FIRE DEPARTMENT CITY OF ~NEW YORK

SAFETY OPERATING BATTALION

INVESTIGATIVE REPORT - - FIREFIGHTER FATALITY SEP. 1 2, 1 991 BROOKLYN BOX 22-1918

FIRE AT 495 ATKINS AVE

CASE NUMBER 33/91 FIREFIGHTER 6th GRADE KEVIN C. KANE LADDER COMPANY 110

SUBMITTED NOV.1, 1991

PREPARED BY: SAFETY OPERATING BATTALION

BC BC BC BC BC BC WILLIAM J. CESARK RICHARD J. POWNER EDWARD J. MCDONALD LAURENCE F. HATTON PETER M. BONGO JOSEPH A. CORDES

CASE NUMBER 33/91 FATALITY 9/12/91 F.F. KEVIN C. KANE - LADDER COMPANY 110 BOX 22-1918 BROOKLYN. SUMMARY. On September 12, 1991 at 0448 hours in the borough of Brooklyn, a telephone alarm of fire was reported to the central dispatching office. This telephone alarm was received from the 911 Police Dispatcher. Uni ts of the F. D. N. Y. were dispatched to a building fire reported to be located on Hegeman Avenue located between Atkins Avenue and Montauk Avenue. The address of the building in which the fire occurred is 495 Atkins Avenue. It is a four story vacant residential building approximately 60x100 feet in size. Although technically vacant, the building housed several squatters, and was a known drug location. The fire originated in a fourth (top) floor apartment, Dl, and was incendiary in origin. The fire rapidly took possession of the apartment and extended to the area between the ceiling and underside of the roof known as the cockloft. During the extinguishment operations of the fire Fire Fighter 6th Grade Kevin C. Kane, operating as part of the Forcible Entry Team of the first arriving ladder company was fatally injured. While performing search and examination of the adjacent apartment (D2) he became trapped in a .bedroom when the ceiling collapsed and the room ignited. He was seen in the fourth floor bedroom by Fire Department members in the street and removed from the window by the Tower Ladder bucket of Ladder 107. He was transported by EMS and Police Helicopter to New York Hospital Burn Center where he died the following day.

FINDINGS On the morning of Sept. 12, 1991 while performing the duties of searching for possible victims and examining for fire extension at a major fire on the top floor of a four story vacant residential building, Firefighter 6th grade Kevin Kane received second and third degree burns over 82% of his body. These injuries resulted his death approximately 22 hours later. Firefighter Kane, under the direct supervision of Lieutenant Charles Daly, had made his way into the bedroom of apartment D2. While performing his duties the entire ceiling suddenly and without warning dropped, cutting off Kane's path of escape. Unable to leave the room by the entrance he went to the window as the room became engulfed in fire. He tried unsuccessfully once more to find the doorway through which he had entered the room and returned to the window, now completely engulfed in flames. Members in the street, alerted to his plight implemented rescue procedures and removed him, via tower ladder (aerial platform). The rescue operation took approximately one and one half minutes, during which time he was almost constantly exposed to direct flame contact. He was removed to Burn Center, New York Hospital Cornell Medical Center where he expired on September 13, 1991.
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Firefighter Kane"s protective clothing was not designed to protect him from this environment. This is covered in detail in the section "PROTECTIVE CLOTHING". While there was one hand-held hose line in operation at the time of the ceiling collapse, it was heavily engaged in trying to extinguish the fire in apartment D1, and could not be readily moved to help the victim. The second and third hand lines were in the process of being "stretched" into position, but had not yet been put into full operation, or were too far away from the trapped firefighter to be of any value. By the time they were able to be moved into position, Kane had been fatally burned and was out of the building. CAUSE OF DEATH: Kevin Kane died as result of inh9-lation. These injuries were impingement for at least one and caused 2nd and 3rd degree burns This also caused smoke inhalation thermal burns and smoke caused by direct flame one half minutes. This to 82% of body surface. with respiratory burns.

CAUSES OF MISHAP 1. DIRECT CAUSE: Kevin Kane was operating in a room with heavy fire in the cockloft, in which a ceiling collapse occurred, thereby exposing him to direct flame contact.

2. INDIRECT CAUSES:
A: B: Use of accelerant in the ignition of the fire. Failure to report fire discovery in early stages. conditions on arrival of initial

C: Advanced fire response assignment.

D: The fallen ceiling blocked Kane's egress and prevented rescue attempt by Lieutenant Daly. Fire rapidly took possession of the room and without hose line readily available Kane was unable to exit the room during the SAFE Safe egress time is defined as the interval EGRESS TIME, between the time hazardous conditions prevail in the room and the time a victim would suffer 2nd degree burns to his body. (Refer to Thermal Protection Performance [TPP) description in Protective Clothing Section.) E: Ignition and burning of rubber boots worn by Kane.

3. CONTRIBUTING CAUSES: Illegal occupancy and .use of the building by squatters A: and for drug purposes. B: The design and construction of the ceiling. (See BUILDINGS section) 2X3 wood ceiling runners Runners butted and cleated with lx2 firring strip. : Wood gridwork hanging by 1x2 wood straps.
: no firm anchoring of ceiling to walls or partitions.
C: The inability to get water on the fire in Apt.D2. Engine 236 had a line stretched to the top floor and had water at about the time of the mishap, but was unable to move the line into position to rescue Kane. The investigative team explored that and found that in April 1987 Deputy Chief Vincent Dunn, Div.3 had conducted tests regarding 5 man vs. 4 man engine manning. His results were the subject of a report dated April 10, 1987 stating in part that when the hose stretch team was reduced by 20 percent (one firefighter) that hose stretch time was increased by 50 to 75 percent. See appendix__ 6_,

THE FIRE FIGHT:

The fire fight is described sequentially but there are many functions going on simultaneously. All times other than those taken from the communications tapes are approximate. The first alarm for a fire at 495 Atkins Ave. was received from a 911 operator at 0448:35. The information is for a fire opposite 1004 Hegeman Ave. in a vacant building. At 0451:12 box 1918 is transmitted over voice alarm. (The Computer Assisted Dispatch System was down at the time of the alarm.) Engine 290, 236~ Ladder 107, 103 & Battalion 39 are directed to respond. At 0453 hours Ladder 110, Which had been acting as Ladder 107 responds to a verbal which had been reported by Mr. Mark Lucas, a securi ty guard in the area, and an individual known to some of the members of Ladder 107. Realizing the probability of a working fire, Ladder 110 volunteers to respond. At 0454 Engine 332 is called on the radio and directed to respond to Hegeman Ave. and Bradford st., a location some 15 blocks from the fire. At 0455 hours Engine 290 and Ladder 110 give 10-75's simultaneously. It is apparent from the background noise that both apparatus are still responding into the scene but arrival is imminent. Engine 332 asks for a 10-7 for the Hegeman Ave. and Bradford st. location. Engine 283 and Ladder 175 are dispatched from Quarters on the 10-75. Batt. 39 had arrived and orders and additional Engine and truck. At 0456 Engine 332 is told to go to Hegeman Ave. and Berriman st. Ladder 107 arrives and Rescue 2 is dispatched via radio. Engine 290 takes a hydrant diagonally across from the fire building, on Atkins Ave. and the members start stretching. The officer, Lt Varriale goes to the front entrance door and waits while Ladder 110 Forcible Entry team cuts the lock and chain with a Partner saw. He then enters building and proceeds to the courtyard door and looks up into the shaft. He sees fire out about four windows and he returns to the front door. Concerned with the volume of fire he considers ordering 2 1/2 inch hose but finds that the company has 1 3/4 inch line already into the front door. He sees members of Engine Co. 236 coming down the block and he directs that they are to stretch a second line and not help his company with the first line. Ladder 107 arrives and begins to set up for tower ladder operation plaCing the apparatus on Hegeman Ave. facing west. Batt 39 gives a quick preliminary report to Brooklyn radio.

Lt. Varriale climbs to the top floor and arrives at 0457. His unit is following him up the stairs and is having difficulty maneuvering through the debris in the front entrance hall and up the return type of stairway. He radios to the 39 Batt. that he has fire in two apartments. Ladder 103 arrives and starts to raise aerial ladder to the roof. The roof man of ladder 110, Fire Fighter Tracy attempts to use Ladder 107's bucket to access the roof but finds that the bucket is already on its way to the top floor fire escape. He and 110's outside vent Fire Fighter watt go to the alley on Exposure 4 side and decide to use the fire escape there to get to the roof. Lt. Daly, L110 and the Forcible Entry team, Fire Fighter Kane and Fire Fighter Monaghan arrive at the top floor. Kane uses the extinguisher on the apartment D-1 doorway from which heavy fire is blowing out of into the public hall. Lt. Daly searches apartment D-4 and The Forceable Entry F.F. Monaghan searches apartment D-6. B.C. Flynn looks up from the first floor court yard door to check conditions and then proceeds to the landing between floors 3 and 4. By 0458 Engine 290 is hooked up and the chauffeur, FF Kelly tells the officer that he is ready to give him water. Engine 236 starts stretching nine lengths of 1 3/4 inch line from Engine 290' s pumper. Ladder 103' s aerial reaches the roof and FF. 6th grade Joyce starts alone up the ladder to the roof with a partner saw. Engine 332 arrives on the scene and positions apparatus at the hydrant on Hegeman Ave. diagonally opposite from the fire building. The chauffeur of Ladder 110 with the Outside Vent of Ladder 103 raises a portable ladder to the Atkins Ave. fire escape. The Ladder 110 roof team, F. F. Tracy and F . F . Wat t take a portable ladder from Ladder 11 0 ' s apparatus and carry it to the fire escape on Exposure 4 side of the building. Lt. Olsen, Ladder 107 and the Forcible Entry team arrive on the top floor of the fire building. Ladder 103 Outside Vent F.F.Libretti, starts up the front fire escape to vent. Ladder 107 Roof Man F.F. O'Neil follows Ladder Co. 110's roof team to the roof via the Exposure 4 side fire escape. At 0459 Engine 290 has arrived at the top floor and is flaking out the hose for an attack on the fire. They flake out the hose on the top floor hallway for a rapid advance into the fire apartment. Engine Co. 332 Chauffeur checks the hydrant and hooks up the apparatus to it. Engine 290 members don their masks. Ladder 103 Forcible Entry team checks out the third floor before proceeding to the fourth floor. Ladder 103 Outside Vent starts to remove the HUD window covering.

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The HUD window closure is designed to prevent unauthorized entry into a vacant building while it waits for rehabilitation. It consists of a system of plywood and 2x4's bolted together. It is particularly frustrating to attempt entry through this type window as described in the BUILDING section of this report.) At 0500 Engine 236 is stretching a line up stairs and having difficulty because the line keeps getting snagged. It is not a "well" stretch, there is a line already in the stairway and there are people going up and corning down the stairway, and they have to work around them. Lt. Varriale radios Engine 290' s chauffeur to start water. Several seconds later F.F. Kelly answers "Here comes your water". Varriale radios the 39 Batt. that there is fire in two apartments. Lt. Henry Gmelin, Eng. 332 radios the 39 Batt. for orders. He is ordered to stretch a third line up the front fire escape. Gmelin proceeds up the fire escape after ordering line stretched from Engine 290. Ladder 103 1 s Forcible Entry team searches rear apartments on top floor. Ladder 107 Officer and Forcible Entry team, start down stair to check exposure #3. They meet Eng. 236 between the 2nd and 3rd floors. They pass each other and Ladder 107 pauses momentarily to assist in the stretch then proceed to the street. Batt. 39 reports "All hands" working and asks dispatcher "who is the additional Engine and Truck?" F.F. Joyce L 103 looks over the roof and reports to Captain Quartuccio that there is fire out in the shaft. Batt. 39 is told by dispatcher that additional engine and truck is Ladder 110 and Engine 248 ACTING 227. At 0501 Lt. Gmelin (Eng.332) arrives at the top floor fire escape landing, F.F. Libretti L103 Outside Vent is finishing forcing the HUD window covering. F.F .Joyce, L 103 roof starts saw. He is in a position directly over the bedroom in the D-2 apartment. Ladder 107 is working their way to the top floor of Exposure 3, which is 1004 Hegeman Ave. Engine 236 is still stretching line to top floor. Engine 290 directs their hose stream into the front door of apartment D1. Lt. Varriale sees Ladder 110 on the fire floor. _L 110 goes into apartment D3. Ladder 175 and Engine 283 arrive on the scene traveling east on Hegeman Ave. The dispatcher announces all hands operating. At 0502 Engine 290 directs line into the room to the right of the door. They move into this kitchen and darken down this room. They hear a saw running on the roof as F.F. Joyce starts to cut the roof. Lt. Olsen and the FE team of Ladder 107 reaches the top floor of Exposure 3 and begins examination for extension in the front (Hegeman Ave. side) of apartments.

At 0503 - Engine 290 had darkened down the fire in the kitchen and start to move into the left room or the living room. Lt. Varriale sees members of Ladder 11 0 go into apartment D-2. F.F. Joyce continues to cut roof. B.C. Flynn radios Engine 283 to stretch a line to the top floor of Exposure 3. Lt. Joyce takes his company towards Engine 332's pumper. (Lt. Joyce, Engine 283 is a brother of FF Joyce, Ladder 103 roof man.) Ladder 110 Roof and Outside Vent arrive on the roof at about 0504. Their ascent up the Exposure 4 fire escape was hampered by debris and ropes and wires strung at various points blocking their route. F. F. Tracy was carrying the Partner.Saw, which further slowed their progress. Tracy tells Watt, the Outside Vent to check the bulkhead and dumbwaiter and then proceeds to the area of the fire. He sees the cuts already made by F.F. Joyce and observes fire through the cuts. He radios Lt. Daly that there is fire in the cockloft. The hole is not yet opened and the smoke condition on the roof is described as very heavy. It is so heavy in fact, that Tracy cannot start the saw. Captain Quartuccio Ladder 103, hears the radio report "Roof opened, fire in cockloft". Engine 290 hears the same message. Ladder 175 is ordered by Batt. 39 to send roof team (Chauffeur, Roof and Outside Vent) to the roof and FE team, (Officer, Can man and Forcible Entry) to report to the fire floor. Ladder 107 ascends from the top floor of Exposure 3 to the roof. Lt. Olsen sees Joyce cutting the roof. The cut is finished but not yet pulled and there is fire visible in the cuts, (the hole is about 3x6 foot). Lt. Gordon, Ladder 175, arrives at the top floor at about the same time as Lt. Gmelin Engine 332 orders their line charged. Lt. Gmelin then enters window to the D-4 apartment from fire escape. Outside vent F.F. Libretti, L 103 enters apartment with him. The front apartment is heavily charged with smoke. He proceeds toward the public hallway. Ladder 175 roof team starts up Ladder 103 1 s aerial. Ladder 110 Forcible Entry team is now in living room of apartment D-2, F.F. Kane proceeds to the bedroom. The officer and members of Engine 283 are walking East on Hegeman Ave. towards Engine 332' s apparatus. There is heavy smoke but no fire showing from top floor windows adjoining Exposure 3. Engine 236 calls for water in their line and the call is acknowledged. L-103 Roof feels the roof move, (bounce or shake). Concerned that the roof may be about to collapse, he steps over parapet wall to Exposure 3 roof. ,

At approximately 0506 Lt. Daly hears a loud noise described as a whoosh-crash. He immediately hears Kane call for help. He tries to enter the bedroom where Kane is but his way is blocked by what proves to be the entire ceiling, which had collapsed in a lean-to fashion.. In the street the Engine 332 Chauffeur FF. Marotta and Lt. Joyce Engine 283 and the three firefighters from Engine 283 all hear Kane shout for help. They look up to see him in the window, with fire over his head. The Eng. 332 Chauffeur gives a message on the radio -"URGENT Fireman Trapped on Hegeman Ave side." Lt. Joyce observes no one in the bucket of Ladder 1 07 and runs to the turntable of the apparatus. Engine Co. 332 officer Lieut. Gmelin, is passing through the D-4 apartment when he hears the URGENT (MAY DAY) message. He enters the public hall and sees two lines in the hall. These lines are going into the Hegeman Ave. side apartments. Only one is .charged. He sees an extinguisher in the public hall, which he takes with him, as he searches the rear apartments on the top floor. Rescue Co. 2 has just arrived at the scene. Its members are approaching the fire building, walking east on Hegeman Ave. when the yelling attracts Capt. Downey's attention to FF . Kane in the window. He immediately orders first aid and burn equipment from the Rescue's apparatus. Kane leaves the window. Lt. Daly, still attempting to reach him from the doorway, sees him run through the room which is now fully involved. He describes him as"High-stepping" through the room. He calls to Kane and pushes the ceiling but Kane runs back to the window. Lt. Daly gives "Mayday". Kane reappears at the window and is seen by the members on the street as well as the members of Ladder 175 on the aerial of Ladder 103. Engine 283 members stretch line from 332's apparatus, and water called for, but the wrong line is charged. This is quickly corrected. Fire Fighter Stanley Ladder 107 OV and Fire Fighter Jordan Ladder 107 Chauffeur quickly exit the apartment to the fire escape, Stanley re-enters the bucket as Lt. Joyce starts the bucket moving toward the window. Batt. 39 transmits a second alarm at the time of the bucket movement, at 0506:35. Lt. Daly succeeds in way but is unable to get goes to the front window D- 2 and sees the bucket F.F. Kane is. pushing the ceiling out of the to Kane due to heavy fire. He of the living room of apartment moving toward the window where
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At this time Engine Co. 236 was entering apartment D-2 with their charged line.

Lt Daly then attempts to locate an Engine with a charged line. He goes to the front of the apartment and finds Engine 236 and directs them towards the rear bed room. As they stretch in to the living room, the hose gets caught on something. They are just short of the small hallway leading into the bedroom. They direct their stream down the short hallway and into the fire room, but it has little effect on the fire until they get more hose. At approximately this time Lieut. Gordon of Ladder Co. 175 crawls past the nozzle team of Engine Co. 236 and starts to enter the small hallway leading to the rear bed room. Meanwhile on the roof Firefighter Sonnenberg, Ladder 107, leans over the parapet and tries to reach Kane with a 6 foot hook. Stanley calls Lt. Joyce via the intercom from the bucket and tells him to leave the controls alone, that he will operate the controls from the bucket. F. F. Jordan is running down the fire escape and tells Joyce verbally to let Stanley have the controls. Jordan mounts the turntable and takes the position from Joyce. Stanley positions the moving bucket so that he is approaching the window that Kane is in from below. This is done because of the heavy fire emanating from the window. As he approaches the window Kane dives into the bucket 1 s open gate on the control side of the bucket. He is partially hanging out of the bucket, and Stanley grabs Kane, then pulls him into the bucket. As Kane comes into the bucket one of his boots drops to the street. Stanley starts to beat the fire out with his hands and body I as they are being brought down to street level. Engine Co. 283 members who had stretched a line from Eng. Co. 332 1 s apparatus starts to apply water as the bucket descends to the ground. They continue to use the line on Kane intermittently to cool him down until they move him to the ambulance. As Lieut. Gordon L-175 enters the rear bed room, his helmet is knocked from his head by the E. 236 1 s hose stream. He feels the radiant heat and sees the glow of fire above his head. He crawls back out of the room to tell the Engine to shut down the line momentarily, so he can complete his search. He is told by one of the Engine members that they have Kane out of the room. At approximately 0507: The 15 Division calls Brooklyn dispatcher and is directed to respond to the second alarm.

Battalion 39 gives an urgent message dispatcher, requesting Police helicopter.

to

the

Eng. Co. 290 Officer Lt. Varriale, hears a message via handie talkie radio that a member is in the window. Fearing that a member has fallen through the roof and into the rear room which was still burning fiercely, the Lieutenant aggressively moves his line into the last room of apartment D-1 and starts to extinguish the remaining fire. Ladder 110 Roofman looks over the parapet wall and sees member in bucket. Ladder 107 I s bucket is being lowered to the ground with Kane and Stanley in the bucket. Eng. Co. 283 members in the street continue to direct the stream of water up to the bucket as it is being brought down. 0507:40 Engine Co. 283's officer dismounts Ladder turntable and transmits an urgent message to dispatcher I using their radio, that he has a burned member, and requests EMS. Co.107's Brooklyn severely

Rescue Co. 2 is in the street and as bucket touches ground, they start treating the injured member. They remove him from the bucket and start cutting his protective gear from him. Engine Co. 283 directs the hose stream on to Kane to extinguish the remaining fire and to cool him down. They will continue to use this line on him until he is wheeled to the waiting ambulance. 0508:02 Battalion 39 requests a mixer off message. They request A Police Dept. helicopter.' B.C. Flynn gives the message. At approximately 0508: Rescue 2 and EMS personnel continue to treat F.F. Kane in the street. Engine Co. 290 has fire knocked down in apartment D-1, and is relieved. Engine Co. 236 makes to the rear bed room in apartment D-2 and extinguishes fire in same.