State inspectors have warned Mayor Brandon Johnson to improve firefighter safety after finding major breakdowns in communication at scenes where firefighters have died, including a blaze that left a rookie dead.
The Illinois Division of Occupational Safety and Health sent a strongly worded letter to Johnson that the Chicago Fire Department must make it “standard operating procedure” for firefighters to stay in touch with each other at all times.
“CFD must extinguish the practice of members operating alone inside structure fires,” agency chief Erik Kambarian wrote last week. “IL OSHA will leverage all available enforcement tools to ensure members enter together, stay together, and exit together.”
An inspection by Illinois OSHA found that a hose on rookie firefighter MaShawn Plummer’s breathing equipment tore in two places while he was alone in a burning apartment building in Belmont Cragin in December 2021.
The agency found no defect in the equipment that could explain the ruptures. But the agency found other failures: Firefighters didn’t stay in touch while working the fire, Plummer was not in radio contact with anyone when he collapsed, and there was a delay in declaring a “mayday.”
The agency said no firefighters were near Plummer when his equipment began rapidly losing air pressure. He was found about 10 minutes later and died five days after the fire.
Similar communications concerns have been cited by the agency in the deaths of two other Chicago firefighters since then: Lt. Jan Tchoryk at a Gold Coast high-rise fire on April 5 last year, and Lt. Kevin Ward at a house fire in Norwood Park last August.
In its report on Ward’s death, Illinois OSHA said the fire department failed to ensure that firefighters “remained in visual or voice contact with one another at all times, exposing firefighters to respiratory and thermal hazards.”
Kambarian sent his letter to the mayor after the Ward report was completed.
The Chicago Fire Department released a statement Wednesday saying it has reviewed the reports and “appreciates their diligent efforts to investigate the tragic loss of our member in the line of duty. CFD will continue our work to provide training, monitor performance and hold our department accountable.”
‘Pressure rapidly decreasing’
Plummer’s crew responded to a fire in a two-story building in the 3100 block of North Marmora Avenue in the early morning hours of Dec. 16, 2021.
Plummer, a firefighter for less than a year, was instructed to head to the basement, according to Illinois OSHA. An officer with the engine company then went down to meet Plummer but could not find him, reporting poor visibility.
Crew members had seen Plummer put on a self-contained breathing apparatus, and logs indicated it was full of air, according to the state agency.
But about three minutes after the apparatus was turned on, logs indicate pressure was rapidly decreasing, and the device was completely out of air in minutes.
Plummer was able to manually activate his personal alert safety alarm, according to Illinois OSHA.
Around the same time, the commander on the scene issued an evacuation order but “it did not appear that the order was heard over the radio by all members on scene,” according to the agency.
The commander was also notified of a possible “mayday” – code for a firefighter in need of assistance — though it was not confirmed.
An engine officer and a firefighter then communicated they could not find Plummer. In the confusion, another crew member who was checking inside the building “was not aware that he was searching for a lost firefighter.”
About 10 minutes after Plummer began losing air pressure, he was found unresponsive on the first floor of the building, his mask pushed up on his forehead. He died five days later.
Illinois OSHA said a “safety memo was issued ordering all hoses to be reexamined prior to use ... Per the manufacturer, no largescale defect was found, and the break in the hose was not replicable in testing.”
The agency determined that exposure to respiratory hazards was the direct cause of Plummer’s death. But they listed several contributing factors.
Plummer had only been on the job for six months, and the agency found he should have been under close supervision.
Illinois OSHA also found fault with radio communication at the scene, noting that Plummer had not established communication with a member outside the “hazard zone” who could assist in an emergency.
Plummer was not in direct visual or voice contact with another firefighter when his hose ruptured, and there was no one to help him, the agency found.
There was also a delay in declaring a mayday, the agency said.
“This incident highlights the critical importance of firefighters entering a structure together, staying together, and exiting together,” Illinois OSHA wrote in the conclusion of its report.
Same concerns at other fires
The same issues were raised by the agency after its inspection of a fire on Aug. 11 last year in the 8300 block of West Balmoral Avenue where Ward was fatally injured.
Ward became trapped in the basement of the burning home and was critically hurt, according to fire officials. He died about two weeks later of complications from respiratory issues.
Illinois OSHA determined Ward was one of at least three crew members who were operating alone at the scene.
Fire officials have not provided any additional details on the circumstances of Ward’s death. Two other firefighters were injured in that blaze.
Illinois OSHA issued five citations concerning the Balmoral fire, telling the fire officials in its report that their “inviolable cardinal rule” must be that firefighters “enter together, stay together, and exit together.”
In its letter to the mayor, the agency also mentioned a fire on the 27th floor of an apartment building in the 1200 block of North Lake Shore Drive on April 5 last year.
Tchoryk, 55, suffered a heart attack while responding to the fire. Another firefighter suffered smoke inhalation. Both were found in the stairwell of the building.
Illinois OSHA did not release any details, but the Illinois OSHA chief cited the fire in his letter to the mayor insisting that the fire department adopt a strict “two-in/two-out” rule.
The letter ends with 10 recommendations for improved training and manpower. They include:
- Provide training for command team members with a focus on fireground safety and survival.
- Develop and implement computer-based simulation training and assessments.
- Dedicate additional staff and resources for training, specifically in areas of command, team continuity, radio communications, dynamic risk assessment, mayday procedures, and the safe person concept.
- Require all teams entering a basement to use a hose line and/or thermal imaging camera.
- Refine radio system software and hardware to ensure proper function and reliability.
- Work with firefighters, company officers, and command officers on an effective Emergency Alert Button (EAB) activation process, develop training for the process, drill on the process and periodically test the process.
