The department had no immediate response to the release of the report Thursday morning.
Berardi is expected later Thursday to discuss the changes the department has made in its policies and procedures to improve safety at fire scenes.
Prosecutors say the fire was arson and have charged the operator of a nail salon in the building, Thu Hong Nguyen, with two counts of second-degree murder and causing the catastrophe. She pleaded not guilty and a trial is set to begin next month in Jackson County.
Federal investigators began their probe a week after the blaze that killed Mesh and Leggio and finished it in July. Family members and department officials reviewed it before it was published online Thursday morning.
It was around 7:30 p.m. on Oct. 12, 2015, when the first alarm was sounded on reports of thick black smoke and flames at a combination apartment and retail building near the corner of Independence Boulevard and Prospect Avenue.
The first firefighters to arrive rescued several occupants and struggled to contain the blaze as more units were requested. Before it was over, more than 110 firefighters and other emergency personnel responded to the scene, the report said.
But about 20 minutes into the operation, the fire was burning out of control and all personnel were ordered out. As firefighters were removing their hoses and other equipment, parts of the building interior began to collapse, which was a signal that the exterior might also fall.
At 8 p.m. the incident commander ordered the establishment of a collapse zone.
“All companies move back,” a dispatcher announced over the radio. “All companies move back. Create a collapse zone.”
At a minimum, that would have meant retreating a distance equal to one and half times the height of the building.
But according to the federal report not everyone on the scene heard the order and several firefighters, including Mesh and Leggio, continued to work in an alley on the east side that was just 30 feet wide, with buildings on both sides.
Recognizing this, a commander was about to reiterate his order to get out when, at 8:06, a chain reaction began, the report said. The interior floors of the burning building collapsed, leading to the failure of the east exterior wall by the alley.
The wall weighed nearly 70 tons, federal investigators said.
Mesh and Leggio were buried completely and died of blunt force trauma. Two other firefighters were injured. The falling bricks forced one to his knees and under a fire truck and another was buried to his waist with debris.
Copyright 2017 The Kansas City Star