A newly released NIOSH line-of-duty death report is among the more chilling I’ve read. It is chilling because otherwise isolated missteps conspired to claim the life of Cincinnati firefighter Daryl Gordon. And it is chilling because of how easy it is to imagine this scenario playing out nearly anywhere.
At about 5:30 a.m. on March 26, 2015, Cincinnati firefighters responded to a fire at a five-story apartment building. Gordon was the apparatus operator on a Heavy Rescue 14, one of the later arriving units. That rig’s crew was assigned to search the fifth floor; the fire was on the second floor.
It was during the search that Gordon, who was separated from his crew, came upon an outward-swinging door; visibility was about 5 feet. Gordon may have believed the door led to an apartment or utility room. In fact, it led to a disabled elevator. Gordon fell down the shaft and died.
The NIOSH report made 12 recommendations based on its line-of-duty-death investigation. Here are three key takeaways from this incident that other departments can use to prevent similar tragedies.
1. Prevention and detection
First and foremost, Gordon’s death rests squarely on the shoulders of the building owner. That elevator door never should have been left unsecured. If not Gordon, it could just as easily have been a curious child who fell down that shaft under everyday conditions.
This incident also points to the need for funded, staffed and robust fire inspection and enforcement measures. It must be more financially painful for building owners to leave hazards in place than it is to correct them — and they have to believe they will be caught.
One of NIOSH’s recommendations is the need for fire sprinklers. We’ll never know if fire sprinklers would have prevented Gordon’s death. But, it’s a safe bet that they would have slowed, if not stopped, the fire.
Anyone who has spent a day in this business knows fire sprinkler rules are a challenge for many jurisdictions. In Cincinnati’s case, because the apartment building was put up in 1962, it was grandfathered in — essentially made exempt from new sprinkler requirements.
That’s a mistake. All multi-family residential buildings, regardless of construction date, should have sprinkler and alarm systems. That, of course, is a tough and on-going battle.
2. Crew integrity
Gordon was the last member of his crew to enter the building. At some point he became separated from them during the apartment-by-apartment search.
One of Rescue 14’s members found the unlocked elevator door and used a permanent marker to write a warning on it. As a side note, that firefighter recognized that the door was different from the others and was cautious enough to determine the hazard.
Cincinnati Chief Richard Braun said the search crew believed Gordon was still with them when they discovered and marked the elevator door.
NIOSH wrote that it is every firefighter’s responsibility to keep the crew together, but that the ultimate burden falls to the officer in charge of the crew. There are too many instances to list where firefighters got in trouble after being separated from their crew.
While obvious, it is worth restating that interior crews must maintain visual or touch contact with other crew members at all times.
3. Resources
A lot of the conspiring factors that led to Gordon’s death and slowed his rescue can be traced back to a lack of resources — both human and equipment.
Firefighters and officers on scene struggled to get a clear, early assessment of the situation, to get water to the fire, to get accurate communications between command and crews, to rescue residents and to set up accountability.
Having the benefit of all the facts, hindsight and no stress, it is easy to Monday-morning quarterback this incident. But this fire must remind us that it is better to call for more help early, than to wait until the additional resources are needed.
And that’s especially true for departments that rely on mutual-aid companies from neighboring jurisdictions, as those resources will take even longer to arrive. Unneeded rigs and firefighters can always be put back in service.
It’s beyond commendable that the Cincinnati Fire Department has exposed itself to the scrutiny that comes from releasing their internal investigation and participating fully with the NIOSH investigation.
We shouldn’t forget that they made the strategic and tactical decisions in the heat of a fluid, dynamic firefight with trapped victims. And we shouldn’t forget that nearly a year and a half later they are still hurting from the loss of Daryl Gordon.
Most importantly, we must remember that a situation similar to what Cincinnati firefighters faced that early March morning can happen just about anywhere, to any department.
