FDNY report on fatal fire, December 18, 1998

8/4/2019 FDNY report on fatal fire, December 18, 1998

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SUMMARYOn December 18, 1998 at 0452 hours, the Brooklyn Fire Communications Office of the New York CityFire Department received a telephone alarm, reporting a fire and smoke condit ion on the 10th floor of 17V andalia Avenue. .Units of the New York City Fire Department were dispatched to the location. The fire was on the 10tbfloor of a 10 story, Class I multiple dwelling measuring approximately 250 x 50 feet. The building wasequipped with a partial'sprinkler system that'protected all of the public hallways and the elevator lobbiesthroughout the building. The building also was protected by a standpipe in the exposure four stairs and ahose outlet on each floor on the exposure two side of the building. Battalion 58 transmitted a 10-75 signalat 0459 hours.The dispatcher notified all responding units that an elderly woman was trapped in apartment 10-E. FireDepartment standard operating procedmes were initiated. Engine Companies stretched hand-lines;Ladder Companies forced entry, implemented ventilation and conducted searches.Members ofLadder Company 170, the first-to-arrive Ladder Company, entered the fire building toperform their assigned duties. While operating on the 10th floor in the public hall, three members ofLadder Company 170 - Lieutenant Joseph Cavalieri, Firefighter ChristopherBeopp and Firefighter JamesBohan - were fatally injured. This occurred when heavy fire, smoke and gases, driven by wind, pushedout into the ball from apartment # 10-D. .All three members were found at different locations on the 10th floor. They were located between the fireapartment and the elevator lobby doors. These irgured members were removed by Firefighters assigned toSquad 252, Rescue 2 and the two FAST Units - Ladder Company 175 and Ladder Company 120. FireDepartment personnel, assigned to the BureauofEMS, treated the injured Firefighters and removed themby' ambulance to area hospitals.

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THE INVESTIGATION ofLadder 170 responded to a reported fire at 17 V andalia Avenue in the Boroughof

Bopp and Firefighter James Bohan incurred serious injuries that resulted in their

n Chief Robert Busch was the chiefon duty in the Safety Battalion. He responded to the :fire onond alarm. He arrived at 0545 hours and was informed that members had been seriously injured.Busch started the initial stages of the investigation. He instituted the Safety Battalion

p r ~ u r e s for firefighter fatalities, which included activation ofall off-duty Battalionto the Safety Battalion. He also arranged with the City Wide Dispatcher to assign all on

to the Box location to assist in thetigation. He established a logbook and instituted the fatal fire investigation checklist.were assigned to conduct interviews ofall personnel who were at this operation at the timethe mishap. During the course of the investigation, the Safety Battalion conducted additional and

p interviews with members of the Fire Department, 90 in total.

ing items, records and documents were collected, examined and evaluated:1. Building and enforcement records from the City ofNew York Department ofBuildings, FDNYBureau of Fire Prevention and the Administrative Company - Engine Company 290.2. Fire Report, Preliminary Report on Death made to the Fire Commissioner and the report of theBureau ofFire Investigation.3. Communications records, including the incident history and Fire Department radiotransmissions.4. Response records from Emergency Medical Service.5. Medical examiner autopsy and report of findings.6. Photographs of the :fire building, adjacent a r e a s ~ member's protective clothing and equipment.7. Duty roster identifying all personnel who responded to the incident.8. OffiCial weather reports.9. Newspaper articles.10. Injury reports and burn charts.ionally, the following resources were used:1. FDNY Audio-Visual Unit

2. FDNY Bureau of Fire Communications3. FDNY Forensic Unit4. FDNY Graphics Unit5. FDNY Mask Service Unit6. FDNY Technical Services7. FDNY Bureau of Fire Investigation8. FDNY Bureau of Fire Prevention9. Department of Investigation of the City ofNew York

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Information from the photographs, witness statements, videotapes, physical evidence and flow testswasanalyzed and a time sequence chart was used to reconstruct the events leading..to.1heiatalities_As : w i 1 h _ ~ ~any investigation of this gravity and magnitude, there were a number of inconsistencies and conflicting. statements obtained from the personnel interviewed. It is the opinion of the Safety Battaiion that theseinconsistencies and_conflicting statements._resulted from varying memories, differing perspectives andemotional factors.

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ENGINE COMPANY 290 - BUILDING RECORDS The Building Inspection Card (A-119) indicates that annual inspections were conducted on April 24,1996, May 12, 1997 and April 6, 1998. A second Building Inspection Card (A-119) shows that there wasa semi-annual inspection conducted on August 23,1983. Another entry on t h ~ s e c o n d card refers to_the __standpipe in the east wing being out of service on September 24, 1984. Beneath that is an entry forSeptember 25, 1984, noting that the west wing standpipe can be used. Both of these cards note, that thereare sprinklers in the hallway. Multiple Dwelling Inspection Fonns (A-291) are filed in the folder andindicate inspections were conducted on April 6, 1990, March 20, 1991 and April 15, 1992. MultipleDwelling Inspection Fonns (A-291) dated April 16, 1990 and March 20, 1991 have the section that .applies to standpipes a.nd sprinklers filled out. There are two Fire Prevention Inspection Checklist forms(A-IO)) indicating that inspections were conducted on March 29, 1995 and April 24, 1996. These fonnsindicate that the inspectors noted sections that apply to the standpipe, sprinkler system and alann system.There are also two Refuse Chute/Compactor Survey Forms (A-291-B) in the folder and one is dated Apri15, 1992. One additional Multiple Dwelling Inspection Fonn (A-291) and one Refuse Chute/CompactorSurvey form are unreadable. It should be noted that the Safety Battalion only has photostats of thecompany records. The originals were delivered to the Department of Investigation. There is no record ofany violations on any of the inspection forms in the folder and there are no copies of any violation ordersin the folder.The building record folder contains two Standpipe Out Of Service Forms (BBC T-292). These formsshow that on January 24, 1984, the standpipe riser on the east side of the building was out of service and iwas repaired on January 28, 1984.The Critical Infonnation Dispatch System (CIDS) Card (CD-201) attached to the Building Record Card(A-119) is dated March 10, 1984. The information contained on the card indicates that this building is anine-story residence for senior citizens, with a total of21 apartments for handicapped people. Theseapartments, lettered "J" and "R", are closest to the elevator. Housing Police also have keys to theseapartments. This is the only CIDS information contained in the company building record folder. Thewritten cms information differs with the cms information that was transmitted by the dispatcher toresponding units on D e c ~ b e r 18,1998. The fact that the hallways and elevator lobbies are equipped witsprinklers is not noted in the transmitted cms information.A further review of the company building record folder disclosed that there were eight prev ious structurafires at 17 V andalia Avenue. Four of these fires were for food on the stove and two were compactor fires.The remaining two fires occurred on May 27, 1994 in.apartment 5L and on April 15, 1997 in apartment3R A civilian was seriously injured at the fire on May 27, 1994 and a civilian fatality occurred at the fireon April 15, 1997.The only time a sprinkler was listed as a factor on any of the fire reports contained in the companybuilding record folder was for a compactor fire. At this fire on October 27, 1991 the sprinkler was presenbut the fire was too small to operate the sprinkler.

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THE MISHAP The Officer and members of Ladder Company 170 responded to a telephone alarm for a fire reported at17 Vandalia Avenue in the Borough ofBrooldyn on December 18,1998 at 0454 hours.The Officer, Lieutenant Joseph Cavalieri, and the Forcible Entry Team of Ladder 170, FirefightersChristopher Bopp and James Bohan, took the elevator to the ninth floor. The Officer, Nozzle and Backup positions ofEngine 290 went into the elevator with them. These companies then went to the lOth floorvia the exposure #2 stair. Engine 290 Door and Control positions, who had walked up the exposure #2stair, rejoined them. )'be Officer ofEngine 290, using his handie-taIkie, contacted his Chauffeur to findout where the fire wasJocated. The Chauffeur of Engine 290 told him that the fire was on the top-floorrear, near the exposure #4 side. The Officer of Engine 290 informed the Officer of Ladder 170 about the, location of the fire and he acknowledged this information. The Officer and Forcible Entry Team ofLadder 170 then entered the elevator lobby. This was the last time that the Officer and Forcible EntryTeam ofLadder 170 were seen until after the mishap occurred. The Officer and members ofEngineCompany 290 went back down to the ninth floor and moved their line to the exposure #4 stair andstretched up to the fire floor from the standpipe located in that stair.The Officer and members of Ladder 170 Forcible Entry Team probably searched the elevator lobby,located the fire apartment and searched the public hall on the exposure #4 side of the elevator lobby. Atsome point, the members of Ladder 170 Forcible Entry Team opened the door into apartment 10-D andthe fire, driven by the wind, swept into the public hall, trapping the Officer and Forcible Entry Team ofLadder 170 in the lOth floor hall. Because of interviews conducted and information developed by thetimeline, the Safety Battalion believes that Firefighter Christopher Bopp, the extinguisher position ofLadder 170, transmitted three separate mayday messages at this time.Firefighter Christopher Bopp was recovered at 0518 hours and removed to the ninth floor. FirefighterJames Bohan was recovered at 0525 hours and taken to the eighth floor. The remaining member,Lieutenant Joseph Cavalieri, was recovered at 0528 hours and he was taken to the ninth floor. FireDepartment personnel, assigned to the Bureau ofEMS, initially treated these injured members when theywere removed from the fire floor. Firefighter Bopp and Firefighter Bohan were removed to BrookdaleHospital and Lieutenant Cavalieri was taken to Kings County Hospital. All three members were -"transported to area hospitals via Fire Department ambulance and they were pronounced dead at therespective hospitals.

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FINDINGS In an interview conducted by the Bureau of Fire Investigation, the building security guard on duty attime of the fire stated that the interior alarm transmitted at approximately 0450 hours. The guard tooelevator to thelOth-tloor, verified the source of the alarm and then..called itin on his cell-phone. Theadvanced fire condition on arrival indicates there was a delay in transmitting the alarm.The eIDS information given to the responding units on their printout, as it pertained to the standpipincorrect. The cms information listed the location of the standpipe in the "B"stair on the exposure #side of the building. The hose outlet in the public ball was located on the exposure #4 side of th e buiIn reality, the standpiPe is located in the exposure #4 stair on the exposure #4 side of the building anhose outlets are located in the public hall on the exposure #2 side of the building. Information concethe sprinkler system in the building was not contained in the CIDS information.The public halls on eachfloor are sprinkled, but the sprinkler system was not functioning at the timethe:fire. Inspection of the system by personnel from the Bureau of Fire Prevention on December 18,disclosed that section valves were in the closed position. There were three section valves, which

. controlled the system in the following manner: one valve controlled the sprinklers in the public hallexposure #2 side of the building; a second valve controlled the sprinklers on the exposure #4 side ofbuilding; a third valve controlled the sprinklers in the elevator lobby itself. These section valves werlocated on the first floor in the ceiling. The access panels to these valves were painted over.Tests on the building sprinkler system were conducted by the Bureau of Fire Prevention on the mornofDecember 18,1998. The results of these tests indicated that the sprinkler system failed to provideto the sprinklers in th e 10th floor public ball and elevator lobby. The valves located in the ceiling offirst-floor lobby were in the closed position. At the time of the fire, responding units were not awarethe sprinkler system in the building because the information about the sprinkler system was not inclin the transmitted cms.In an interview conducted by a member of the Bureau of Fire Investigation, the occupant of apartm10C stated that he awoke at approximately 0500 hours when he smelled smoke. He opened the doorthe public ball, saw smoke and a glow coming from the area of apartment 1 O D ~ He saw the occupan100 on the floor in the ball. There was no one else in the hall and he pulled the victim into his apartand closed the door. He also stated that when he opened the wiridow in his apartment to vent it , heobserved flames ,out the window of apartment 100.Engine Company 290 and Ladder Company 170 entered the building at approximately 0500 hours.east elevator, located on the exposure #4 side of the elevator lobby, was out of service. Along with tForcible Entry Team ofLadder 170, the Officer, Nozzle and Backup positions of Engine 290 enterewest elevator, located on the exposure #2 side of the elevator lobby. These members of Engine 290took their hose, which consisted of five lengths of2 Yz ..inch hose and two lengths of 1 %-inch hose,the elevator. Tbese units took the elevator to the ninth floor. Engine 290 Door and Control positionswalked lip to the fire floor in the exposure #2 stair.On arrival, Battalion 58 noticed that there was smoke coming from windows located on the 10th flothe front middle section of the building. The Safety Battalion believes that th e smoke Battalion 58observed was from apartment 1OJ. This would ~ d i c a t e that the door to that a p a r t m e ~ t was open. Italso indicate that the door to the fire apartment was at least partially open. Damage to the interior o

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apartment 10J was done mostly by smoke. The smoke detector located on the ceiling just inside theapartment door was distorted by heat. T h e r e w e r e - n ~ t h e r - i n d i c a 1 i o n s - o h e a t damage in the-apartm.ent.Smoke also was seen coming from apartment 10J by different members of various companies, includinSquad252,_Battalion 44, Division 15, Ladder 175, Engine 225, Ladder 107 and Ladder 120.In interviews conducted by the Safety Battalion, Ladder 170 OVM stated that fire was reported on thetop-floor rear with "Nothing coming out of the fire apartment windows". Ladder 103 OVM stated that"fire was pulsing in and out of the fire apartment windows". Both Outside-vent (OVM) positions went tothe rear of the fire building when they arrived at the scene. Ladder 170's OVM then went inside thebuilding and immediately went to the roof. Ladder 103's OVM remained in the rear to assist theChauffeur placing Ladder 103's aerial ladder.in operation.The Chauffeur of Ladder 170 went to the fire floor via the exposure #4 stair, as did Ladder 103 Roof.Ladder 170 OVM and Roofpositions went to the roof via the exposure #2 stair. Ladder 170 Roof foundthe roof door, at the head of the exposure #2 stair chocked open with a brick. Ladder 170 Roof openedand chocked the bulkhead door over the exposure #4 stair. He then notified the Officer of Ladder 170 thatthe roof was open, but did not receive a reply. Ladder 170 Chauffeur confi rmed that he heard thistransmission.The bulkhead windows in the exposure #4 stairs on the exposure #4 side were vented by Ladder 170OVM after he checked the perimeter of the building from the rooflevel. At the time he vented thewindows in the bulkhead, there were heavy smoke and heat coming out of the bulkhead.Ladder 103 Chauffeur and OVM repositioned their apparatus at the rear of 17 Vandalia Avenue, wherethey raised the aerial to the 1Olh-floor window adjoining the fire apartment. .After their arrival on the ninth floor, the Officer from Engine 290 and the Officer and Forcible EntryTeam from Ladder 170 went to the 101b floor via the exposure #2 stair. The Nozzle and Backup positionsof Engine 290 rejoined Engine 290 Door and Control positions after they walked up to the ninth floor.These members proceeded to connect their hose lengths to the outlet in the ninth-floor public hall andstretch their hose lengths in the exposure #2 stair to the 101h f loor . . .Engine 290 Nozzle told his Officer that he thought the fire was on the other side ofthe building. TheOfficer of Engine 290, using his handie-talkie, contacted his Chauffeur to find out where the fire waslocated. The Chauffeur ofEngine 290 told his Officer that the fire was on the top-floor rear, near theexposure #4 side. The Officer of Engine 290 then told the Officer ofLadder 170 that the fire was on theother side. The Officer of Ladder 170 acknowledged the Officer ofEngine 290.At the time of this exchange between the Officers, the Officer and Forcible Entry Team of Ladder 170were on the exposure #2 side of the building, just outside of the door leading into the elevator lobby. TheOfficer and Forcible Entry Team of Ladder 170 opened the elevator lobby door and the Officer of Engine290 observed that there was a l ight smoke condition in the elevator lobby. This was the last time theOfficer and Forcible Entry Team of Ladder 170 were seen until after the mishap occurred.Engine Company 257 arrived on the ninth floor after waiting for the elevator that was used by Engine ~ 9 0 to return to the lobby. They walked toward the exposure #4 side of the building, entered the exposure #4stair and went up to the fire floor. Hete, they started to hook up to the standpipe outlet on the 10lb floorand flake out their hose-line, which consisted of three lengths of2 'l2-inch hose. Engine 257 was unable

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to remove the cap to the standpipe on th e 10tb floor because they could not fit a spanner on the cap.Insulation on t h ~ s t a n d p i p e amla missing-vaLve wheel on the standpipe-were the reasons.Ladder 103 Roof entered the building and walked 'Up to the fire floor via the exposure #4 stair. At thefloor l a n d i n ~ the Lieutenant of Engine 257 was .crouched down at thtuioor to-the public hall. .pushing out from the closed door. Ladder 103 R90ftalked to the Lieutenant of Engine 257 and toldabout the wind condition and that he was going up to vent the roof. The Chauffeur ofLadder 170 then .came up onto the landing and started to go up to the roof. The Lieutenant opened the door to thehall and heavy smoke filled the stair. Engine 257 Control was in the process of hooking up to thestandpipe on that floor. Ladder 103 Roof and Ladder 170 Chauffeur then went down to the ninth floorand crossed over to the exposure #2 stair instead of continuing up to the roof in the exposure #4 stair.The Officer of Ladder 103 had determined the location of apartment 10E by checking the floor layout onthe ninth floor. The Officer of Ladder 103 and the Irons position removed a woman in a wheelchai r from'apartment 10E. This apartment was directly across from the exposure #4 stair door to the public hall.After they removed her from the apartment, they took her down to the ninth floor via the exposure #4stair. At the time ofremoval, the heat condition in the hall was not hot enough to warrant taking thewoman out of her wheelchair, but the smoke condition was heavy and down to the floor. This smokecondit ion indicated that the door to the fire apartment was at least partiaUy open.In an interview conducted by Investigators from the Investigative Squad of th e New York CityDepartment of Investigation, the occupant of apartment 10E stated that when the firefighters took her outof he r apartment into the hallway, it was really hot..She did not see any fire, just smoke.Ladder 170 Chauffeur assisted members of Ladder 103 who carried the woman in the wheelchair down tothe ninth floor. He then started to cross over on the ninth floor to the exposure #2 side of the building andhe attempted to contact the Officer of Ladder 170. He thinks he received a response, "Ladder 170 havi,ngdifficulties trying to get in door." He cannot be sure i f it was the Officer ofLadder 170.Whenever the door from the stair to the public hall was o p e n ~ it allowed heat and smoke to enter theexposure #4 stair. This hampered the efforts ofEngine 257 to accomplish their hook-up to the standpipeon the 10tb floor. Engine-257 never succeeded in their attempt to hook up to the standpipe.After determining the fire's location, Engine 290 stopped their efforts to stretch their line between theninth and 10tb floors in the exposure #2 stair. They then moved their partially connected line across theninth floor to the exposure #4 stair. Here, they successfully connected one length of 1 %-inch hose andtwo lengths of 2 Y2-inch hose to the standpipe outlet on the ninth floor. The remaining hose that they hadmoved over from the exposure #2 stair was left in the public hall on the ninth floor.Ladder 170 Chauffeur and Ladder 103 Roof then left the 10tb floor exposure #4 stair and dropped down tothe ninth floor to cross over to the exposure #2 stair. They both saw Engine 290 bringing their partiallyconnected l ine from the exposure #2 stair. Ladder 170 Chauffeur returned to the exposure #4 stair whenhe heard, on his handie-talkie, Ladder 17 0 Roofs report that the roof was open. Ladder 103 Roofcontinued over to the exposure #2 stair. He went up the stair and stopped briefly at the 1Olb-floor landing.He looked into the public hall and noted that there was a light smoke condition. He did not look down thepublic hall. He then continued to the roof and transmitted a warning over the handie-talkie aboutthe windcondition. The Officer ofLadder 103 acknowledged this message. Fire was coming over the roof of thebuilding and shooting parallel to the roofat this time. Ladder 103 Roof then crossed over toward theexposure #4 side of the roof. He observed that the bulkhead over the exposure #4 stair was open and

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heavy black smoke was coming ou t of it. He then went to the rear of the fire building directly over the~ ~ ~ e n 1 . - 1 h e w i n d - w a s - b l o w i n g c i n t o t h e - f i r e - a p a r t m e n t and the fire was in the apartment. He didnot feel any heat coming out of the apartment window and there was little smoke coming from thebedroom window. Fire did come out of the windows from the fire apartment, once or twice, while he waslooking-at the..apartment.

Engine 257 Officer was unable to have his line connected to the standpipe on the 10th floor. He contactedEngine 290 to find out if they had hooked up their line to the standpipe outlet on the floor below. Engine290 stated that Engine 257 had Engine 290 bring their line up to the 10

thfloor. Engine 257 assistedEngine 290 in stretching their line up to the 10th-floor landing.

Battalion 58 arrived on the ninth floor and observed Engine 290, assisted by Engine 257, stretching a lineto the top floor. Battalion 58 then entered apartment 9B. He saw that the fire had vented out of the fireapartment window on the 10th floor and transmitted this information over the handie-talkie.Engine 290 started their stretch up the stairs as the woman in the wheelchair was being brought downfrom the 10th floor. They were forced to move to 'the side so the woman could be removed.After their arrival, Engine 332 entered the building, took the elevator to the eighth floor and then went upthe exposure #2 stair to the 10th floor. The Officer of Engine 332 opened the door to the public hall andsaw that the smoke was black and down to the floor. This would indicate that the elevator lobby doorswere opened after the Officer of Engi:p.e 290 left Ladder 170 at them. The Officer then went back down tothe ninth floor and took his 'company over to the exposure #4 stair.The Officer and members of Squad 252 arrived on the scene and went to the ninth floor via the exposure#2 stair. They stopped briefly on the seventh floor to determine the layout of the apartments. Squad 252Roof continued to the roof.Engine 283 took the elevator to the eighth floor and hooked up their line, which consisted of four lengthsof 2 %-inch hose, to the standpipe outlet on the eighth-floor landing of the exposure #4 stair. The Officerof Engine 283 went to the ninth floor and then had his company stretch to that point. He then moved theuncharged line and the company up the stairs to the 10th floor. The stair was very crowded and stretchingthe line was extremely difficult due to the woman being removed in the wheelchair, the number ofFileDepartment personnel and the amount of hose in the stair. It is estimated that, at this time, there wereapproximately 15 members in the stair or on the landings between the ninth and the 10th floor. At leastthree uncharged lengths of2 %-inch hose from Engine 257, one charged length of 1 %-inch hose and onecharged length of2 %-inch hose from Engine 290, and one charged length of2 %-inch hose from Engine283, were also located in that same stair.Engine 283 Officer heard the first mayday while his company was advancing the line between the ninthand lOth floors. This was prior to Engine 283 getting water in their line.

When Squad 252 arrived on the ninth floor in the exposure #2 stair, they entered the public hall andstarted to cross over to the exposure #4 stair. The Officer of Squad 252 heard the mayday when he gotnear the exposure #4 stair. It was very crowded and he heard Battalion 58 acknowledge the mayday. Hestarted back toward the exposure #2 stair and heard another mayday.Ladder 103 Roof called on his handie-talkie to the Officer ofLadder 103 and told him that they were notgoing to vent and aSked him to advise when they were in the apartment. He did not receive anacknowledgment from the Officer ofLadder 103. He then looked over the front of the building and saw

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smoke drifting ou t of the apartment near the elevators. He returned to the rear of the building andheard the first of the maydays. .The Officer of Engine 290 heard the first mayday just before he reached the 10th floor landing. Engine 290 moved their charged line up to the stair door to the public hall. The door was opened and Engine 29Q was hit with a tremendous blast of heat that drove them of f the 10th floor landing and partially down the stairs. They did not operate their line on that attempt to enter the public hall. Engine 290 regrouped and made a second attempt to enter the 10

th-floor public hall. This attempt als9 was unsuccessful because of the extremely high heat condition. They did not operate their line on this

second attempt. The ~ O f f i c e r of Engine 290 called for a second line and Engine 283 brought the second line up to the lOth-floorlanding. A third attempt was made to enter the hallway by Engine 290 in conjunction with Engine 283. When Engine 290 and Engine 283 were ready to advance into the publ ic hall, Engine 290 Nozzle opened the nozzle and then the door was opened into the public hall. Both companies succeeded in their effort to make their way out into the public hall and began to extinguish the fire. Engine 283 was on the left side and Engine 290 was on the right side of the public hall, slightly behind Engine 283, as they made their way toward the fire apartment. Engine 290 operated their line above and ahead of Engine 283. When the Officer of Rescue 2 arrived on the ninth floor, Battalion 58 ordered him to locate Ladder170Can. Because of mayday messages, he also ordered the r e s p o ~ ef aramedics to treat the possibly injured firefighters. 1'/ The Safety Battalion believes that t h ~ use of a lead length of ' . ch hose by Engine 290 had no bearing on the mishap, since it occurred before the line was in operation. However, the use of an 1 %-inch lead length substantially reduced the flow of water from their line. This added to the amount of time that it took to control the fire, effect final extinguishment, and remove the victims of the mishap. According to statements made in interviews conducted by tlie Safety Battalion, the extremely high heat condition that existed in the hallway as Engine 290 and Engine 283 advanced their lines down the public hall, made moving the lines extremely difficult. Officer of Rescue 2 heard a mayday as he entered the fire building and the 10-84 time for Rescue 2 is05:10:16 hours. The Officer of Ladder 175, the FAST unit, heard a maydayjust after arriving at the fire building. They transmitted signal 10-84 at 05: 10:53 hours. Division 15 also heard the mayday just as he walked up to the front door of the building. He had transmitted signal 10-84 at 05:08:58 hours, got out of the car, took his bunker gear from the trunk. and walked to the front entrance. Ladder 175 was just coming up the walk to the front of the building and Division 15 ordered them to the lOth floor to find the reason for the mayday. Ladder 175 proceeded to the fire floor Via the exposure #4 stair. Division 15 tried to ascertain information from the person transmitting the mayday, but was unsuccessful because handie-talkie communications were a problem. Division 15 later established a relay system with the radios to improve communications, but it remained a problem throughout the operation. Engine 283 Door heard a mayday as he chased kinks in both lines on the stair, before Engine 283 had water in their line. Engine 283 Control heard a mayday while still connecting to the standpipe outlet on

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the eighth floor. Battalion 58 heard a mayday and tried to determine the location and identity of it. He alsoorderedEngine 283 to stretch a second line. Squad 252 Roof also heard a mayday. The-Officerof-Engine332 heard a maydaywhile he was in the exposure #4 stair on the ninth floor. Battalion.44 heard themayday and ordered Engine 332 to go back to the exposure #2 stair.The Safety Battalion believes that a total of three mayday messages were heard and all three weretransmitted by Ladder 170 Can. The time of the :first maydaywas approximately 0511 hours. The secondand third were transmitted at approximately 0512 hours.The Vibralerts on Engine 290 SCBA started to sound approximately six minutes after they entered the10th-floor public hall to extinguish the fire. Engine 283's Vibralerts sounded just after Engine 290's.Engine 290 Officer and Door continued to operate after their SCBA were expended. The Safety Battalionestimates that Engine 290 ran out of air at approximately 0517 hours and Engine 283 at approximately0520 hours.Rescue 2 was able to continue to operate because they were using SCBA cylinders with a 45 minuterating. Rescue 2 Forcible Entry initially backed up Engine 290 and then relieved them when they wereunable to continue. Rescue 2 Officer,.Can and Floor Above Hook positions initially backed up Engine283 on the 2 Yz-inch line and relieved Engine 283 when they ran out of air.Battalion 44 ordered Engine 332 to hook up to the hose outlet located on the ninth floor in the exposure#2 stair and stretch their line up to the public hall on the 10th floor. This l ine consisted of three lengths of2 Yz-inch hose. This line was charged and did not reach the elevator lobby because of the distance fromthe outlet in the public hall on the ninth floor. Batta lion 44 contacted Engine 225 on the handie-talkie andordered them to bring their line to the top floor. Engine 225 added two lengths ofhose to Engine 332'sline. This line was not charged again.The Officer of Squad 252 found Firefighter Christopher Bopp, the Can position from Ladder 170.Firefighter Bopp was found on the exposure #4 side of the elevator lobby door, next to apartment 1.OJ. Hewas in the prone position with his feet facing the elevator lobby door. The Officer of Squad 252 pulledFirefighter Bopp's legs and started to remove him to the exposure #2 stair. The Safety Battalion estimatesthat this recovery started at approximately 0518 hours.The Officer of Squad 252 initially received help from other members of Squad 252 and the Chauffeur ofRescue 2 in the removal. Additional help was provided by Ladder 175 Chauffeur and Ladder 103 OVMwhen they encountered the removal effort in the hallway between the exposure #2 stair door and theexposure #2 side of the elevator lobby door. Firefighter Bopp was removed to the exposure #2 stair andtaken down to the ninth floor.While helping the Officer of Squad 252, the Chauffeur of Rescue 2 discovered Firefighter James Bohan,Ladder 170 Irons position, when he moved around toward the head and shoulders of Firefighter Bopp.Firefighter Bohan was found in the supine position with his legs facing the elevator lobby doors. He wasnot removed at this time due to the effort being expended on the removal ofFirefighter Bopp.Ladder 120, the second FAST unit assigned to the fire, transmitted signal 10-84 at 05:21:14 hours. Theyentered the building and were ordered to the fire floor by Division 15. The members of Ladder 120 sawmembers working on a firefighter on the ninth floor. Based on interviews, the Safety Battal ion believesthat Firefighter Bopp was on the ninth floor at this time.

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','Rescue 2 Chauffeur encountered the Officer ofLadder 175 in the public hall on the exposure #2 side the elevator lobby on the lOth floor and told him thatthere were two firefighters d o . w n - i n - t h ~ l . Officer and Forcible EntryTeam ofLadder Company 175 then continued to move toward the elevator lobby in the public hall on the 10th floor. For safety purposes, the Officer ofLadder 175 ordered the position to remain at the elevator lobby. Ladder 175 Officer and Irons position then continued to the exposure #4 side of the elevator lobby. Here, they found the body o rfirefighter James Bohan and " ' ' ' ~ ' T ' ' ' ' to move him toward the exposure #2 stair. The Safety Battalion believes that this recovery occurred at approximately 0525 hours. 'Bat talion 44 ordered Ladder 120 to enter the hallway and search for downed firefighters. Ladder 120'sOfficer and Forcible EJ:1try position started down the hallway toward the elevator lobby door. When theyreached the elevator lobby, they encountered the members ofLadder 175 removing Firefighter Bohan.They then assisted Ladder 175 take Firefighter Bohan to the eighth floor.Lieutenant Cavalieri was found when the Officer ofRescue 2 heard a PASS device sounding as he wasoperating a line into the fire apartment. He left the line and found Lieutenant Cavalieri in the supineposition with his feet toward the fire apartment. The Safety Battalion believes that he was locatedbetween the "H" and "}" apartments, but closer to the "J" apartment. The Officer ofRescue 2 initiallystarted to remove Lieutenant Cavalieri toward the exposure #4 stair and was successful in moving himapproximately 15 feet. He then realized he needed help, so he left Lieutenant Cavalieri and returned towhere the line was operating. The Officer of Rescue 2 had Rescue 2 Irons Floor Above position returnwith him to Lieutenant Cavalieri. Together they moved the Lieutenant toward the exposure #2 stair. TheSafety Battalion estimates that the time of recovery was approximately 0530 hours. Ladder 120 assistedafter encountering them in the 1Oth-floor public hall. Lieutenant Cavalieri was taken to the ninth floor.The occupant of apartment 10J stated in his interview that when his smoke detector first sounded, hedisarmed it and opened the door from his apartment to the public hall to find the cause. Heavy smokecame into the apartment and he closed the door. He did not recall ifhe closed the door fully, but heknows that he did not lock it. This would mean that the door to the fire apartment had been open, leavingthe smoke condition present in the hallway.Inspection of the door to the fire apartment on the day of the fire showed that the pins to the self-closing'binges were not in place. Subsequent examination ofphotographic evidence supports that inspection.The self-closing hinges failed to operate properly because the pins were not in place.Interviews conducted by a member of the Bureau ofFire Investigation indicate that the fire loading in theapartment was heavy. The occupant had just put new carpeting and foam padding on the floor in theapartment and the furniture had foam rubber cushions.The'interior of the outside wall in the apartment had sheetrock placed over foam insulation. This foaminsulation contributed to the fire load in the apartment.The windows in the public hall on the exposure #2 side of the building and the windows in the elevatorlobby were vented by the Officer of Engine 332. The Safety Battalion never discovered anyone whoadmitted to venting the windows in the public hall on the exposure #4 side of the building.According to an interview conducted by a member of the Bureau of Fire Investigation, the ,occupant of thefire apartment tried, unsuccessfully, to extinguish the fire'when it first started. In addition, the occupant

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opened the window above the couch where the fire started in an effort to relieve the smoke in theapartment.Ladder 1.03' s and Ladder 170' s OVMs both went to the rear of the :fire building when they arrived.Ladder 103 DVM stated in his interview that the:fire was pulsing in and out -Of the fire apa.rtrilent. Ladder170 OVM, stated in his interview, that he reported that the fire was on the top-floor rear. The fire thatLadder 103 DVM saw was from the window left open by the occupant. The pulsing in and out was theresult of the gusting wind conditions that night. The differing reports can be attributed to the fact thatboth firefighters viewed the apartment for different lengths of time. Ladder 103 OVM remained in therear, waiting for the Chauffeur of Ladder 103 to bring the apparatus to the rear of the building. Ladder170 OVM observed t h ~ fire, then entered the building and went to the roof.Members ofLadaer 103 removed the female occupant of apartment 10E at approximately 0508 hours.The occupant was taken, in her wheelchair, directly across the hall from her apartment to the exposurefour stairs. At the time of removal, the conditions in the public hall included a heavy smoke condition andsome heat. These conditions suggest that the door to the fire apartment was at least paitially open whenthe woman from apartment 10E was taken out of her apartment.According to the timeline, the Officer and Forcible Entry Team ofLadder 170 were last seen atapproximately 0503 hours. The next time they were heard from again, according to the timeline, wasapproximately 0511 hours when the mayday was transmitted. The operations that Ladder 170 conductedduring that time are speculation. The Safety Battalion believes that the members of Ladder 170 ForcibleEntry Team probably searched the elevator lobby and the public hall on the exposure #4 side of theelevator lobby and found the fire apartment. The Safety Battalion discovered no physical evidence thatthe members ofLadder 170 operated in the fire apartment.The Safety Battalion believes that at some point after Ladder 103 removed the woman in the wheelchairfrom apartment 10E, the members of Ladder 170 Forcible EntryTeam opened the door to the fireapartment. It is unknown at what point the windows in the:fire apartment failed completely. However, .the wind speed on the night of the mishap was 17 miles per hour and it's direction was from thenorthwest. This wind had the necessary force to push the fire in the apartment out into the public hall.When that happened, the members of the Ladder 170 Forcible Entry Team, operating in the public hall,were trapped and burned by the heat and flames from the :fire.Battalion 58 ordered Ladder 107 to relieve members operating on the lines. Ladder 107 relieved Rescue 2Irons Floor Above position on the 1 %-inch line. Ladder 107 then relieved members of Rescue 2 on the 2%-inch line. Rescue 2 Floor Above Hook position switched lines with. the members ofLadder 107 on the1 %-inch line. The fire in apartment 10D was extinguished by the joint efforts ofRescue 2 Floor AboveHook position operating the 1 %-inch line and Ladder 107 Officer and Forcible Entry Team operating the .2 V:z-inch line.

All three members of were transported to area hospitals via Fire Department ambulances and where theywere pronounced dead.Firefighter Bopp and Firefighter Bohan were removed to Brookdale Hospital. Lieutenant Cavalieri wasremoved to Kings County Hospital.

IThe cause of death for Firefighter Christopher Bopp was determined to be bums of the head, trunk andarms involving approximately 15% ofbody surface area and smoke inhalation.25


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Firefighter James Bohan's cause odea'lh-W3S-burns of the head, trunk and extremities involvingapproximately 20% body surface area and smoke inhalation.Lieutenant Joseph Cavalieri's cause ofdeath was burns of the head, trunk and extremities involvingapproximately 300/0 body surface area and smoke inhalation.On December 30, 1998, members oftheSafety and Inspection Service Command conducted flow tests ofthe standpipe system at 17 Vandalia Avenue, from 0445 hours throUgh 0615 hours. The tests used hose,fittings and stretches similar to those that were used by units operating on December 18, 1998, the day ofthe mishap. The follo:yying flow results were obtained:

Three lengths of2 ~ - i n c h hose with a lead length of 1 %-inch hose stretched from the ninth-floorstandpipe produced a flow of 154 gallons per minute.Four lengths of2 %.inch hose stretched from the eighth floor produced a flow of 290 gallons perminute.Both of these hose-lines were operated simultaneously and the output was measured by pitotgauge as the water was discharged out ofa 10th-floor window.

A member detailed to the Safety Battalion was assigned to verify the following:TASK TIME TAKEN

to have the elevator go to the fire floor and return tothe lobby Approximately one minute to the fire. floor, and oneminute to return to the lobbyto cross over from one stairwell to the other on thesame floor

Approximately one minuteto walk. up to the ninth floor Approximately th ree minutes

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CAUSES OF THE MISHAP DIRECf:The at tempt to stretch and operate a hand-line from the standpipe outlet located in the stair on the samefloor as the fire and the failure to get the initial line charged and operating.Inadequate communication and coordination amongst units operating in the stair and the unit operdtingout on the fire floor. Engine 290 was the only unit that knew where the members of Ladder 170 wereoperating.Members ofLadder 170 operating in an atmosphere that contained high heat, heavy smoke and otherproducts of combustion.Members ofLadder 170 operating in the hallway without the protection of a 2 ~ - i n c h hand-line whenheavy fire, heavy smoke and toxic gases vented from apartment 10-D

. Failure by units operating in the exposure #4 stair to inform Ladder 170 of the seriousness and extent ofthe escalating fire conditions.INDIRECT CAUSES:Wind gusting from 17 to 25 mph and blowing directly into the fire apar tmentDelayed. alarm caused by the occupant's attempt to extinguish a couch fire in the apartment and thebuilding security guard going up to the 10th floor to verify the cause of the interior alarm going of f beforenotifying the Fire Department.Fire forced by the wind into the 10th-floor public hallway trapped members and inflicted fatal injuries.Failure of the sprinkler system to operate.CONTRIBUTORY CAUSES:

. High heat release rate of the fire loading in the fire apartment. All of the furniture was made of foamrubber and the occupant had just installed new carpeting. The foam insulat ion between the exterior walland the sheetrock wall also contributed to the heavy fire load.Failure of the building 's maintenance personnel to maintain and inspect the sprinkler system to determineits operability.Failure of the administrative unit to verify and check the accuracy of CIDS card information and includeinformation about the sprinkler system .Insulation on the standpipe outlet on the 10th floor in the exposure #4 stair prevented proper hook-up ofhose to the standpipe.

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Documents

FDNY report on fatal fire, December 18, 1998