fdny report on fatal fire, january 5, 1996

8/4/2019 FDNY report on fatal fire, January 5, 1996

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FIRE DEPARTMENT CITY OF NEW YORK

FATAL FIRE REVIEW BOARD

QUEENS BOX 2-2-1201 40-20 BEACH CIIANNEL DRIVE

JANUARY 5, 1996

FATAL rNJURY

FIREFIGHTER JAMES B. WILLIAMS

LADDER COMPANY 121

PREPARED BY FATAL FIRE REVIEW BOARD:

FRANK P CRUTHERS CHIEF OF DEPARTMENT

DAC PETER E. HAYDEN CHIEF OF SAFETY

DC PHILfP 1. BURNS DIVISION 6

BC JOHN W. McELROY BATTALION 17

CAPT. ALLEN S. HAY ENGINE COMPANY 16

LT. LARRY W WESTON LADDER COMPANY 175

FF. MICHAEL MULUGAN ENGINE COrvtPANY 235



I-SUMMARY

On January 5, 1996 at 2210 hours, the New York City Fire Department

Queens Central Communications Office received a telephone alarm

reporting a fire in apartment 3F at 40-20 Beach Channel Drive, Edgemere,Queens. The building is a 13 story fireproof multiple dwelling

approximately 130' x 250', irregular shape.

Units of the NYC Fire Department were dispatched. The units arrived in

normal response sequence. There were no delays in response. The officer of

Ladder Company 121 observed smoke issuing from the exposure 2 side of

the fire building. Via handie-talkie, the officer of Ladder Company 121

instructed Engine Company 264, the second due engine, to transmit the 10

75 via department radio. The 10-75 was transmitted at 2215 hours.

Fire Department operations were initiated. Engine Companies used

standpipe stretches. Ladder companies performed ventilation, entry and

search. During the initial search of the fire apartment by the members of

Ladder Company 121, wind conditions caused a sudden and unexpected

intensification of the fire, forcing the ladder company to quickly exit the fire

apartment. The rapid deterioration of conditions caused the Officer and

members of the Forcible Entry Team to become disoriented and theybecame trapped at the opposite end of the hallway. The Officer and Forcible

Entry Man were able to later escape to the stairwell. However, Firefighter

James B. Williams '-vas subsequently found lying approximately ten feet

from the fire apartment door in the west end of the hall, unconscious, with

serious facial bums. He was removed to the second floor where cardio

pulmonary resuscitation was performed. Firefighter Williams was removed

by Emergency Medical Services (EMS) persormel to Peninsula General

Hospital where he expired.



QUE;ENS BOX 22-1201 - 115/96

LADDER 121 OPERATIONS

Ladder 121 Assignments

RANK NAME POSITION

Capt. Rokee, John Officer

FF Olsen, John Chauffeur

FF Boyle, Dennis OYM

FF Sandhaas, Michael Roof

FF Gallagher, Brian Forcible Entry

FF (Deceased) Williams, James Can

2210:12

Assigned to Box 1201 as the first due ladder company.

2214:08

10-84 transmitted via MDT.

2215

Capt. Rokee, FF Williams, FF Gallagher and L-121 Roofman, with their

masks and tools, proceeded to the fire building. Capt. Rokee ordered

arriving E-264, via handie-talkie, to transmit a 10-75 because he saw smoke

blowing around from the exposure 2 side of the building.

2216

L-121 Chauffeur and L-121 OYM moved their apparatus into exposure 2

parking lot and assisted L 134 Chauffeur, OYM and Roofman with the

carrying and raising of two 35' ladders on the exposure 2 side, to the fire

apartment windows. Capt. Rokee, FF Williams, and FF Gallagher went tothe third floor via the A stair and found the fire apartment. L-121 Roofman

went to 4th floor for search and vent in the apartment above.



L-121 Operations

2217

Capt. Rokee told Lt. E-265 of the fire's location. Capt. Rokee donned his

facepiece. Capt. Rokee instructed FF Williams to follow him to the left for

search, and for FF Gallagher to go to the right. FF Gallagher donned his

facepiece, and when Capt. Rokee opened the unlocked apartment door, theyall entered the fire apartment. ,L-121 Roofman couldn't force the door of Apt

4F, over the fire apartment, and started toward roof.

2218

Within 15 seconds, conditions in the fire apartment deteriorated to extreme

heat and blinding smoke conditions.

2219

Capt. Rokee, FF Williams, and FF Gallagher had by this time exited the fire

apartment and left the apartment door open. L-121 Roofman entered the A

stair to go to the roof, but conditions deteriorated to such an extent that he

left the stairs at the 6th floor. He put on his facepiece, and re-entered the

stair to ascend to the roof.

2220

Capt. Rokee, FF Williams, and FF Gallagher retreated to the east end of the

hallway, 70' away. They missed the intersection of the "T" that led to the

stairs.

2221L-134 Chauffeur inquired on his handie-talkie whether they had water on

the fire floor. An unidentified voice said, emphatically, twice, to "Take the

glass". L-121 OYM vented the window (exposure 2 south window of fire

apartment). Fire vented out the window seconds later. L-121 Roofman

reached the roof level and opened the roof.

2222

FF Williams told FF GaEagher to force an apartment door. Capt. Rokee had

been sharing his facepiece with FF Williams. After several exchanges of the

facepiece, Capt. Rokee lost contact with FF Williams. FF Williams, out of

air, attempted to escape from the east end of the hallway, missed the

intersection and continued down the hallway toward the fire apartment. He

2



L-121 Operations

subsequently collapsed dl,le to serious facial bums and smoke inhalation,

approximately 10' from the fire apartment door.

2223

FF Gallagher transmitted a "Mayday" via his handie-talkie, after severalunsuccessful attempts to make his way out of the east end of the hallway.

2224

FF Gallagher's vibralert activated. FF Gallagher told Capt. Rokee that he

had to get out of there. FF Gallagher followed the left wall to the

intersection of the "T", heard the sound of water, and was hit by a stream of

water as he entered the intersection.

2225

FF Gallagher made his way to the south landing on the third floor. After

climbing over the members operating E-264's line, he entered the A stair.

Capt. Rokee similarly left the east end of the hallway and was assisted by L

134 Canman after entering the intersection of the "T". Capt. Rokee was

pulled into the north landing by Lt. Drennan E-265.

2226

Capt. Rokee and FF Gallagher were assisted to 2nd floor, Capt. Rokee via

the B stair and FF Gallagher via the A stair.

2227

Capt. Rokee transmitted a liMAYDAY - L-121 Canman is missing" while

on the 2nd floor south stair landing and attempted several times to get back

to the fire floor to search for FF Williams. BC 47 heard and verified the

"Mayday" from Capt. Rokee. L-121 Roofman was on the roof and heard the

I'v1ayday. FF Williams was found by the L-134 Canman who had taken over

E-264's nozzle. FF \Villiams was found 10 feet from the fire apartment,

lying on his left side, parallel to and facing the south wall. FF \Villiams was

dragged back to the north stair landing and carried down the B stair to the

2nd floor, where CPR was started by the Lt. E-264.

3



L-121 Operations

Subsequently:

121 Chauffeur assisted in carrying FF Williams from the second floor to

the street. FF Williams was then taken by EMS to Peninsula Hospital where

he was pronounced dead.

4



v -Findings

Queens Box 22-1201 - 1/5/96

In March of 1995, Battalion Chief Michael Maggio distributed to units of

Battalion 47 a Safety Message which dealt with operations in standpipe

equipped fireproof multiple dwellings (Housing Projects).

A disturbing number of Battalion 47 personnel who testified before the

Review Board were unfamiliar with the Battalion Safety Message.

Had this Safety Message and the policies and procedures of this Department

been adhered to by the first arriving units, this mishap would likely havebeen prevented.

FDNY firefighting procedures allow the initial line from the standpipe to be

operated from outlets in enclosed stairways on the same floor as the fire. At

this fire, the standpipe outlets were located in the hallways. The proper

procedure would have been to connect to the outlet on the floor below the

fire.

The first arriving engine company, Engine 265, connected their line to the

standpipe outlet on the fire floor. When conditions deteriorated, they were

forced to discontinue their operation. This line was never charged, and

265 never placed a line in operation.

Further, the investigation revealed that the initial line stretched from the

standpipe consisted of 2 lengths of 2!h" hose and a lead length of 1%" hose.

AUC 206R Section 5 states Department policy on standpipe use. The initial

line from a standpipe must be 2!h" in diameter. Subsequent lines stretchedafter the standpipe system is supplied by a Fire Department pumper may be

2!hl!, or when compatible with fire conditions, 1%" hose.



Findings

The Company Commanders of Engine companies 264, 265, 268 and 328, in

violation of Department policy, established policy and/or practice of

including a lead length of 1 3/4" hose in initial standpipe stretches. Had

proper procedure and policy been followed, the first arriving engine

companies would have provided a charged line on the fire floor earlier thanwas accomplished.

Even without a Fire Department supply to the standpipe siamese, the 2Y2"

line would have provided significantly more water than the 1Y.t" line. (See

standpipe test Volume II, Appendix.)

Had the fire apartment door been closed by Ladder Company 121 as they

exited the fire apartment, the fire would have been confined and immediate

escape would have been possible. With the fire apartment door open, the

fire extended into the public hall and drove the Officer and Forcible Entry

Team to the far (east) end of the hall.

Had the first arriving engine companies followed proper policy and

procedure, they would have placed an operating 2Y2" hose line between the

Officer and Forcible Entry Team at the east end of the hall, and the fire at

the west end of the hall.

Box 1201 was transmitted at 2210: 12 hours, January 5, 1996. The first

arriving Engine Company transmitted 10-84 at 2213:42. At 2240:41 hours,

Rescue 4 transmitted 10-84 and observed blow torch like fire extending

from two windows of the fire apartment. The first hoseline to reach the fire

apartment door and operate into the fire apartment did so at approximately

2241 hours, one half hour after the initial alarm. It was more than fifteen

minutes later that the main body of fire was extinguished.

There is no evidence that completion of primary search was reported.

Secondary search report, the only search report, was transmitted at 2344

hours.

2



Findings

A. WEATHER CONDITIONS

• Adverse weather conditions were a significant contributing factor at this

fire. The wind was blowing from the northwest. A window in the

bedroom where the fire originated was opened by the tenant in anattempt to remove the smoke from the apartment. When the tenant fled

the apartment, she left this window open. The open window contributed

to rapid fire growth. When the door to the fire apartment was opened,

gusting winds drove the fire back into the apartment toward the members

ofL-121.

• Gusting and shifting winds caused heat and smoke conditions on the fire

floor to alternate between extreme and moderate levels during the

operation.

• Snow and ice, in addition to the wind conditions, hampered exterior

operations. The first and second arriving ladder companies had difficulty

in raising portable ladders.

B. MECHANICAL DEVICES

• The door to the fire apartment had an inoperable self closing device.The open door allowed fire, heat and other products of combustion to

enter the hallway and upper floors.

• Inoperable flow meters on Engine 265 apparatus prevented adequate

monitoring of the flow from operating hoselines.

• There was a missing standpipe wheel handle on the third floor. This

delayed Engine 265's efforts to obtain water.

• Energy efficient windows were present in the fire apartment. The

Review Board was unable to determine if their presence was a

contributing factor.

3



Findings

c. COMMUNICATIONS

• Battalion 39 was not promptly dispatched on the receipt of the 10-75

signaL There was a delay of over six minutes in their response. There

is no record of any phone notification from the Queens Dispatcher tothe Brooklyn Dispatcher requesting the response of Battalion 39 upon

the receipt of the 10-75 signal.

• Dispatch personnel were unaware of any fonnal protocol for

interborough phone notifications when a borough Computer Assisted

Dispatch System (CADS) is IIdown".

• Procedure for verification of units responding from one borough intoanother borough when the CADS is "down" is not clearly understood.

• The Queens Dispatcher was persistent in his efforts to transmit

infonnation to the Incident Commander. At times it was difficult to

contact units at the scene.

• Less than professional language was used in conversation between

the Queens and Brooklyn dispatchers.

Transmission No.9 - phone channel 20 @ 2241 :49 hours.Transmission No. 10 - phone channel 12 @ 2242:55 hours.

See transcript of excerpts Queens Master Tape No. 475 dated 1/5/96.

D. FIREGROUND COMMUNICATIONS

• There were instances at this operation, in which notifications of

changing conditions or actions taken were not promptly

communicated to the Incident Commander. These included

conditions on the fire floor, members being trapped, and recovery of

the missing firefighter.

e In several cases, company Officers were unaware of the location of

one or more of their men for a significant period of time. Some

handie-talkie equipped members did not maintain contact with their

Officers when they were operating alone or changing location.

4



Findings

E. UNIT INTEGRITY

• Several companies did not maintain unit integrity. Although well

intentioned, some companies operated as individuals rather than as a

coordinated unit.

F. TACTICS AND PROCEDURES

• The FDNY has established standard procedures for initiating

extinguishment in fire situations. Adherence to these procedures is

expected.

ENGINE COMPANY 265

• The Officer of Engine 265 did not direct, supervise or control his unit

beyond his initial order to, "Bring a line".

• The Officer allowed the initial standpipe line to be connected to the

standpipe outlet in the hallway of the fire floor. This is a dangerous

and completely unacceptable tactic.

• The Officer brought the standpipe kit to the fire floor but did notbring it to the standpipe location, nor did he give it to any of his men.

• The Officer allowed 1314" line to be connected to a standpipe as the

initial line.

• The Officer did not notify the Incident Commander, or any other unit,

that his company was driven from the fire floor, was unable to obtain

water, and would not be able to place a line in operation.

• The Officer did not fully infonn the Incident Commander of the

severity of conditions on the fire floor.

The Officer did not personally account for all his members when

conditions deteriorated and they were dciven from {he fire floor. The

Officer did not account for his Controlman for approximately 10

minutes.

5



Findings

• The Control man did not use his handie-talkie to re-establish contact

after being separated from his unit.

• The Officer did not notify the Incident Commander of loss of contactwith L 121 or of the vulnerability of their position.

• ECC supplied the sprinkler siamese. This was the incorrect siamese.

The ECC did not verify that the supply line was connected to the

standpipe siamese.

• ECC did not attempt to augment the supply line to the siamese.

• ECC was unable to adequately monitor the flow readings of the

supply line to the siamese.

NOTE: Engine 265 flow meters were inoperable at the time of the

fire.

ENGINE COMPANY 264

• The Officer did not communicate with Engine 265 regarding

assistance in placing the first line in operation.

• The Officer did not notify the Incident Commander that he was

experiencing water pressure problems.

• The Officer did not notify the Incident Commander that he was

having difficulty advancing the line.

• Unit included lead length of 1 3/4" hose in line from standpipe and

did not properly flake out the line.

• ECC connected Engine 265's standpipe supply line to the incorrect

Slamese.

ECC did not connect to a serviceable hydrant.

6



Findings

• The Officer initiated CPR on Firefighter Williams and continued until

he was removed.

ENGINE COMPA1\fY 328

• The Officer did not notify the Incident Commander his unit was

having difficulty advancing the line.

• The Officer did not notify the Incident Commander th,,!t Firefighter

Williams was recovered and being removed from the fire floor.

• ECC assisted Engine 264 ECC in connecting to the sprinkler siamese.

This was the incorrect siamese.

• ECC tested a serviceable hydrant and then repositioned his pumper to

provide better access for anticipated hand stretches.

• ECC notified EMS on the scene that a firefighter was injured and that

their services were needed in the building.

• ECC brought a resuscitator to the second floor to assist members in

distress. The ECC performed CPR on Firefighter Williams.

• Stretched handline from E-265 hose bed, more than 6 lengths of I 3/4

inch hose.

LADDER COMPANY 121

• The Officer and Forcible Entry Team did not control the door to the

fire apartment. This was critical to the operations on the fire floor.Failure to control this door allowed fire, intense heat and products of

combustion to enter the hallway and upper floors.

• The Officer did not transmit a "Mayday" message immediately after

conditions deteriorated and members were in distress.

• The Officer and Forcible Entry Team did not activate their PASS

alarms to signal their location.

-;



Findings

• Firefighter Williams' PASS alarm was not armed.

• Firefighter Williams was not wearing his mask facepiece at the time

of his injury. The mask cylinder tentati vely identified as his, was

found expended. (Report of mask test is found in volume II,

Appendix.)

• The Roofman did not notify his Officer that he was unable to

complete his assignment on the floor above and was proceeding to

the roof via the interior stairs.

• The outside team did not thoroughly examine the exposure three sideof the building after hearing a "Mayday" radio transmission.

• The outside team of Ladder 121 teamed up with the outside team of

Ladder 134 and together raised two 35' portable extension ladders to

the fire apartment under extremely adverse weather (snow, ice and

wind) conditions.

LADDER COMPANY 134

• The Officer did not communicate with the first ladder company to

determine their position on the fire floor.

• The Officer, upon finding Firefighter Williams, did not notify the

Incident Commander that Firefighter Williams had been recovered.

• The Chauffeur, prior to commencing any horizontal ventilation,

contacted the fire floor to coordinate such ventilation.

• The Officer directed his Roofman to assist Chauffeur and OYM with

portable ladder operation due to difficult conditions.

• Firefighter Smith, after assisting Capt. Rokee, Ladder 121, to the

north stair landing, returned to the nozzle of Engine 264. He

advanced this line down the hallway, past the intersection of the "Til.

He found Firefighter Williams lying in the hallway and initiated

8



Findings

efforts to remove·. him. His aggressive actions under adverse

conditions allowed for the recovery of Firefighter Williams. His

actions were in the finest tradition of the Department.

• The Officer of Ladder 134 performed aggressively in attempting togain control of the fire floor and to direct the actions of the

companies operating on the fire floor. This proved crucial in

coordinating the extinguishment, search and rescue efforts on the fire

floor.

BATTALION 47

• Did not announce his arrival at the scene to operating units.

• Did not communicate with the first arriving Ladder company to

determine conditions on the fire floor.

• Did not communicate with the second Engine and Ladder companies

to determine their locations, operations, and progress.

• Did not enter the fire building sufficiently early in the operations to

personally apprise himselfof the following:A. Conditions on the fire floor.

B. Operations in progress.

C. Effectiveness of tactics and procedures employed.

• Did not transmit a second alarm sufficiently early in the operation.

Conditions and numerous phone calls for assistance indicated need

for additional resources.

• Did not maintain communication with Queens Dispatcher to receive

additional information. Numerous phone calls were received by the

Queens Communication office. The Dispatcher had to make several

attempts to communicate this information to the 47 Battalion.

Did not question the lack of a primary search on the fire floor.

9



Findings

• BC 47 operated as the Incident Commander for approximately

twenty-three minutes before the" 10-75" Battalion Chief arrived on

the scene.

• Immediately ca11ed for an additional ladder company on arrival.

(Dispatcher notified him that an additional engine would also be

dispatched)

• Conducted "face-to-face" verbal roll call with units on scene

following Mayday.

• Organized first aid efforts following recovery of Firefighter Williams.

• Directed the Captain of the FAST Ladder Company to take control of

the fire floor.

• After becoming aware of water problems on the fire floor, ordered

handline stretched from Engine 265 pumper and directed a second

unit to assist with the stretch.

10



VI - Conclusions

Queens Box 22-1201 - 1/5/96

Fighting fires is an inherently dangerous business and Firefighters accept a

degree of risk with every response to a fire or other emergency. However,

we must not overlook the things that we can do to reduce and control those

risks.

Adherence to basic procedures that have been developed over many yearshas been neglected. We cannot cut comers when fighting fires. In our

profession, letting one's guard down can have tragic consequences.

Had this operation been conducted in accordance with FDNY policies,

tactics and procedures, it is unlikely that this tragic loss would have

occurred. The loss ofFirefighter Williams is painful and difficult to accept,

but experience is a teacher and its lessons are critical. It is important for us

to focus on those lessons, and the changes that must be made to prevent the

recurrence of such tragedies.

fdny report on fatal fire, january 5, 1996

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