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‘Broken’: New report on Worcester FD highlights dysfunctional communication as a key element in LODDs

A nearly 250-page report described leadership that needs “immediate intervention” and a lack of on-scene management that lead to firefighter deaths


Members of Rescue 1 honor fallen Firefighter Jon Davies Sr.

Photo/Scott Croteau

Michael Bonner

WORCESTER, Mass. — A nearly 250-page report, submitted to the Worcester City Council on Monday, described a “broken” communication system within the Worcester Fire Department, leadership that needs “immediate intervention,” and a lack of on-scene management that lead to firefighter deaths.

The city wanted an unabridged examination of the fire department following nine line of duty deaths in 21 years.

While many of the recommendations in the report drafted by Emergency Services Consulting International provided broad strokes on training and staffing, the areas of leadership, communication and on-scene management received the most criticism.

“Scene accountability must be maintained at all times,” the report said. “... The Worcester Fire Department does not currently have a system that accomplishes this requirement. This lack of accountability is a fundamental element in the line of duty deaths.”

Since 1999, the Worcester Fire Department has endured more tragedies than most. Ten members of the department have died in line of duty deaths. Their names and corresponding last alarms are included on page 10 of the 248-page report: the Worcester 6 — Lt. Timothy Jackson Sr., Lt. James Lyons II, Lt. Thomas Spencer, and Firefighters Paul Brotherton, Jeremiah Lucey and Joseph McGuirk — to Jon Davies Sr., Christopher Roy and Lt. Jason Menard.

The department also suffered another line of duty death in July 2019 when Lt. John Kennedy died after fighting a fire. Kennedy’s death however, was not mentioned in the ESCI report.

Those lost lives inspired the city to contract the report in March of 2020 to ensure another name wouldn’t be added to the list.

ESCI held listening sessions at every fire station in the city on all four shifts at the end of February as part of the study. ESCI also initiated an anonymous survey after the listening session, in which 266 firefighters, or 62.2% of the force, participated.

Through the interviews and surveys, ESCI developed a report outlining everything from earthquake preparedness in the city to leadership within the fire department.

Overall, 62% of the respondents said morale was poor in the Worcester Fire Department, however, the report also said most firefighters reported strong morale within their station.

“I think we have a great fire department. I think we have amazingly dedicated men and women, uniformed and nonuniformed folks from the fire department that do incredible work every day,” City Manager Edward Augustus Jr. said in an interview with MassLive. “And we owe it to them to make sure they have all the tools, all the support so they can do the job that we ask them to do every day.”

The report shone a spotlight in some new areas such as a fire chief versus a fire commissioner but also resurrected old talking points that date back to 1999. The city paid roughly $95,000 for the consulting company to produce the report.

The ESCI report resurfaced recommendations provided by the National Institute of Occupational Safety and Health in 2000 regarding the Worcester Cold Storage and Warehouse Co. fire that killed six firefighters.

More than two decades separate the reports but similar language recommending clear on-scene protocols and management exist in both.

In the 2000 report, NIOSH said, “Accountability on the fireground is of paramount importance. It is the responsibility of all officers to account for every firefighter assigned to their company and relay this information to Incident Command.”

The 2021 report said the NIOSH recommendations specific to the firefighter deaths in Worcester should be followed. It said currently the department doesn’t possess the accountability and its absence acted as a key element in the line of duty deaths.

The consensus among those interviewed was that the communication chain in the department is “broken, causing even the best of intended programs to fail, or be undermined due to a lack of explanation of the purpose, need or vision,” the report said.

According to the report, one firefighter said he received four different orders at a fire the week before ESCI arrived for its interviews.

The situation is common in Worcester, the report said, as district chiefs often give orders despite not being on scene.

“The District Chief will give an order to the apparatus to his division because ‘they are my guys,’” the report said.

Some of the on-scene problems may result from a disjointed chain of command system. Firefighters reported to ESCI that senior staff is only visible when “something is going wrong.”

Transparency also was a problem within the departments as firefighters expressed “anger, frustration and disappointment” after the department didn’t release much information surrounding Board of Inquiry reports for the deaths of Firefighter Christopher Roy and Lt. Jason Menard.

“There was a perception among many of those who spoke with ESCI that the Roy inquiry might have contained information that could have prevented the Jason Menard line of duty death,” the report said. “There is current concern that the Jason Menard inquiry may contain information that could potentially prevent the next line of duty death.”

When new information is discovered, it doesn’t appear to be implemented into the department’s rules and regulations and guidelines.

The rules and regulations of the Worcester Fire Department came into effect in 1972 and firefighters told ESCI that they are still relied upon today, despite many outdated items.

For example, Chapter VI, Section 3 states that members of the department must provide themselves with a fire helmet, fire boots, a rubber coat and work gloves.

Chapter X, Section 40, requires Fire Chief Edward Hackett to be called on a third alarm. Hackett retired 42 years ago and died in 2008, according to the report.

Many of the same issues appear in the department’s guidelines with the report stating that 65% were created before 2018.

ESCI said rules and regulations and guidelines should be reviewed and updated every three years. It also suggested that following updates, the department consult the third party to ensure compliance and best practices are followed within the department.

“The development and implementation of updated rules, regulations and guidelines will enable the Worcester Fire Department to move forward in an organized and effective manner,” the report said. “In the absence of these documents, an organization will tend to operate in a random and generally ineffective manner.”

Who oversees the undertaking of recommendations in Worcester remains a question.

Possibly the most notable change within the 10 recommendations issued by ESCI involves establishing a temporary fire commissioner and abandoning the city’s current leadership which is a fire chief.

“The Worcester Fire Department has some very capable people within its organization,” the report said. “The city could not be setting them up for success as the next chief of the Worcester Fire Department if anyone within the organization were to be promoted chief without the organization first being stabilized.”

Fire Chief Michael Lavoie is set to retire on Jan. 22.

Augustus said he plans to follow the recommendations of the report and install a fire commissioner that would work out of his office rather than within the fire department.

The commissioner could be an outside hire rather than promoting from within the department.

The best candidate, the report said would be someone with fire chief experience, but someone who can also captain the culture change within the department over the next few years.

“It’s really to get some of these big recommendations off the ground, to really facilitate that whole implementation phase,” Augustus said. “Because there are going to be some tough things to do.”

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