NIOSH urges training improvements after firefighter's fatal fall
Daniel Capuano fell through an elevator shaft while fighting a fire in a former slaughterhouse in December 2015
By Peter Nickeas
CHICAGO — A Chicago Fire Department battalion chief saw one of his firefighters fall to his death seconds after the chief radioed crews to be on the lookout for openings in the floor that weren't secured or covered, according to a federal safety report.
Daniel Capuano, 42 years old and a 15-year veteran of the department, fell through a 7-foot-square elevator shaft while fighting a fire in a former slaughterhouse in the 9200 block of South Baltimore Avenue in December 2015.
Capuano and another firefighter had split up after reaching the second floor and encountered heavy smoke as they conducted a search for anyone trapped, according to the report by the National Institute for Occupational Safety and Health.
The report recommended better use of the "buddy system" so firefighters aren’t alone when searching buildings.
The report also noted that one of the engines responding to the scene was down a firefighter. If fully staffed, it “would have provided additional personnel for a more efficient rapid intervention and to aid in removing (Capuano) from the basement.”
Chicago Fire Department spokesman Larry Langford said firefighters normally do work in pairs, but not always.
“Our standard procedure is two in, two out. You go in as a pair, you go out as a pair,” he said. "There are times when a firefighter will separate, but the intent is to keep them together.
“There was actually a group of four, and other people in the group literally missed that hole by inches,” Langford said. “But they were together. The problem there was visibility and lack of proper safety measures in place, which should have been in place in a building like that. There should never be open floors in building without some form of railing or some barrier to prevent you from walking into a hole.”
Langford disputed the report’s assertion that an extra member on an engine would have helped in removing Capuano from the basement.
“When he went down, he was spotted, literally spotted falling,” Langford said. “Crews were immediately dispatched to go get him, and multiple members went to that spot. An additional body in our opinion would not have made a difference in getting him out of there.”
Capuano and another firefighter had been assigned to search the second floor, where the heaviest smoke was found by arriving crews around 2:50 a.m. Dec. 14, 2015, according to the report. They were the second pair of firefighters to check the second floor during an initial search of the building.
Capuano’s lieutenant and another firefighter had made their way through the smoke using a pry bar and "right-hand" search, the lieutenant in front and the other firefighter immediately behind him. When Capuano and a firefighter from a different truck reached the second floor, Capuano went left and the other firefighter went right, according to the report.
After other crews had encountered open holes on the second floor, the battalion chief radioed firefighters to “watch where they are walking,” the report states.
Seconds later, the chief saw something fall and asked what it was. He walked to the opening and saw Capuano in the basement. He radioed “mayday” to bring more firefighters and ambulances to the scene.
There was an aluminum ladder from the first floor through the elevator shaft to the basement, and a lieutenant climbed down while the chief went outside and directed crews toward Capuano. The firefighter was taken to Advocate Christ Medical Center in Oak Lawn, where he was pronounced dead less than two hours later.
City officials later said the owners of the building had been removing the elevator without authorization and had failed to secure it.
The fire was caused by a welder who worked alone in the building about 12 hours before the fire was reported. He worked until about 1 p.m. and “had extinguished a number of small fires in the area where he was working on the second floor” but “did not recognize that fire was smoldering within the wall," the report states.
The fire smoldered until about 2:35 a.m. before someone passing by noticed smoke and called 911. Investigators from the National Institute for Occupational Safety and Health weren’t able to get inside the building because of "ongoing criminal investigations,” but the report stated that the Fire Department was able to track movement of firefighters by tracks in the powder left behind by the welder’s fire extinguisher.
The first crews found heavy smoke on the second floor and glowing embers falling along the wall with the elevator shaft, according to the report. Despite the heavy smoke, the first engine’s lieutenant didn’t find "elevated heat conditions" using a thermal imager.
Fire crews had to return the next day to put out “deep-seated smoldering fire” in insulation materials that had been used to keep the building cool since it had once been a slaughterhouse.
The NIOSH report listed several factors that contributed to Capuano’s death: searching the second floor alone; unsecured floor openings; deep-seated fire; zero visibility; and inadequate shielding of flammable materials during welding.
The report’s first three recommendations deal directly with the search that led to Capuano’s death. It notes that the Fire Department should ensure crew integrity, train firefighters on becoming proficient in limited-visibility searches and better train firefighters on situational awareness.
Langford said training and protocols for "large-area searches” over areas of low visibility have been revised since the fire to include the use of ropes. About 75 percent of department members have undergone “rope-assisted search technique” training, Langford said. The Fire Department fills a building on Pershing Road with smoke and the members go through a simulated fire search using ropes.
The report also recommends using "risk management" principles to evaluate how aggressive they should be in fighting some fires. It noted that “more caution” should be used fighting fires in abandoned, vacant and unoccupied structures or if there is no evidence of people inside. The first sweep of a building — meant to find possible occupants — is called a "primary search."
“Firefighters should anticipate the possibility of floor openings and other hazards whenever they enter buildings that may be under construction, renovation or otherwise unsafe," it adds. Obvious signs would be dumpsters and construction debris outside.
That’s not the way the Chicago Fire Department evaluates fires, Langford said. Every building gets a primary search on the assumption it’s occupied — and the only limiting factor is the safety of the firefighters making the search.
If the building is unstable or too engulfed, it would delay the search, Langford said.
“We’re going to do a primary search. We do fires in a lot of abandoned buildings. They’re supposedly abandoned, and vacant and many times we find people living them,” Langford said. “We know fires don’t start by themselves.”
The report noted that fires in cold-storage buildings present a unique challenge: layers of insulation on outside walls. Six firefighters died in Massachusetts when they became lost in a “mazelike” cold-storage warehouse.
The report also refers frequently to unsafe building conditions and says the city should ensure firefighters have more information when rolling up on vacant buildings. There could be a marking system for buildings under renovation, including specifics about the work for a crew that is dispatched, it suggested.
The owners of the building had received permits in September 2015 for construction work, but none authorized the removal or demolition of an elevator. If they had, the city would have completed an elevator inspection to make sure it was safely decommissioned before issuing the permit for its removal, according to the building department.
“If building owners choose to ignore the permit process and (fail to put) commonsense safety procedures in place, a database won’t help with that,” Langford said. “There won’t be any data in it. If building owners comply with requests for permitting and safety, a database would be filled with information that would be very useful to Fire Department. In this case, it wasn’t done.”
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