The National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention program recently released its report on the death of Cincinnati Fire Apparatus Operator Daryl Gordon, who died after falling down an unsecured elevator shaft during a 2015 incident. The Cincinnati Enquirer said the federal report largely concurs with the department’s own investigation.
According to the NIOSH report, on March 26, 2015, a 54-year-old male career fire apparatus operator (FAO) died after falling down an unsecured elevator shaft. The FAO was assigned to Heavy Rescue 14, which responded on the second alarm to a working fire on the second floor of a five-story residential apartment building. The four-person Heavy Rescue 14 was assigned to search for occupants on the fifth floor. The crew advanced to the fifth floor and began searching apartments. The FAO was the last Heavy Rescue 14 crew member to enter the fifth floor and became separated from the rest of his crew. Visibility was limited to about five feet because of moderate smoke. The floor had a centrally located hallway providing access to eight residential apartments. A hydraulic elevator located near the center of the building provided access to each floor. The elevator was accessible on each floor by an outward-swinging metal door that included a locking mechanism at the top left corner designed to keep the door closed until the elevator car reached that floor. The locking mechanism on the fifth floor was not functioning properly on this date.
Three members of Heavy Rescue 14 observed that the door could be easily opened. They reported this finding to the search and rescue operations chief (District Chief 3) who was on the fifth floor. A fire fighter used a permanent marker to write “Do Not Enter. Open Shaft” on the elevator door. A short time later, the FAO, believed to be looking for his crew, opened the elevator door and fell approximately 24 feet down the elevator shaft, striking the top rear edge of the elevator car and became stuck between the rear of the elevator car and the elevator shaft wall. The acting officer on Heavy Rescue 14 radioed a Mayday after realizing the FAO had fallen down the elevator shaft. Extrication efforts took approximately 14 minutes from the time of the Mayday. The FAO was pronounced dead at a local hospital. Three firefighters received minor injuries extinguishing the fire. The fire department successfully rescued 21 civilian occupants from their apartments during the incident.
- Breakdown in crew integrity
- Unsecured and unguarded elevator hoistway door
- Poor visibility due to moderate smoke conditions
- Delay in getting water onto the fire burning in a second-floor apartment
- Acting officers in several key positions
- No standpipe or sprinkler system within the residential apartment building.
- Ensure that crew integrity is properly maintained by sight, voice or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere.
- Train and empower all firefighters to report unsafe conditions to Incident Command.
- Ensure that appropriate staffing levels are available on scene to accomplish fireground tasks and be available for unexpected emergencies.
- Review standard operating procedures used to account for all fire fighters and first responders assigned to an incident.
- Ensure that interior attack crews always enter a hazardous environment with a charged hoseline.
- Integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (UL) into operational procedures by developing or updating standard operating procedures, conducting live fire training, and revising fireground tactics.
- Consider ways to block open shafts and other fall hazards.
Additionally, state, local, and municipal governments, building owners and authorities having jurisdiction should:
- Consider requiring sprinkler systems be installed in multi-family housing units.
The full report is available as a PDF HERE.