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 66/08 FATAL INJURY LIEUTENANT ROBERT J. RYAN JR.
ENGINE COMPANY 155

VOLUME I
THE INVESTIGATION

I.

SUMMARY

On Sunday November 23, 2008, at 0028 hours, the Staten Island Communications Office received a telephone alann reporting a fire at 39 Van Buren Street. The initial

response to Staten Island Box 0021 was two Engine Companies, two Ladder Companies and one Battalion Chief. Because numerous phone calls were received, the Staten Island

Dispatcher filled out the alann to a total of four Engine Companies, two Ladder Companies, a Rescue Company, a Squad Company, a Marine Company and a Battalion Chief. The Officer of Engine Company 155, Lieutenant Robert J. Ryan Jr., transmitted a 10-75 for fire showing on the 2 nd floor of a detached, private dwelling. initiated 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 heat from electrical wiring. BFI detennined that the fire originated in a rear bedroom on the Standard firefighting operations were

second floor between the sheetrock ceiling and the attic floor. The fire extended horizontally into the rear attic void and vertically through the attic flooring to the attic closet and the underside of the roof sheathing. The fire smoldered undetected before it was discovered by neighbors who alerted the sleeping occupant. Lieutenant Ryan of Engine Company 155 became unconscious while operating in the attic. He was transported by ambulance to Richmond University Medical Center where he succumbed to his injuries. The autopsy revealed that Lieutenant Ryan's cause of death was smoke inhalation. As a result of the investigation into this fatality the Safety and Inspection Services Command makes 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 Unit Circular 329 FDNY Policy/OSHA Respiratory Standards as they relate to the use of the Scott 4.5 SCBA. Iof64

3.

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

4.

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

5.

Continue to train all members to immediately transmit a MAYDAY message when faced with a life threatening situation.

6.

Continue to train all members to be proficient in roll call procedures as per

Communications 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 OPERATIONS

On 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 at 39 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 the alarm due to a second source. Engine Company 156, Engine Company 157, Marine Company 9, Rescue Company 5 and Squad Company 1 were assigned. All of the Engine Companies assigned on the first alarm were staffed with four Firefighters and an Officer. The Ladder, Rescue, and Squad Companies were staffed with five 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 Dwelling

The 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 the

second floor between the sheetrock ceiling and the attic floor. The fire extended horizontally into the rear attic void and vertically through the attic flooring to the attic closet and the underside of the roof sheathing. The fire was undetected and smoldered until it was

discovered by neighbors who alerted the sleeping occupant.

INITIAL OPERATIONS
At 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. Engine Company 155 arrived within 3 minutes and 17 seconds after the receipt of the alarm at the Staten Island Communications Office. 120f64

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 the Firefighter Assist and Search Team (FAST Unit). The Engine Company 155 Chauffeur stopped the apparatus a few feet past the fire building. The Engine Company 155 Nozzle and Back-Up Firefighters each removed folded lengths of 1%" hoseline and stretched them toward the front of the fire building. Lieutenant Ryan 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 nearest fire hydrant approximately 100 feet down the street. (Diagram 1) The hydrant was partially blocked by an illegally parked car. The Engine Company 155 Chauffeur was able to use the 35-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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39 Van Buren street

Drawing Not To Scale

.=

Hydrant

Diagram 1 Position of Apparatus

Photo 2 35-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 ladders were used to vent, enter and search (VES) different areas of the fire building.

At approximately 0033 hours, the Ladder Company 78 Officer, Forcible Entry and Can Firefighters (Inside Team) entered the building to search for the seat of the fire. The Ladder Company 78 Outside Ventilation Firefighter reported smoke pushing from the exposure #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 up to the attic. There was no visible fire in either location. Lieutenant Ryan returned to the second floor and encountered the Ladder Company 78 Inside Team. He told the Ladder Company 78 Officer that he checked the attic and did not observe any fire. He recommended that Ladder Company 78 conduct an investigation of the attic. The Ladder Company 78 Inside Team continued up to the attic to search for the fire. Lieutenant Ryan returned to the first 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 10-75 signal had been transmitted for Box 0021.

At approximately 0034 hours, the Ladder Company 78 Inside Team arrived in the attic and observed a light smoke condition. The Ladder Company 78 Officer looked out the attic window at the top of the attic stairs and observed fire burning on the exterior of the building. He opened the closet door at the attic stair landing and smoke pushed out from the closet space. (Diagram 2) He scanned the attic with a thermal imaging camera (TIC). The TIC indicated a high heat condition in the area of the exposure #3/4 comer. The Ladder Company 78 Officer ordered the Inside Team to open up the walls and ceiling in that section of the attic. Engine Company 155 entered the fire building with the uncharged hoseline and proceeded to the second floor. At 0034:07, Lieutenant Ryan transmitted the following
~~155

message; "55 to 78. Anything on the third floor?" At 0034:32, he transmitted,

to

Chauffeur, give us water ... "

Battalion 22 arrived on the scene and assumed the role of Incident Commander. Division 8 was assigned and responded. 150f64

Initial opening in knee wall made by Ladder 78

Exposure #4
f o o - - - - - - 1 3 5'-------..+-0-----8' 6'--....,

4'

11'

Void Behind Knee Wall

o o
Closet

I
11'

Storage Area
Note: Roof slopes down toward front of building

7' 6"

7 ft.--I111+---4

Attic Stair Landing

JC

Attic Window

Drawing Not To Scale

. . . Denotes Lieutenant Ryans' Helmet

Exposure 112

Diagram 2 Diagram of Attic at 39 Van Buren Street

At approximately 0035 hours, the Ladder Company 78 Inside Team opened a 3 foot x

3 foot hole in the knee wall in the exposure #3/4 comer of the attic. (Diagram 2) Fire and
heavy smoke pushed from the opening. Due to the slope of the ceiling and lack of horizontal ventilation, the heat and smoke built up quickly in the attic. (Photo 3)

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Photo 3
Slope of Attic Ceiling

At 0035:08, Lieutenant Ryan requested water a second time, "155 to Chauffeur, give

us water." The Engine Company 155 Chauffeur responded, "Water's on the way." When
water arrived at the nozzle, the Engine Company 155 Nozzle Firefighter bled the hoseline of air. 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 THE FACEPIECE 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 had checked the basement. The Ladder Company 78 Roof Firefighter informed the Ladder Battalion 22

Company 78 Officer that there was nothing showing in the basement.

acknowledged this transmission. The Ladder Company 78 Chauffeur positioned a 20 foot portable ladder against the front of the fire building and heard the transmission concerning possible fire in the basement. The Ladder Company 78 Chauffeur checked the basement window on the exposure #4 side of the building and entered the fire building to check from the interior. The Ladder Company 78 Chauffeur transmitted that the basement was clear at

0038 hours.
Engine Company 156 arrived on the scene.

At approximately 0036 hours, Engine Company 155 entered the attic with a charged hoseline. 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 via handie-talkie and asked if he was set up with a hydrant. The Engine Company 155 Chauffeur replied that he did have a hydrant. The Ladder Company 78 Outside Ventilation Firefighter called the Ladder Company 78 Officer via handie-talkie and requested permission to vent the windows from the exterior.
18 of 64

Battalion 22 ordered the Battalion Firefighter to Special Call an additional Engine Company and Ladder Company. The Staten Island Borough Communications Office notified Emergency Medical Services (EMS) of the 10-75 at 39 Van Buren Street.

At 0037:06, the Ladder Company 78 Officer responded to the request from the Ladder Company 78 Outside Ventilation Firefighter to vent the windows and transmitted, "Take the

windows, take the windows."

COMPANY

(THE INVESTIGATION TEAM BELIEVES THAT THE LADDER

78 OFFICER

WAS APPROVING THE VENTILATION OF THE WINDOWS iN THE ATTIC.)

The Ladder Company 78 Outside Ventilation Firefighter observed fire burning on the exterior of the building directly above a window on the second floor on the exposure #2 side and vented it. The ventilation of this window had no effect on the smoke condition in the attic. (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 the second floor. The Ladder Company 77 Officer contacted the Ladder Company 78 Officer via hand ie-talkie and asked if he needed any help. The Ladder Company 78 Officer transmitted, 190f64

"Yeah, listen, the fire looks like it's in the walls. We gotta check the walls, check the basement ... thefirstfloor." The Ladder Company 77 Outside Ventilation Firefighter made a
handie-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 the hoseline that was stretched into the attic. At 0037 hours, Engine Company 158 and Ladder Company 81 were assigned and responded 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 were operating. The Ladder Company 77 Officer informed Battalion 22 they were operating on the second floor and Ladder Company 78 was in the attic. The Ladder Company 77 Officer notified 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 from the 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 and

Ladder 78 are on the top floor, we're trying to open up the walls. Fires got up in the walls." (THE
INVESTIGATION TEAM BELIEVES THAT LIEUTENANT RYAN HAD THE FACEP[ECE OF

HIS SCBA DONNED WHEN HE MADE THIS TRANSMISSION.)

The Ladder Company 77 Officer called Battalion 22 and requested a second hoseline to the 2nd floor because fire was dropping down from the ceiling. The Engine Company 156 Officer 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 Island Communications Office, "Box 21, we have a two and a half story private dwelling fire on the

top floor. One is a street, two is a similar detached, three is a yard, and four is a similar detached. One line stretched in operation. Second line being stretched. Fire is doubtful. " 200f64

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

(THE

INVESTIGATION

TEAM

BELIEVES

THAT

AT

APPROXIMATELY

0040

HOURS,

LIEUTENANT RYAN'S HELMET WAS EITHER DISLODGED OR REMOVED FROM HIS HEAD FOR AN UNKNOWN REASON. THE LADDER COMPANY

78

CAN FIREFIGHTER HEARD LIEUTENANT RYAN

SA Y, "I LOST MY HELMET." THE HEAVY SMOKE CONDlTlON MAY HAVE PREVENTED LIEUTENANT RYAN FROM LOCATING HIS HELMET. IT lS BELIEVED THAT LIEUTENANT RYAN'S FACEPIECE WAS DONNED AT THlS TIME.)

At approximately 0040 hours, Ladder Company 77 was operating in the bedroom on the 2 nd floor directly below Engine Company 155 and Ladder Company 78. The Ladder Company 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 down

into 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 investigate conditions on the second and third floors. Battalion 22 asked the Engine Company 156 Officer if they needed assistance from the fourth due engine to stretch the second hoseline. replied that no assistance was needed. Ladder Company 80 (FAST Unit) and Division 8 arrived on the scene. The Engine Company 156 Officer

At 0041:11, Battalion 22 requested a primary search from Ladder Company 78 and Ladder Company 77. The Ladder Company 77 Officer reported that the primary search on the second floor was negative. At 0041:48, the Ladder Company 78 Officer, in the attic, made the following transmission, "We need a line on the second jloor Chief." The smoke and heat conditions increased dramatically in the attic. The Ladder Company 78 Officer vented the attic window on the exposure #2 side. (Photo 5) He descended the stairs to investigate a possible fire condition on the 2 nd floor. remained in the attic. 210f64 The other members of the Ladder Company 78 Inside Team

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.

WINDOW.)

AN INTACT WINDOW OF THE ADJACENT BUILDING CAN BE SEEN THROUGH THE VENTED

At approximately 0041 hours, Engine Company 156 arrived at the front of the fire building with the second hoseline, uncharged. Lieutenant Ryan continued to operate without the thermal protection provided by a donned 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 ladder from 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 side

of 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 down Van Buren Street toward the fire building. The Ladder Company 80 Outside Ventilation Firefighter walked past the fire building to the Battalion 22 vehicle to obtain the FAST Unit handie-talkie to monitor fireground communications. (Diagram 1)

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At 0042:02, Lieutenant Ryan transmitted, "155 to ...Back out. Back out."

(THE

INVESTIGATION TEAM BELIEVES THAT LIEUTENANT RYAN'S FACEPfECE WAS NOT DONNED AT THIS TIME. THE SOUND OF HIS VOICE CAPTURED BY THE BATTALION HANDlE-TALKIE RECORDER DIFFERED FROM HIS EARLIER TRANSMISSIONS.)

The Engine Company 155 Back-Up Firefighter moved to the stairs leading down to the second floor. He notified the Engine Company 155 Nozzle Firefighter that he located the stairs. The Engine Company 155 Back-Up Firefighter backed the hoseline down to the

second floor. As the Engine Company 155 Nozzle Firefighter returned to the stairs, he felt someone move past him. He called out twice asking if anyone was still in the attic. He did not hear any response and believed that he was the last member to leave the attic. The Engine Company 155 Nozzle Firefighter shut down the nozzle and backed the hoseline down the stairs. 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 his facepiece 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 to Command, "We got a lot ofguys on tile second floor

if you could start pulling some oftilem

down. "
Lieutenant Ryan and the Ladder Company 78 Can Firefighter were next to each other in the attic. The Ladder Company 78 Can Firefighter heard Lieutenant Ryan say, "I'm
(THE INVESTIGATION TEAM BELIEVES THAT LIEUTENANT

burning up ... where are the stairs?"

RYAN WAS STILL OPERATING IN THE ATTIC WITHOUT THE PROTECTION OF HIS HELMET AND THAT THE FACEPIECE OF HlS SCBA WAS NOT DONNED.)

At 0042:41, the Ladder Company 78 Can Firefighter transmitted, "78, URGENT

URGENT-URGENT. We Ilave to hack out oft/lis room."

The Ladder Company 78 Officer was on the second floor when the URGENT transmission was given by the Ladder Company 78 Can Firefighter. The Ladder Company 78 Officer returned to the base of the attic stairs. The Ladder Company 78 Forcible Entry Firefighter finished re-adjusting his facepiece and exited the attic. Lieutenant Ryan and the Ladder Company 78 Can Firefighter began to exit the attic and crawled toward the stairs. The Ladder Company 78 Can Firefighter guided Lieutenant Ryan to the attic stairs. 230f64

The members of Ladder Company 80, except the Outside Ventilation Firefighter, were on Van Buren Street walking toward the fire building when they heard the URGENT transmission. They arrived at the front of the fire building, placed the Stokes Stretcher on the ground and informed Battalion 22 that they were ready to operate as the FAST Unit. The Ladder Company 80 Outside Ventilation Firefighter was at the Battalion 22 vehicle when he heard the URGENT transmission. He turned on the FAST Unit handie-talkie to monitor any additional emergency transmissions. He walked to the front of the fire building and teamed up with other members of the FAST Unit. At 0042:46, Battalion 22 responded to the URGENT transmission and replied, "10-4.
Guys, let them hack down. Clear the stairs. Let them hack down. Let them hack down. "

At 0043:03, Battalion 22 transmitted a 2nd Alarm.

The following units were assigned to the 2nd
Alarm by the Staten Island Communications Office at 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 1

At approximately 0043 hours, Division 8 arrived in front of the fire building and assumed the role of Incident Commander. After a brief discussion concerning the status of the fire, Division 8 ordered Battalion 22 into the fire building to investigate the circumstances surrounding the URGENT transmission. 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
with you?"
(THE INVESTIGATION TEAM BELIEVES THAT THE LADDER COMPANY

78

OFFICER

WAS TRYING TO CONFIRM THAT THE LADDER COMPANY FIREFIGHTERS WERE TOGETHER.)

78

FORCIBLE ENTRY AND CAN

240f64

LIEUTENANT RYAN BECOMES UNCONSCIOUS

As Lieutenant Ryan and the Ladder Company 78 Can Firefighter crawled to a position near the top of the attic stairs, the Ladder Company 78 Can Firefighter witnessed Lieutenant Ryan collapse and become unconscious. The Ladder Company 78 Can Firefighter realized Lieutenant Ryan was in grave danger and in need of immediate removal. The Ladder

Company 78 Can Firefighter called out to members operating on the second floor for help. In an attempt to remove him as quickly as possible, the Ladder Company 78 Can Firefighter pushed 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 he discovered Lieutenant Ryan unconscious. behind Lieutenant Ryan. At 0043:53, the Ladder Company 78 Officer transmitted, "78 to Command, The Ladder Company 78 Can Firefighter was

MA YDA Y-MA YDA Y-M4 YDA Y. "

At 0044:00, Command acknowledged the MAYDAY transmission, "Unit with the

MAYDAY go." At 0044:02, the Ladder Company 78 Officer transmitted, "We got, we got an unconscious 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 unconscious Firefighter. Ladder Company 80 entered the building and moved up the stairs to the second floor. The Ladder Company 80 Outside Ventilation Firefighter remained outside the fire

building and continued to monitor the FAST Unit handie-talkie. Command was not certain which member transmitted the MAYDAY and attempted several times to clarify the identity of the member who transmitted the MAYDAY. The Ladder Company 80 Outside Ventilation Firefighter used the display screen on the FAST Unit hand ie-talkie to identify the member transmitting the MAYDAY and responded to Command at 0044:25, "That's 78 Officer with

the MA YDA Y. 78 Officer with the M4 YDA Y. "

The Ladder Company 78 Officer and Can Firefighter continued the attempt to remove Lieutenant Ryan from the attic. Due to the heavy smoke condition, the members could not see the left shoulder strap of Lieutenant Ryan's SCBA caught on the banister. (Photo 6) The Ladder Company 78 Officer and Can Firefighter were unable to free Lieutenant Ryan, so the Ladder Company 78 Officer descended to the second floor to get assistance. Battalion 22 arrived on the second floor. 250f64

Photo 6
Bannister of Attic Staircase

The Rescue Company 5 Officer was on the second floor when the MAYDAY was transmitted. He informed Battalion 22 that he was proceeding to the attic to address the MA YDA Y. The Rescue Company 5 Officer ascended the stairs followed by the Ladder Company 78 Officer. The Rescue Company 5 Officer encountered Lieutenant Ryan at the top of the stairs. Lieutenant Ryan was unconscious, in a seated position, with his back facing the Rescue 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 Can

Firefighter was behind Lieutenant Ryan attempting to free him. The Rescue Company 5 Officer lifted and pulled the shoulder straps of Lieutenant Ryan's SCBA several times and freed him from the banister. Lieutenant Ryan was quickly brought down the stairs by the Rescue Company 5 Officer and the Ladder Company 78 Can Firefighter. (Photo 7)

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Photo 7
2 nd Floor Landing

At approximately 0045 hours, Lieutenant Ryan reached the second floor landing where his vital signs were evaluated by the Rescue Company 5 Officer. He unfastened the top 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 to remove 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."
transmitted.

Command was uncertain for whom the MAYDAY was

The Ladder Company 78 Officer responded to Command's inquiry and transmitted at

0045:57, " ... it's the Officer from 155".

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

270f64

At approximately 0046 hours, the Ladder Company 80 Officer and Can Firefighter reached Lieutenant Ryan on the second floor. The Ladder Company 80 Can Firefighter

immediately evaluated Lieutenant Ryan's air needs and turned the purge valve of Lieutenant Ryan's SCBA to the open position. No air escaped from the SCBA. The Ladder Company 80 Roof and Forcible Entry Firefighters were on the stairs between the first and second floor and were ordered by the Ladder Company 80 Officer to get the Stokes Stretcher. The two Firefighters retrieved the Stokes Stretcher from the front of the building, and returned to the bottom of the first floor stairs. Lieutenant Ryan was brought down to the first floor by

members of Ladder Company 80, Rescue Company 5 and Engine Company 153. (Photo 8)

Photo 8 First Floor

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At approximately 0047 hours, Lieutenant Ryan was placed in the Stokes Stretcher at the 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 roll call, Battalion 22 informed Command that he was with the Ladder Company 78 Inside Team and they were accounted for.

OPERATIONS AFTER LIEUTENANT RYAN WAS REMOVED FROM THE FIRE BUILDING
At 0047:53, Command contacted the Staten Island Dispatcher and stated, "... we need

EMSforthwith. We're doing CPR on an Officer."

At approximately 0048 hours, Lieutenant Ryan was in the Stokes Stretcher and placed on the ground near the front of the fire building. The members of Ladder Company 80 removed Lieutenant Ryan's bunker coat and SCBA and initiated CPR. They attempted to establish 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 oxygen equipment and a suction unit from Engine Company ISS's apparatus. The members inserted an 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 shock advised. For approximately the next five minutes, Firefighters primarily from Ladder Company 80 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 EMS Communications Office that CPR was being performed on an FDNY Officer. Command called the Rescue Company 5 Officer and asked if there were any other members in distress in the building. Squad Company 1 arrived on the scene.

290f64

At approximately 0049 hours, Battalion 22 ordered Engine Company 156 and Ladder Company 77 to operate in the attic. Engine Company 156 stretched their hoseline to extinguish the remaining body of fire. Ladder Company 77 performed the primary search in the 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 Engine Company 155 to exit the fire building and ordered the remaining members of Engine Company 153 to take over Engine Company 155's hoseline. extinguished the remaining fire on the second floor. Engine Company 153

Battalion 22 ordered the Rescue

Company 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 5 Officer informed Command that the MAYDAY had been transmitted for the Officer of Engine Company 155 and that no other member required assistance. When completed at 0109 hours, the roll call confirmed that no other members were missing or in need of assistance. Firefighters continued CPR on Lieutenant Ryan in front of the fire building.

At 0050 hours, the Staten Island Communications Office made a second notification to the EMS Communications Office and requested that a rush be placed on the ambulance because CPR was in progress. At approximately 0050 hours, the EMS BLS Unit 21Cl (Richmond University Medical Center) ambulance was now positioned on Van Buren Street near the comer of Franklin Avenue. (Diagram 4) The two Emergency Medical Technicians (EMTs) donned their personal protective clothing, removed the stretcher and medical equipment. They were approached by a civilian who stated that a Firefighter had been seriously injured. The civilian claimed 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 the injured member was in cardiac arrest. The EMS crew proceeded down the block with their equipment toward the location of the injured member. They could not maneuver the stretcher over the charged hoseline and decided to leave it behind. Firefighters continued CPR on Lieutenant Ryan in front of the fire building.

At 0051 hours, Firefighters continued CPR on Lieutenant Ryan in front of the fire building. 300f64

At 0052 hours, EMS C2ll, the Conditions Officer, arrived on the scene and positioned 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 aware of an injured Firefighter in the street. The EMS ALS Unit 22Z 1 arrived on the scene and also backed down Van Buren Street to a position in front of the EMS BLS Unit 2ICl. (Diagram 4) The EMS ALS Unit 22Z1 also heard that CPR was in progress on a Firefighter. The crew noticed that the

stretcher from EMS BLS Unit 21Cl had been removed. The ALS crew prepared the BLS ambulance for a cardiac patient. They awaited the arrival of the injured Firefighter. Firefighters continued CPR on Lieutenant Ryan in front of the fire building.

Position of BlS 21 C1 & AlS 22Z1 When Lt Ryan Was Placed in Ambulance

Location Where BlS 21C1 & AlS 22Z1 First Arrived on Scene

'I~;;';I' III
Approximate Location were
EMS First Made Patient
Contact With Lt Ryan

Orawiog Not To Scale

Diagram 4 Location Where EMS First Made Contact with Lieutenant Ryan
At approximately 0053 hours, as CPR continued, members carried Lieutenant Ryan in the Stokes Stretcher toward York Avenue. They were at a position somewhere between the fire building and the corner of York Avenue, when the EMS Conditions Officer made contact with them. (Diagram 4) 3lof64

The crew from EMS BLS Unit 2IC} moved past the fire building and also made contact with the Firefighters carrying Lieutenant Ryan towards York Avenue. The Conditions Officer ordered one EMT to reposition the BLS ambulance to York Avenue and Van Buren Street. The other EMT 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 between Van Buren Street and Richmond Terrace.

At 0054 hours, Firefighters continued CPR on Lieutenant Ryan as he was carried toward York Avenue.

At 0055 hours, Firefighters continued CPR on Lieutenant Ryan as he was carried toward York A venue.

At approximately 0056 hours, members carrying Lieutenant Ryan reached the comer of Van Buren Street and York Avenue. The members placed the Stokes Stretcher on the ground and continued CPR on Lieutenant Ryan. The EMS Conditions Officer retrieved the Intubation Kit from his vehicle. unsuccessful. Battalion 42 arrived on the scene. He attempted to intubate Lieutenant Ryan but was

At 0057 hours, Firefighters continued CPR on Lieutenant Ryan at the comer of Van Buren Street and York Avenue.

At approximately 0058 hours, the members carried Lieutenant Ryan down York Avenue toward Richmond Terrace. As they proceeded down the hill, the Battalion 42 Firefighter and the MER V Operator obtained a stretcher from the MERV. Battalion 42 called Command and requested a police escort for the ambulance to transport Lieutenant Ryan to the hospital.

At approximately 0059 hours, as the members who carried Lieutenant Ryan approached Richmond Terrace, they transferred him to the stretcher which had been obtained from the MERV. Richmond Terrace. 320f64 Members continued CPR on Lieutenant Ryan as they approached

At approximately 0100 hours, the EMS BLS Unit 21Cl ambulance arrived at the corner of York Avenue and Richmond Terrace with a Paramedic from ALS 22Z1 in the back of 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 to Richmond University Medical Center. Efforts to revive Lieutenant Ryan continued in the ambulance during his transport to the hospital. The Paramedic established an IV on

Lieutenant Ryan. Two attempts were made to intubate him and were unsuccessful. The EMT and Paramedic continued CPR and suctioned his airway enroute to the hospital.

At 0107 hours, the ambulance transporting Lieutenant Ryan arrived at Richmond University Medical Center. Medical care was transferred to the emergency room staff of the hospital. 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 his death was November 23,2008. The cause of death was smoke inhalation.

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

At 0131 hours, the fire was declared Under Control.

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v.
1.

FINDINGS

Lieutenant Ryan entered the attic of the fire building wearing full Personal Protective Equipment (PPE) including an SCBA with the facepiece donned. He operated in the attic for approximately five minutes before his helmet either became dislodged, or was removed by him for an unknown reason. The heavy smoke and high heat condition in the attic could have prevented Lieutenant Ryan from locating his helmet. The

members who operated in the attic did not witness Lieutenant Ryan's helmet become dislodged nor did they see him remove it.

2.

Lieutenant Ryan operated with the facepiece of his SCBA donned for between six and seven minutes. Battalion Handie-Talkie Recorder transmissions and interviews with members who operated with him confirm that the facepiece was donned. For an unknown reason, the facepiece of his SCBA was no longer donned in the Immediately Dangerous to Life and Health atmosphere (IDLH). He continued to operate without his facepiece donned for approximately an additional two minutes before he collapsed and became unconscious.

3.

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

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4.

The cylinder of Lieutenant Ryan's SCBA was completely depleted when he was brought to the second floor landing. The amount of time Lieutenant Ryan operated in the IDLH (between six and seven minutes) would not be expected to deplete the cylinder. 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 Ryan was tested and inspected by BW Technologies (Honeywell Life Safety) and found to be operating properly. The data taken from the meter shows that levels reached the maximum 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 Francis Brannigan, the rapid involvement of a large combustible surface combined with a restricted air supply alters the fire chemistry to increase CO production as much as 50 fold over the burning area. The fire was undetected and smoldered until it was discovered by neighbors who alerted the sleeping occupant. When the knee wall in the attic area was opened it created an extremely high level of CO in this area.

6.

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

7.

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

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8.

The members of Ladder Company 80, the FAST Unit, were properly equipped and ready to deploy prior to the transmission of the MA YDA Y. Once the MAYDAY was transmitted the members of the FAST Unit were ordered into the fire building by the Incident Commander to address the MAYDAY. The Ladder Company 80 Outside Ventilation Firefighter remained outside to monitor the FAST Unit handie-talkie. Members of Rescue Company 5 and Engine Company 153 assisted members of Ladder Company 80 with the removal of Lieutenant Ryan from the fire building. He was placed in a Stokes Stretcher on the first floor and brought outside the building where the members began to perform CPR.

9.

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

10.

The Ladder Company 78 Can Firefighter was with Lieutenant Ryan when he collapsed and became unconscious in the attic. He immediately began to remove Lieutenant Ryan from the attic.
I

The Ladder Company 78 Can Firefighter verbally alerted

members on the second floor for assistance. The Ladder Company 78 Officer arrived at the top of the attic stairs and transmitted a MAYDAY for an unconscious Firefighter 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 they observed during their exterior size up. They also requested permission from their Officer to vent windows on the exterior prior to performing the outside ventilation. Because of an illegally parked automobile which partially blocked the positioning of the apparatus at the closest hydrant, the Engine Company 155 Chauffeur used the 35-Foot Soft Connection to rapidly provide water to the hose line stretched by his unit.

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Overhead electrical lines prevented the use of Ladder Company 78's aerial ladder. Portable ladders were positioned on all four sides of the fire building by 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 and Ladder Company to assist the first alarm companies. Immediately after

acknowledging an URGENT transmission he transmitted a 2nd Alarm. The MA YDA Y transmission occurred one minute later.

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VI. CAUSES

DIRECT CAUSES
1. Smoke Inhalation

INDIRECT CAUSES
1. Removal of seBA facepiece in IDLH atmosphere.

BASIC CAUSES
1. 2. Heat from electrical wiring. 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 and hydrogen cyanide to all members. Design and deliver a presentation that outlines the numerous dangers of carbon monoxide and hydrogen cyanide. Include safe actions to take in order to prevent carbon monoxide and hydrogen cyanide poisoning. This

presentation should be included in both the regular company drill schedule as well as Annual Education Day.

2.

Chief and Company Officers must strictly enforce policies and procedures of All Unit Circular 220, Self-Contained Rreathing Apparatus (SCRA) Policy, and All Unit Circular 329 FDNY Policy/OSHA Respiratory Standards as they relate to the use of the 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, or to improve communication is dangerous and this practice must not be allowed to continue. As per Training Bulletin SCRA, Addendum 3, "Exposure to 1.3% of carbon monoxide will cause unconsciousness in two or three breaths and will cause death in a few minutes. Exposure to small concentrations for only a few seconds inhibits one's ability to think clearly, rapidly causes

disorientation, and gives a feeling of euphoria compounding the risk hazard." Each member should inspect and attach their personal facepiece to their assigned SCBA at the beginning of each tour.

3.

Chief and Company Officers must strictly enforce policies and procedures for the proper use of the firefighting helmet chin strap. No member should enter or operate in an IDLH without a helmet properly secured by a chin strap. Failure to utilize the chin strap 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 serious inj ury 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 Medical Services Operations participate in an after action review (AAR) for every incident which involves the serious injury or death of an on-duty member. This AAR should take place as soon as possible after the injury or fatality. The purpose of this AAR should be to evaluate the effectiveness and improve the quality of the operation.

5.

Continue to train members to immediately transmit a MAYDAY message when faced with a life threatening situation.

6.

Continue to train all members to be proficient in roll call procedures as per

Communications Manual Chapter 9, Addendum 2, "Emergency Roll Call Procedures."

7.

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

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