Probe: Tactical Errors, Response Blamed for Toledo FF Deaths

An internal report on the 2014 North Toledo apartment building arson blaze that killed two firefighters concluded 12 factors contributed to their deaths — including a delay in getting to the building, communication failures, incorrect assessments of where the fire had started, and deployment of crews to the second floor while the fire burned below them downstairs.

The 82-page report by the Toledo Fire Department, obtained Thursday by The Blade, follows the release earlier this year of a National Institute for Occupational Safety and Health report that also detailed the Jan. 26, 2014, fire at 528 Magnolia St. Pvts. Stephen Machcinski, 42, and James “Jamie” Dickman, 31, died when they became trapped inside the burning two-story, six-unit apartment building. Both men were assigned to Engine 3.

The internal report, written by Deputy Chief Tom Jaksetic, Battalion Chief Sally Glombowski, and Captain Mike Benadum, offered some sobering findings regarding the fatal fire, accompanied by recommendations.

Among the communication failures outlined in the report was a revelation that the command officer did not hear the first two mayday calls made during the fire.

“Communication failures included vague instruction, no communication of fire ground observations to command via radio transmission not heard, and information transmitted not acknowledged,” the report said.

Mayor Paula Hicks-Hudson said she would follow the recommendations of the report.

“You cannot point to one thing or person to say ‘this is the fault,’” the mayor said. “What happened on that day is a tragedy.”

The fact that the blaze was intentionally set was listed by the report’s authors as their top finding.

The apartment building's owner, Ray Abou-Arab, 61, is charged with two counts of aggravated murder, two counts of murder, eight counts of aggravated arson, and one count of tampering with evidence. He faces the death penalty if convicted.

The report found that the response time to 528 Magnolia was delayed because Toledo Fire Station 3 was closed for renovations, the Craig Memorial Bridge was closed to all traffic, and four “first due” fire companies were either on emergency medical incidents or out of service. “First due” refers to fire apparatus expected at the scene first.

The bridge closure forced Engine 3 and Engine Company 13 to take longer routes to the blaze.

In 2013, the average response time for the so-called “first due” fire apparatus was less than four minutes. The first fire truck did not arrive to the deadly 2014 until five minutes and 45 seconds after a 911 call was received.

The report recommended revising department policy “that addresses the need to fill-in stations when companies are out of service for any reason.”

The report also found that the incident commander’s “initial size-up of the fire ground did not reveal the fire” on the first floor.

“The building configuration not only made it difficult to perform a 360-degree scene survey, but also to monitor conditions on all sides of the fire ground,” the report said. “Despite the [unusual] building configuration, Battalion 1, before taking command, did observe three sides of the building.”

That battalion chief later wrote that white smoke, but no fire, was observed coming from the second floor. The chief did not observe any smoke or fire coming from the first floor.

The report points out that commanders mistakenly thought the origin of the fire was on the second floor when it was in fact on the first floor.

“The decision to initiate attack on [the second floor] put both attack crews above the seat of the fire,” the report said.

“It was only after crews gained entry to [the first floor], seven minutes later, that command announced, ‘We've located the seat of the fire on [the first floor],’” it read. “Unfortunately, [Engine 3 and Engine 6] were already operating on [the second floor].”

The report recommended adding fire ground strategy and tactics to the department’s officer handbook, including language that addresses the importance of locating “the seat of the fire” and “dangers of operating above the seat of the fire.”

The report cited mistakes made by firefighters on the scene.

“Fire crews encountered a ventilation-limited fire when they arrived on they scene but did not recognize it,” it said.

The fire was ventilated in multiple locations, first when occupants of the second floor left a door open as they fled.

A second source of air was created when Engine 13 opened a left garage door on the first floor. That allowed air to flow directly to the fire, which was on that level.

“Shortly after [an Engine 13 officer] opened the garage door, Firefighter Dickman climbed the ladder and used his fire ax to open the second story window … thereby creating a third ventilation opening.”

Firefighters on another side of the building opened a door and created yet another source of air for the blaze, the report said.

“Shortly after the door on [the first floor] was opened the [wooded] addition [of the structure] became heavily involved,” the report said. “Sixteen minutes had elapsed between the 911 call and acting lieutenant Engine 6 reported water on the fire.”

Additionally, the report said Truck 17 was unable to reach the roof because of hazardous fire ground conditions and the roof was never opened for ventilation.

The report also cited wind direction and speed, which was out of the south-southwest at 12.7 mph during the blaze, as a contributing factor.

Among the 11 recommendations in the National Institute for Occupational Safety and Health report was that the fire department should reinstate a full-time safety officer.

Addressing the department's shift from a dedicated full-time safety officer in favor of widespread safety training, Fire Chief Luis Santiago in June said it was a more efficient system for responding to multiple calls across the city.

The union representing rank and file firefighters, Toledo Firefighters Local 92, has claimed that that policy change contributed to the two firefighters’ deaths.

The internal report also addressed the safety officer issue.

“Command assigned Engine 19 as Safety [Officer] … six minutes after command arrived on scene,” one of the findings stated.

The report also cited water-supply problems.

“Engine 6 did not have a permanent water supply when the second floor apartment erupted in flames,” it said.

It also said Engine 3 and Engine 6 entered the structure “without a charged hose line.”

Chief Santiago prefaced the report with an executive summary that seemingly contradicted the report's findings regarding charged hoses.

“[Engine 3] crew experienced rapidly changing fire conditions shortly after applying water to the fire,” the chief wrote. “[Engine 3] officer was able to escape out a second story door, but extreme heat overpowered firefighters Machcinski and Dickman despite having a charged hose line.”

The fire chief could not be reached for comment Thursday.

Mayor Hicks-Hudson established a panel to review the federal report, which also concluded several fire department practices contributed to the two deaths.

That report listed eight factors as contributing to the deaths: arson, risk assessment and scene size-up, resource deployment, fire ground tactics, inadequate water supply, crew staffing, lack of a full-time safety officer, and no sprinkler system in the building.

That committee reviewing the federal report — which was made up of Toledo Councilman Theresa Gabriel, City Chief Operating Officer Mark Sobczak, and Joe Walter, the Lucas County Emergency Management Agency's former director — corroborated the federal agency's conclusion that no single factor caused the line-of-duty deaths.

Contact Ignazio Messina at: [email protected] or 419-724-6171 or on Twitter @IgnazioMessina.

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