FDNY report on fatal fire, November 23, 2008

8/4/2019 FDNY report on fatal fire, November 23, 2008

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FIRE DEPARTMENT CITY OF NEW YORK SAFETY AND INSPECTION SERVICES COMMAND

INVESTIGATIVE REPORT STATEN ISLAND BOX 2-2 0021

39 VAN BUREN STREET NOVEMBER 23, 2008

CASE NUMBER SB 66/08FATAL INJURY

LIEUTENANT ROBERT J. RYAN JR. ENGINE COMPANY 155

VOLUME I THE INVESTIGATION


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I. SUMMARY

On Sunday November 23, 2008, at 0028 hours, the Staten Island CommunicationsOffice received a telephone alann reporting a fire at 39 Van Buren Street. The initialresponse to Staten Island Box 0021 was two Engine Companies, two Ladder Companies andone Battalion Chief. Because numerous phone calls were received, the Staten IslandDispatcher filled out the alann to a total of four Engine Companies, two Ladder Companies, aRescue Company, a Squad Company, a Marine Company and a Battalion Chief. The Officerof Engine Company 155, Lieutenant Robert J. Ryan Jr., transmitted a 10-75 for fire showingon the 2nd floor of a detached, private dwelling. Standard firefighting operations wereinitiated for a fire in a private dwelling.

The fire building was a 2Y:! story, wood frame, peaked roof, detached private dwelling.The building dimensions were approximately 20 feet by 40 feet.

The Bureau of Fire Investigation (BF!) determined that the fire was caused by heatfrom electrical wiring. BFI detennined that the fire originated in a rear bedroom on thesecond floor between the sheetrock ceiling and the attic floor. The fire extended horizontallyinto the rear attic void and vertically through the attic flooring to the attic closet and theunderside of the roof sheathing. The fire smoldered undetected before it was discovered byneighbors who alerted the sleeping occupant.

Lieutenant Ryan of Engine Company 155 became unconscious while operating in theattic. He was transported by ambulance to Richmond University Medical Center where hesuccumbed to his injuries.

The autopsy revealed that Lieutenant Ryan's cause of death was smoke inhalation. Asa result of the investigation into this fatality the Safety and Inspection Services Commandmakes the following recommendations:1. Reinforce, on a regular and recurring basis, the dangers of carbon monoxide (CO) and

hydrogen cyanide (HCN) to all members.2. Chief and Company Officers must strictly enforce policies and procedures of All Unit

Circular 220, Self-Contained Breathing Apparatus (SCBA) Policy, and All UnitCircular 329 FDNY Policy/OSHA Respiratory Standards as they relate to the use ofthe Scott 4.5 SCBA.

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3. Chief and Company Officers must strictly enforce policies and procedures for theproper use of the firefighting helmet chin strap.

4. Ensure that the Department's Bureau of Operations and the Emergency MedicalServices Operations participate in an after action review (AAR) for every incidentwhich involves the serious injury or death of an on-duty member.

5. Continue to train all members to immediately transmit a MAYDAY message whenfaced with a life threatening situation.

6. Continue to train all members to be proficient in roll call procedures as perCommunications Manual Chapter 9, Addendum 2, "Emergency Roll Call Procedures."

7. Continue to train all members on Unconscious Firefighter Removal procedures.

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IV. FDNY OPERATIONSOn Sunday, November 23,2008 at 0028 hours, the New York City Fire Department's

Staten Island Borough Communications Office received a telephone alarm reporting a fire at39 Van Buren Street.

At 0029 hours, Engine Company 155, Engine Company 153, Ladder Company 78,Ladder Company 77 and Battalion 22 were assigned to respond. The dispatcher filled out thealarm due to a second source. Engine Company 156, Engine Company 157, Marine Company9, Rescue Company 5 and Squad Company 1 were assigned.

All of the Engine Companies assigned on the first alarm were staffed with fourFirefighters and an Officer. The Ladder, Rescue, and Squad Companies were staffed withfive Firefighters and an Officer.The temperature was 26 Fahrenheit with the wind out of the west at 13-16 mph.

The fire building was a 212 story, wood frame, peaked roof, detached private dwelling.The dimensions of the building were approximately 20 feet wide by 40 feet deep.

The exposures were as follows: Exposure #1 - Van Buren Street Exposure #2 - 212 Story Detached Private Dwelling Exposure #3 - Rear Yard Exposure #4 - 212 Story Detached Private DwellingThe Bureau of Fire Investigation (BPI) determined that the fire was caused by heat

from electrical wiring. BFI determined that the fire originated in a rear bedroom on thesecond floor between the sheetrock ceiling and the attic floor. The fire extended horizontallyinto the rear attic void and vertically through the attic flooring to the attic closet and theunderside of the roof sheathing. The fire was undetected and smoldered until it wasdiscovered by neighbors who alerted the sleeping occupant.

INITIAL OPERATIONSAt 0032 hours, the Engine Company 155 Officer, Lieutenant Robert J. Ryan Jr.

transmitted a 10-75 for fire showing on the 2 nd floor of a detached, private dwelling. EngineCompany 155 arrived within 3 minutes and 17 seconds after the receipt of the alarm at theStaten Island Communications Office.

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Ladder Company 80 and Battalion 42 were assigned on the transmission of the 10-75.The Staten Island Dispatcher notified Ladder Company 80 that they were designated theFirefighter Assist and Search Team (FAST Unit).

The Engine Company 155 Chauffeur stopped the apparatus a few feet past the firebuilding. The Engine Company 155 Nozzle and Back-Up Firefighters each removed foldedlengths of 1%" hoseline and stretched them toward the front of the fire building. LieutenantRyan entered the building through the unlocked front door to search for the fire. (Photo 1)

Photo t 39 Van Buren Street

The Engine Company 155 Chauffeur and Control Firefighter proceeded to the nearestfire hydrant approximately 100 feet down the street. (Diagram 1) The hydrant was partiallyblocked by an illegally parked car. The Engine Company 155 Chauffeur was able to use the35-foot Soft Connection to connect to the hydrant. (Photo 2) A total of five lengths of 1 3/4"hoseline were used to complete the stretch.

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Drawing Not To Scale

39 Van Buren street

.= HydrantDiagram 1

Position of Apparatus

Photo 235-foot Soft Connection used by Engine Company 155

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Ladder Company 78's apparatus was positioned directly in front of the fire building.The aerial ladder could not be used because of overhead electrical wires. Portable ladderswere used to vent, enter and search (VES) different areas of the fire building.

At approximately 0033 hours, the Ladder Company 78 Officer, Forcible Entry andCan Firefighters (Inside Team) entered the building to search for the seat of the fire. TheLadder Company 78 Outside Ventilation Firefighter reported smoke pushing from theexposure #3/4 comer, and fire on the exposure #2/3 comer of the fire building.

Lieutenant Ryan proceeded to the second floor via the interior stairs and continued upto the attic. There was no visible fire in either location. Lieutenant Ryan returned to thesecond floor and encountered the Ladder Company 78 Inside Team. He told the LadderCompany 78 Officer that he checked the attic and did not observe any fire. He recommendedthat Ladder Company 78 conduct an investigation of the attic. The Ladder Company 78Inside Team continued up to the attic to search for the fire. Lieutenant Ryan returned to thefirst floor to lead the Engine Company 155 Nozzle and Back-Up Firefighters (Nozzle Team)into the fire building. The exact location of the fire was unknown.

Division 8 was notified by the Staten Island Communications Office that a 10-75signal had been transmitted for Box 0021.

At approximately 0034 hours, the Ladder Company 78 Inside Team arrived in theattic and observed a light smoke condition. The Ladder Company 78 Officer looked out theattic window at the top of the attic stairs and observed fire burning on the exterior of thebuilding. He opened the closet door at the attic stair landing and smoke pushed out from thecloset space. (Diagram 2) He scanned the attic with a thermal imaging camera (TIC). TheTIC indicated a high heat condition in the area of the exposure #3/4 comer. The LadderCompany 78 Officer ordered the Inside Team to open up the walls and ceiling in that sectionof the attic.

Engine Company 155 entered the fire building with the uncharged hoseline andproceeded to the second floor. At 0034:07, Lieutenant Ryan transmitted the followingmessage; "55 to 78. Anything on the third floor?" At 0034:32, he transmitted, ~ ~ 1 5 5 toChauffeur, give us water ..."

Battalion 22 arrived on the scene and assumed the role of Incident Commander.Division 8 was assigned and responded.

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Exposure #4Initial opening inknee wall madeby Ladder 78 foo------13 5 ' - - - - - - - . . + -0 - - - - -8 ' 6 ' - - . . . . ,

11' VoidBehindKneeWall

7' 6"

ooCloset

7 f t . - - I111+- - -4

I

rAttic Stair LandingJ C Attic Window

. . . Denotes Lieutenant Ryans' HelmetExposure 112

Diagram 2

4'

Storage AreaNote: Roof slopes down11' toward front of building

Drawing Not To Scale

Diagram of Attic at 39 Van Buren Street

At approximately 0035 hours, the Ladder Company 78 Inside Team opened a 3 foot x3 foot hole in the knee wall in the exposure #3/4 comer of the attic. (Diagram 2) Fire andheavy smoke pushed from the opening. Due to the slope of the ceiling and lack of horizontalventilation, the heat and smoke built up quickly in the attic. (Photo 3)

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Photo 3 Slope ofAttic Ceiling

At 0035:08, Lieutenant Ryan requested water a second time, "155 to Chauffeur, giveus water." The Engine Company 155 Chauffeur responded, "Water's on the way." Whenwater arrived at the nozzle, the Engine Company 155 Nozzle Firefighter bled the hoseline ofair. Engine Company 155 advanced the hoseline up the narrow stairs to the attic. (Photo 4)(THE INVESTIGATION TEAM BELIEVES THAT AT THIS TIME LIEUTENANT RYAN HAD THEFACEPIECE OF HIS SCBA DONNED AND HIS HELMET ON.)

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Photo 4 Narrow Staircase from 2nd floor to the Attic

Battalion 22 called the Ladder Company 78 Chauffeur and asked if anyone hadchecked the basement. The Ladder Company 78 Roof Firefighter informed the LadderCompany 78 Officer that there was nothing showing in the basement. Battalion 22acknowledged this transmission. The Ladder Company 78 Chauffeur positioned a 20 footportable ladder against the front of the fire building and heard the transmission concerningpossible fire in the basement. The Ladder Company 78 Chauffeur checked the basementwindow on the exposure #4 side of the building and entered the fire building to check fromthe interior. The Ladder Company 78 Chauffeur transmitted that the basement was clear at0038 hours.

Engine Company 156 arrived on the scene.

At approximately 0036 hours, Engine Company 155 entered the attic with a chargedhoseline.

At 0036 hours, Engine Company 153 and Ladder Company 77 arrived on the scene.The Engine Company 153 Chauffeur contacted the Engine Company 155 Chauffeur viahandie-talkie and asked if he was set up with a hydrant. The Engine Company 155 Chauffeurreplied that he did have a hydrant. The Ladder Company 78 Outside Ventilation Firefightercalled the Ladder Company 78 Officer via handie-talkie and requested permission to vent thewindows from the exterior.

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Battalion 22 ordered the Battalion Firefighter to Special Call an additional EngineCompany and Ladder Company.

The Staten Island Borough Communications Office notified Emergency MedicalServices (EMS) of the 10-75 at 39 Van Buren Street.

At 0037:06, the Ladder Company 78 Officer responded to the request from the LadderCompany 78 Outside Ventilation Firefighter to vent the windows and transmitted, "Take thewindows, take the windows." (THE INVESTIGATION TEAM BELIEVES THAT THE LADDERCOMPANY 78 OFFICER WAS APPROVING THE VENTILATION OF THE WINDOWS iN THE ATTIC.)

The Ladder Company 78 Outside Ventilation Firefighter observed fire burning on theexterior of the building directly above a window on the second floor on the exposure #2 sideand vented it. The ventilation of this window had no effect on the smoke condition in theattic. (Diagram 3)

Diagram 3 Windows of the Exposure #2 Side of the Building

The Ladder Company 77 Inside Team entered the fire building and proceeded to thesecond floor. The Ladder Company 77 Officer contacted the Ladder Company 78 Officer viahand ie-talkie and asked if he needed any help. The Ladder Company 78 Officer transmitted,

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"Yeah, listen, the fire looks like it's in the walls. We gotta check the walls, check thebasement .. hefirstfloor." The Ladder Company 77 Outside Ventilation Firefighter made ahandie-talkie transmission which also confirmed that there was no fire in the basement.

Engine Company 153 teamed up with Engine Company 155 and assisted with thehoseline that was stretched into the attic.

At 0037 hours, Engine Company 158 and Ladder Company 81 were assigned andresponded as the additional Engine Company and Ladder Company.

The following units were assigned by the EMS Dispatcher and responded: EMS Unit 21 C 1 (Richmond University Medical Center), a BLS (Basic Life

Support) unit EMS Unit 22Z1, an ALS (Advanced Life Support) unit EMS Unit C211, the Conditions Officer (EMS Lieutenant)

At 0038 hours, Battalion 22 asked the Ladder Company 77 Officer where they wereoperating. The Ladder Company 77 Officer informed Battalion 22 they were operating on thesecond floor and Ladder Company 78 was in the attic. The Ladder Company 77 Officernotified Battalion 22 that they were going to open up the ceiling directly below the fire.Battalion 22 cautioned the Ladder Company 77 Officer that heavy smoke was pushing fromthe exposure #2 side of the building.

Rescue Company 5 arrived on the scene.Engine Company 159 with Satellite 5 were assigned and responded.

At 0039:00, Lieutenant Ryan made the following transmission, "155 to Command."Battalion 22 responded, "Go ahead 155." At 0039:05, Lieutenant Ryan reported, "155 andLadder 78 are on the top floor, we're trying to open up the walls. Fires got up in thewalls." (THE INVESTIGATION TEAM BELIEVES THAT LIEUTENANT RYAN HAD THE FACEP[ECE OFHIS SCBA DONNED WHEN HE MADE THIS TRANSMISSION.)

The Ladder Company 77 Officer called Battalion 22 and requested a second hoselineto the 2nd floor because fire was dropping down from the ceiling. The Engine Company 156Officer informed Command that his unit would stretch a hoseline to the 2nd floor.

At 0039:19, Battalion 22 transmitted the following preliminary report to the Staten IslandCommunications Office, "Box 21, we have a two and a halfstory private dwelling fire on thetop floor. One is a street, two is a similar detached, three is a yard, and four is a similardetached. One line stretched in operation. Second line being stretched. Fire is doubtful. "

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At 0039:34, EMS Unit MV51, the Major Emergency Response Vehicle (MERV), wasassigned and responded.

(THE INVESTIGATION TEAM BELIEVES THAT AT APPROXIMATELY 0040 HOURS,LIEUTENANT RYAN'S HELMET WAS EITHER DISLODGED OR REMOVED FROM HIS HEAD FOR ANUNKNOWN REASON. THE LADDER COMPANY 78 CAN FIREFIGHTER HEARD LIEUTENANT RYANSA Y, "I LOST MY HELMET." THE HEAVY SMOKE CONDlTlON MAY HAVE PREVENTED LIEUTENANTRYAN FROM LOCATING HIS HELMET. IT lS BELIEVED THAT LIEUTENANT RYAN'S FACEPIECE WASDONNED AT THlS TIME.)

At approximately 0040 hours, Ladder Company 77 was operating in the bedroom onthe 2nd floor directly below Engine Company 155 and Ladder Company 78. The LadderCompany 77 Officer opened the center of the ceiling where a light fixture had burnt away.He observed fire burning in the attic above him as well as fire dropping down to his location.The Ladder Company 77 Officer transmitted, "We got fire burning thru, it's dropping downinto the secondjloor. Ah, exposure 2 side. You get a line up here, we'll start opening up.Just let the ah, guys know upstairs."

Battalion 22 ordered the Rescue Company 5 Officer to split his unit to investigateconditions on the second and third floors.

Battalion 22 asked the Engine Company 156 Officer if they needed assistance fromthe fourth due engine to stretch the second hoseline. The Engine Company 156 Officerreplied that no assistance was needed.

Ladder Company 80 (FAST Unit) and Division 8 arrived on the scene.

At 0041:11, Battalion 22 requested a primary search from Ladder Company 78 andLadder Company 77. The Ladder Company 77 Officer reported that the primary search onthe second floor was negative.

At 0041:48, the Ladder Company 78 Officer, in the attic, made the followingtransmission, "We need a line on the second jloor Chief." The smoke and heat conditionsincreased dramatically in the attic. The Ladder Company 78 Officer vented the attic windowon the exposure #2 side. (Photo 5) He descended the stairs to investigate a possible firecondition on the 2nd floor. The other members of the Ladder Company 78 Inside Teamremained in the attic.

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Photo 5 Attic Window on the Exposure #2 Side Vented by the Ladder Company 78 Officer

(PHOTO 5 SHOWS THE WINDOW OF THE FIRE BUILDING COMPLETELY REMOVED. AN INTACT WINDOW OF THE ADJACENT BUILDING CAN BE SEEN THROUGH THE VENTED

WINDOW.)

At approximately 0041 hours, Engine Company 156 arrived at the front of the firebuilding with the second hoseline, uncharged.

Lieutenant Ryan continued to operate without the thermal protection provided by adonned fire helmet. He made the decision to back the hoseline out of the attic.

Rescue Company 5' s Inside Team entered the fire building and moved to the second floor.The Rescue Company 5 Roof and Outside Ventilation Firefighters obtained a portable ladderfrom Ladder Company 78's apparatus and positioned it to a second floor window on the exposure#4 side of the fire building. The Rescue Company 5 Chauffeur operated on the exposure #2 sideof the building and assisted the Ladder Company 77 Chauffeur force entry to the side door.

Ladder Company 80 removed the FAST Unit tools and equipment and walked downVan Buren Street toward the fire building. The Ladder Company 80 Outside VentilationFirefighter walked past the fire building to the Battalion 22 vehicle to obtain the FAST Unithandie-talkie to monitor fireground communications. (Diagram 1)

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At 0042:02, Lieutenant Ryan transmitted, "155 to .. .Back out. Back out." (THEINVESTIGATION TEAM BELIEVES THAT LIEUTENANT RYAN'S FACEPfECE WAS NOT DONNED ATTHIS TIME. THE SOUND OF HIS VOICE CAPTURED BY THE BATTALION HANDlE-TALKIE RECORDERDIFFERED FROM HIS EARLIER TRANSMISSIONS.)

The Engine Company 155 Back-Up Firefighter moved to the stairs leading down tothe second floor. He notified the Engine Company 155 Nozzle Firefighter that he located thestairs. The Engine Company 155 Back-Up Firefighter backed the hoseline down to thesecond floor. As the Engine Company 155 Nozzle Firefighter returned to the stairs, he feltsomeone move past him. He called out twice asking if anyone was still in the attic. He didnot hear any response and believed that he was the last member to leave the attic. The EngineCompany 155 Nozzle Firefighter shut down the nozzle and backed the hoseline down thestairs. As the hoseline was backed out of the attic by the members of Engine Company 155,the Ladder Company 78 Forcible Entry Firefighter was struck by someone who caused hisfacepiece to be pushed to the side. He stopped to re-adjust his facepiece and helmet.

At 0042:20, the Ladder Company 77 Officer made the following transmission toCommand, "We got a lot ofguys on tile second floor ifyou could start pulling some of tilemdown. "

Lieutenant Ryan and the Ladder Company 78 Can Firefighter were next to each otherin the attic. The Ladder Company 78 Can Firefighter heard Lieutenant Ryan say, "I'mburning up .. .where are the stairs?" (THE INVESTIGATION TEAM BELIEVES THAT LIEUTENANTRYAN WAS STILL OPERATING IN THE ATTIC WITHOUT THE PROTECTION OF HIS HELMET AND THATTHE FACEPIECE OF HlS SCBA WAS NOT DONNED.)

At 0042:41, the Ladder Company 78 Can Firefighter transmitted, "78, URGENTURGENT-URGENT. We Ilave to hack out oft/l is room."

The Ladder Company 78 Officer was on the second floor when the URGENTtransmission was given by the Ladder Company 78 Can Firefighter. The Ladder Company 78Officer returned to the base of the attic stairs.

The Ladder Company 78 Forcible Entry Firefighter finished re-adjusting his facepieceand exited the attic. Lieutenant Ryan and the Ladder Company 78 Can Firefighter began toexit the attic and crawled toward the stairs. The Ladder Company 78 Can Firefighter guidedLieutenant Ryan to the attic stairs.

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The members of Ladder Company 80, except the Outside Ventilation Firefighter, were

ission. They arrived at the front of the fire building, placed the Stokes Stretcher on thenformed Battalion 22 that they were ready to operate as the FAST Unit. The

22 vehicle when hethe URGENT transmission. He turned on the FAST Unit handie-talkie to monitor any

ency transmissions. He walked to the front of the fire building and teamedof the FAST Unit.

At 0042:46, Battalion 22 responded to the URGENT transmission and replied, "10-4.them hack down. Clear the stairs. Let them hack down. Let them hack down. "

At 0043:03, Battalion 22 transmitted a 2nd Alarm. 2ndThe following units were assigned to the Alarm by the Staten Island

0044:39. Engine Companies 166, 165,242 Ladder Company 168 Battalion 23, Safety Battalion 1, Rescue Battalion 1 Tactical Support Unit 2 Field Communications Unit 1At approximately 0043 hours, Division 8 arrived in front of the fire building and

of Incident Commander. After a brief discussion concerning the status of22 into the fire building to investigate the circumstances

At 0043: 11, the Ladder Company 78 Officer transmitted, "78 to 78 Irons."At 0043:16, Battalion 22 transmitted, "Who's got the URGENT?"At 0043:18, the Ladder Company 78 Officer transmitted, "78 to 78 Irons."At 0043:22, Battalion 22 responded, "Go ahead. Go ahead Irons. "At 0043:25, the Ladder Company 78 Officer transmitted, "Do you got the Can Man

you?" (THE INVESTIGATION TEAM BELIEVES THAT THE LADDER COMPANY 78 OFFICERTRYING TO CONFIRM THAT THE LADDER COMPANY 78 FORCIBLE ENTRY AND CAN

TOGETHER.)

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LIEUTENANT RYAN BECOMES UNCONSCIOUS

As Lieutenant Ryan and the Ladder Company 78 Can Firefighter crawled to a positionnear the top of the attic stairs, the Ladder Company 78 Can Firefighter witnessed LieutenantRyan collapse and become unconscious. The Ladder Company 78 Can Firefighter realizedLieutenant Ryan was in grave danger and in need of immediate removal. The LadderCompany 78 Can Firefighter called out to members operating on the second floor for help. Inan attempt to remove him as quickly as possible, the Ladder Company 78 Can Firefighterpushed Lieutenant Ryan to the landing at the top of the attic stairs.

The Ladder Company 78 Officer returned to the top of the attic stairs where hediscovered Lieutenant Ryan unconscious. The Ladder Company 78 Can Firefighter wasbehind Lieutenant Ryan.

At 0043:53, the Ladder Company 78 Officer transmitted, "78 to Command,MA YDA Y-MA YDA Y-M4 YDA Y. "

At 0044:00, Command acknowledged the MAYDAY transmission, "Unit with theMAYDAY go." At 0044:02, the Ladder Company 78 Officer transmitted, "We got, we got anunconscious fireman in the attic", and again at 0044: 17, "78 .. We got a downed fireman. "

Command ordered Ladder Company 80 into the building to remove the unconsciousFirefighter. Ladder Company 80 entered the building and moved up the stairs to the secondfloor. The Ladder Company 80 Outside Ventilation Firefighter remained outside the firebuilding and continued to monitor the FAST Unit handie-talkie. Command was not certainwhich member transmitted the MAYDAY and attempted several times to clarify the identityof the member who transmitted the MAYDAY. The Ladder Company 80 Outside VentilationFirefighter used the display screen on the FAST Unit hand ie-talkie to identify the membertransmitting the MAYDAY and responded to Command at 0044:25, "That's 78 Officer withthe MA YDAY. 78 Officer with the M4 YDA Y. "

The Ladder Company 78 Officer and Can Firefighter continued the attempt to removeLieutenant Ryan from the attic. Due to the heavy smoke condition, the members could notsee the left shoulder strap of Lieutenant Ryan's SCBA caught on the banister. (Photo 6) TheLadder Company 78 Officer and Can Firefighter were unable to free Lieutenant Ryan, so theLadder Company 78 Officer descended to the second floor to get assistance.

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Photo 6 Bannister of Attic Staircase

The Rescue Company 5 Officer was on the second floor when the MAYDAY wastransmitted. He informed Battalion 22 that he was proceeding to the attic to address theMA YDAY. The Rescue Company 5 Officer ascended the stairs followed by the LadderCompany 78 Officer. The Rescue Company 5 Officer encountered Lieutenant Ryan at the topof the stairs. Lieutenant Ryan was unconscious, in a seated position, with his back facing theRescue Company 5 Officer. Lieutenant Ryan's left shoulder was leaning against the exposure#2 wall. His helmet and facepiece were not donned. The Ladder Company 78 CanFirefighter was behind Lieutenant Ryan attempting to free him. The Rescue Company 5Officer lifted and pulled the shoulder straps of Lieutenant Ryan's SCBA several times andfreed him from the banister. Lieutenant Ryan was quickly brought down the stairs by theRescue Company 5 Officer and the Ladder Company 78 Can Firefighter. (Photo 7)

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Photo 7 2nd Floor Landing

At approximately 0045 hours, Lieutenant Ryan reached the second floor landingwhere his vital signs were evaluated by the Rescue Company 5 Officer. He unfastened thetop two buckles of Lieutenant Ryan's bunker coat and checked for a pulse and respirations.No pulse or respirations were detected. The Rescue Company 5 Officer made the decision toremove Lieutenant Ryan from the fire building immediately.

All members who operated in the attic were now on the second floor.Battalion 22 contacted Command via handie-talkie and requested an Advanced Life

Support (ALS) Unit from EMS to administer care to the unconscious member.At 0045:04, the Ladder Company 78 Officer transmitted "78 to Command .. we got

an unconscious fireman." Command was uncertain for whom the MAYDAY wastransmitted.

The Ladder Company 78 Officer responded to Command's inquiry and transmitted at0045:57, " .. . t's the Officer from 155".

The EMS BLS Unit 21Cl arrived on the scene at the corner of Van Buren Street andLafayette A venue. They began to back the ambulance down VanBuren Street toward thecorner of Franklin Avenue. (Diagram 4)

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At approximately 0046 hours, the Ladder Company 80 Officer and Can Firefighterreached Lieutenant Ryan on the second floor. The Ladder Company 80 Can Firefighterimmediately evaluated Lieutenant Ryan's air needs and turned the purge valve of LieutenantRyan's SCBA to the open position. No air escaped from the SCBA. The Ladder Company80 Roof and Forcible Entry Firefighters were on the stairs between the first and second floorand were ordered by the Ladder Company 80 Officer to get the Stokes Stretcher. The twoFirefighters retrieved the Stokes Stretcher from the front of the building, and returned to thebottom of the first floor stairs. Lieutenant Ryan was brought down to the first floor bymembers of Ladder Company 80, Rescue Company 5 and Engine Company 153. (Photo 8)

Photo 8First Floor

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At approximately 0047 hours, Lieutenant Ryan was placed in the Stokes Stretcher atthe bottom of the first floor stairs and was removed from the fire building.

At 0047:02, Battalion 22 asked Command to perform a roll call. As part of the rollcall, Battalion 22 informed Command that he was with the Ladder Company 78 Inside Teamand they were accounted for.

OPERATIONS AFTER LIEUTENANT RYAN WAS REMOVED FROMTHE FIRE BUILDING

At 0047:53, Command contacted the Staten Island Dispatcher and stated, " .. . we needEMSforthwith. We're doing CPR on an Officer."

At approximately 0048 hours, Lieutenant Ryan was in the Stokes Stretcher and placedon the ground near the front of the fire building. The members of Ladder Company 80removed Lieutenant Ryan's bunker coat and SCBA and initiated CPR. They attempted toestablish a patent airway, performed mouth-to-mouth resuscitation and chest compressions.The Engine Company 156 Chauffeur obtained the Automated External Defibrillator (AED)from Engine Company ISS's apparatus. Members of Engine Company 153 obtained oxygenequipment and a suction unit from Engine Company ISS's apparatus. The members insertedan oropharyngeal airway (OPA) and utilized a Bag Valve Mask (BVM) with supplied oxygen.The pads of the AED were applied to Lieutenant Ryan's chest, but there was no shockadvised.

For approximately the next five minutes, Firefighters primarily from Ladder Company80 and Rescue Company 5 performed CPR on Lieutenant Ryan in front of the fire building.

At 0048:24, the Staten Island Communications Office notified the EMSCommunications Office that CPR was being performed on an FDNY Officer.

Command called the Rescue Company 5 Officer and asked if there were any othermembers in distress in the building.

Squad Company 1 arrived on the scene.

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At approximately 0049 hours, Battalion 22 ordered Engine Company 156 andLadder Company 77 to operate in the attic. Engine Company 156 stretched their hoseline toextinguish the remaining body of fire. Ladder Company 77 performed the primary search inthe attic. The secondary search of the attic was later completed by Squad Company 1.

Battalion 22 ordered the Nozzle, Back-Up and Control Firefighters of EngineCompany 155 to exit the fire building and ordered the remaining members of EngineCompany 153 to take over Engine Company 155's hoseline. Engine Company 153extinguished the remaining fire on the second floor. Battalion 22 ordered the RescueCompany 5 Officer to perform the secondary search of the second floor.

The roll call of all members operating at the fire continued. The Rescue Company 5Officer informed Command that the MAYDAY had been transmitted for the Officer ofEngine Company 155 and that no other member required assistance. When completed at0109 hours, the roll call confirmed that no other members were missing or in need ofassistance.

Firefighters continued CPR on Lieutenant Ryan in front of the fire building.

At 0050 hours, the Staten Island Communications Office made a second notificationto the EMS Communications Office and requested that a rush be placed on the ambulancebecause CPR was in progress.

At approximately 0050 hours, the EMS BLS Unit 21Cl (Richmond UniversityMedical Center) ambulance was now positioned on Van Buren Street near the comer ofFranklin Avenue. (Diagram 4) The two Emergency Medical Technicians (EMTs) donnedtheir personal protective clothing, removed the stretcher and medical equipment. They wereapproached by a civilian who stated that a Firefighter had been seriously injured. The civilianclaimed that the Firefighter was lying on the sidewalk in front of the fire building.Firefighters on Van Buren Street near Franklin Avenue informed the EMS crew that theinjured member was in cardiac arrest. The EMS crew proceeded down the block with theirequipment toward the location of the injured member. They could not maneuver the stretcherover the charged hoseline and decided to leave it behind.


At 0051 hours, Firefighters continued CPR on Lieutenant Ryan in front of the firebuilding.

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At 0052 hours, EMS C2ll, the Conditions Officer, arrived on the scene andpositioned his vehicle on York Avenue between Van Buren Street and Richmond Terrace.(Diagram 4) He proceeded toward the fire building on Van Buren Street and became awareof an injured Firefighter in the street.

The EMS ALS Unit 22Z 1 arrived on the scene and also backed down Van BurenStreet to a position in front of the EMS BLS Unit 2ICl. (Diagram 4) The EMS ALS Unit22Z1 also heard that CPR was in progress on a Firefighter. The crew noticed that thestretcher from EMS BLS Unit 21Cl had been removed. The ALS crew prepared the BLSambulance for a cardiac patient. They awaited the arrival of the injured Firefighter.


Position of BlS 21 C1 &AlS 22Z1When Lt Ryan Was Placed in Ambulance

Location WhereBlS 21C1 &AlS 22Z1First Arrived on Scene

' I ~ ; ; ' ; I ' IIIOrawiog Not To Scale

Approximate Location were EMS First Made Patient ContactWith Lt Ryan

Diagram 4Location Where EMS First Made Contact with Lieutenant RyanAt approximately 0053 hours, as CPR continued, members carried Lieutenant Ryan in

the Stokes Stretcher toward York Avenue. They were at a position somewhere between thefire building and the corner of York Avenue, when the EMS Conditions Officer made contactwith them. (Diagram 4)

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The crew from EMS BLS Unit 2IC} moved past the fire building and also made contactters carrying Lieutenant Ryan towards York Avenue. The Conditions Officer

ed one EMT to reposition the BLS ambulance to York Avenue and Van Buren Street. TheMT from the BLS crew remained with the Conditions Officer and Lieutenant Ryan.EMS MV51, the MERV Unit, arrived on the scene and was positioned on York Ave

At 0054 hours, Firefighters continued CPR on Lieutenant Ryan as he was carriedYork A venue.

At 0055 hours, Firefighters continued CPR on Lieutenant Ryan as he was carriedYork A venue.At approximately 0056 hours, members carrying Lieutenant Ryan reached the comer

f Van Buren Street and York Avenue. The members placed the Stokes Stretcher on then. The EMS Conditions Officer retrieved the

He attempted to intubate Lieutenant Ryan but was

Battalion 42 arrived on the scene.

At 0057 hours, Firefighters continued CPR on Lieutenant Ryan at the comer of

At approximately 0058 hours, the members carried Lieutenant Ryan downAs they proceeded down the hill, the Battalion 42

er and the MER V Operator obtained a stretcher from the MERV.Battalion 42 called Command and requested a police escort for the ambulance to

At approximately 0059 hours, as the members who carried Lieutenant Ryan

the MERV. Members continued CPR on Lieutenant Ryan as they approached

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At approximately 0100 hours, the EMS BLS Unit 21Cl ambulance arrived at thecorner of York Avenue and Richmond Terrace with a Paramedic from ALS 22Z1 in the backof the ambulance. The members who transported Lieutenant Ryan to the corner were waiting.Lieutenant Ryan was placed in the back of the ambulance.

At 0102 hours, EMS BLS Unit 21Cl left the scene with an NYPD escort en route toRichmond University Medical Center. Efforts to revive Lieutenant Ryan continued in theambulance during his transport to the hospital. The Paramedic established an IV onLieutenant Ryan. Two attempts were made to intubate him and were unsuccessful. The EMTand Paramedic continued CPR and suctioned his airway enroute to the hospital.

At 0107 hours, the ambulance transporting Lieutenant Ryan arrived at RichmondUniversity Medical Center. Medical care was transferred to the emergency room staff of thehospital. Despite the efforts of the Richmond University Medical Center medical staff,Lieutenant Ryan succumbed to his injuries at 0134 hours.

As noted on the Certificate of Death for Lieutenant Robert J. Ryan Jr. the date of hisdeath was November 23,2008. The cause of death was smoke inhalation.

At 0108 hours, Command reported that all visible fire had been extinguished and thatboth the primary and secondary searches were complete and negative throughout. The firewas declared Probably Will Hold.

At 0131 hours, the fire was declared Under Control.

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v. FINDINGS

1. Lieutenant Ryan entered the attic of the fire building wearing full Personal ProtectiveEquipment (PPE) including an SCBA with the facepiece donned. He operated in theattic for approximately five minutes before his helmet either became dislodged, or wasremoved by him for an unknown reason. The heavy smoke and high heat condition inthe attic could have prevented Lieutenant Ryan from locating his helmet. Themembers who operated in the attic did not witness Lieutenant Ryan's helmet becomedislodged nor did they see him remove it.

2. Lieutenant Ryan operated with the facepiece of his SCBA donned for between six andseven minutes. Battalion Handie-Talkie Recorder transmissions and interviews withmembers who operated with him confirm that the facepiece was donned. For anunknown reason, the facepiece of his SCBA was no longer donned in the ImmediatelyDangerous to Life and Health atmosphere (IDLH). He continued to operate withouthis facepiece donned for approximately an additional two minutes before he collapsedand became unconscious.

3. The Safety Command impounded SCBA Engine 155-1 worn by Lieutenant Ryan atthe scene of the fire. This SCBA was a Scott 4.5 positive pressure breathing apparatuswith an EZ flow II regulator and a 45 minute cylinder. The SCBA was tested by theMask Service Unit on November 24, 2008. It was subjected to visual and functionaltests using the PosiChek3 testing procedures. The facepiece attached to the SCBAwas marked with the name of the Engine Company 155 Chauffeur who was on dutyfor the 6x9 tour ofNovember 22, 2008. The cylinder contained 0 psi of compressedair when confiscated and tested. This SCBA passed both the visual inspection and thefunctional tests which include the PASS Alarm. The SCBA was sent to IntertekTesting Services for independent analysis. The testing concluded that the SCBA metthe air flow requirements of National Fire Protection Association (NFPA) 1981, 2007edition standard and the PASS device met all Sound Pressure Level (SPL) designrequirements ofNFP A 1982, 2007 edition standard.

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4. The cylinder of Lieutenant Ryan's SCBA was completely depleted when he wasbrought to the second floor landing. The amount of time Lieutenant Ryan operated inthe IDLH (between six and seven minutes) would not be expected to deplete thecylinder. It is not known how the cylinder of the SCBA became depleted. SCBA Engine Company 155-1 was inspected at the 1800 hour roll call and no

defects were found. The sound of a vibralert activation was not heard on the scene. The sound of air escaping rapidly from the SCBA was not heard on the scene.

5. The Engine Company 155 carbon monoxide (CO) meter worn by Lieutenant Ryanwas tested and inspected by BW Technologies (Honeywell Life Safety) and found tobe operating properly. The data taken from the meter shows that levels reached themaximum readable level of 999 ppm at the time Lieutenant Ryan operated in the attic.According to Building Construction for the Fire Service, Third Edition by FrancisBrannigan, the rapid involvement of a large combustible surface combined with arestricted air supply alters the fire chemistry to increase CO production as much as 50fold over the burning area.The fire was undetected and smoldered until it was discovered by neighbors whoalerted the sleeping occupant. When the knee wall in the attic area was opened itcreated an extremely high level ofCO in this area.

6. The New York City Medical Examiner Report of Autopsy determined the cause ofdeath for Lieutenant Ryan was smoke inhalation. The carbon monoxide saturation inhis blood was 46%.

7. After becoming unconscious in the attic Lieutenant Ryan was quickly removed fromthe IDLH to the second floor of the fire building in approximately two minutes. Inless than three minutes, he was carried down from the second floor to the front of thebuilding. The total time for his rapid removal from the attic to the outside of thebuilding was less than five minutes.

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8. The members of Ladder Company 80, the FAST Unit, were properly equipped andready to deploy prior to the transmission of the MAYDAY. Once the MAYDAY wastransmitted the members of the FAST Unit were ordered into the fire building by theIncident Commander to address the MAYDAY. The Ladder Company 80 OutsideVentilation Firefighter remained outside to monitor the FAST Unit handie-talkie.Members of Rescue Company 5 and Engine Company 153 assisted members ofLadder Company 80 with the removal of Lieutenant Ryan from the fire building. Hewas placed in a Stokes Stretcher on the first floor and brought outside the buildingwhere the members began to perform CPR.

9. After Lieutenant Ryan was removed from the fire building, there was a period ofapproximately five minutes before EMS was able to provide medical treatment. CPRwas performed by Firefighters during this time. After Lieutenant Ryan was removedfrom the fire building, there was a period of approximately 12 minutes before he wasplaced in an ambulance.

10. The Ladder Company 78 Can Firefighter was with Lieutenant Ryan when he collapsedand became unconscious in the attic. He immediately began to remove LieutenantRyan from the attic. The Ladder Company 78 Can Firefighter verbally alertedmembers on the second floor for assistance. The Ladder Company 78 Officer arrivedIat the top of the attic stairs and transmitted a MAYDAY for an unconsciousFirefighter in accordance to Section 9.4.1 of the Communications Manual.

11. Members showed initiative and capability in several areas while operating at this fire: Members of the Ladder Company 78 Outside Team transmitted accurate

information over the hand ie-talkie concerning the smoke and fire conditions theyobserved during their exterior size up. They also requested permission from theirOfficer to vent windows on the exterior prior to performing the outside ventilation.

Because of an illegally parked automobile which partially blocked thepositioning of the apparatus at the closest hydrant, the Engine Company 155Chauffeur used the 35-Foot Soft Connection to rapidly provide water to thehose line stretched by his unit.

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Overhead electrical lines prevented the use of Ladder Company 78's aerialladder. Portable ladders were positioned on all four sides of the fire buildingby various members.

Handie-talkie communications were effective and efficient. The first arriving Battalion Chief was proactive about calling for additional

assistance early during the operations. He special called an extra Engine andLadder Company to assist the first alarm companies. Immediately afteracknowledging an URGENT transmission he transmitted a 2nd Alarm. TheMA YDA Y transmission occurred one minute later.

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VI. CAUSES

DIRECT CAUSES1. Smoke Inhalation

INDIRECT CAUSES1. Removal of seBA facepiece in IDLH atmosphere.

BASIC CAUSES1. Heat from electrical wiring.2. Delayed notification to the Fire Department.

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VII. RECOMMENDATIONS

1. Reinforce, on a regular and recurring basis, the dangers of carbon monoxide andhydrogen cyanide to all members. Design and deliver a presentation that outlines thenumerous dangers of carbon monoxide and hydrogen cyanide. Include safe actions totake in order to prevent carbon monoxide and hydrogen cyanide poisoning. Thispresentation should be included in both the regular company drill schedule as well asAnnual Education Day.

2. Chief and Company Officers must strictly enforce policies and procedures of All UnitCircular 220, Self-Contained Rreathing Apparatus (SCRA) Policy, and All UnitCircular 329 FDNY Policy/OSHA Respiratory Standards as they relate to the use ofthe Scott 4.5 SCBA, including the following: The SCBA facepiece must be continuously donned when in an IDLH

atmosphere. Removal of the facepiece to conserve air, to increase visibility, orto improve communication is dangerous and this practice must not be allowedto continue. As per Training Bulletin SCRA, Addendum 3, "Exposure to 1.3%of carbon monoxide will cause unconsciousness in two or three breaths andwill cause death in a few minutes. Exposure to small concentrations for only afew seconds inhibits one's ability to think clearly, rapidly causesdisorientation, and gives a feeling of euphoria compounding the risk hazard."

Each member should inspect and attach their personal facepiece to theirassigned SCBA at the beginning of each tour.

3. Chief and Company Officers must strictly enforce policies and procedures for theproper use of the firefighting helmet chin strap. No member should enter or operate inan IDLH without a helmet properly secured by a chin strap. Failure to utilize the chinstrap can result in serious consequences which affect operations as well as members'personal safety. When a helmet is lost or dislodged, the member is at risk of seriousinjury and is no longer effective in conducting assigned tasks.

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4. Ensure that the Department's Bureau of Operations and the Emergency MedicalServices Operations participate in an after action review (AAR) for every incidentwhich involves the serious injury or death of an on-duty member. This AAR shouldtake place as soon as possible after the injury or fatality. The purpose of this AARshould be to evaluate the effectiveness and improve the quality of the operation.

5. Continue to train members to immediately transmit a MAYDAY message when facedwith a life threatening situation.

6. Continue to train all members to be proficient in roll call procedures as perCommunications Manual Chapter 9, Addendum 2, "Emergency Roll Call Procedures."

7. Continue to train all members on Unconscious Firefighter Removal procedures. Aswas the case at this operation, being proficient in the procedures will expedite theremoval of an injured member.

Documents

FDNY report on fatal fire, November 23, 2008