Investigators with IL OSHA found the primary cause of Plummer’s death was a catastrophic malfunction of his self-contained breathing apparatus. The hose connecting Plummer’s mask to his air tank tore in two places, rapidly depleting his only source of breathable air in heavy smoke conditions. It remains unknown why the air hose tore during the fire; the SCBA passed an inspection the day before.
Both of these factors violated the Chicago Fire Department’s written policy and standard operating procedures, which states:
-Firefighters must enter a structure together, stay together, and exit together.
-Company officers must ensure that all firefighters under their command are on appropriate tactical radio channels.
-Personnel on the scene, including battalion chiefs, company officers, and firefighters, must monitor tactical radio channels for reports.
-Plummer’s company and the battalion chief that took over incident command did not follow these procedures, IL OSHA said. Not only was Plummer alone for 10 minutes, but the CFD’s main dispatch center was aware of his mayday call before the chief was, due to a radio call on the wrong channel.
-Plummer was not closely supervised as a rookie Firefighter should be.
-The SCBA’s malfunction was so serious that it was unlikely to be corrected inside the burning building. It also left Plummer with only minutes to find another source of air or leave the building
-Plummer’s mayday call did not include a unique identifier, such as his name.
-At least one firefighter heard Plummer’s personal alert safety system (PASS) going off, but dismissed it as a false alarm.
-Once located, Plummer did not receive emergency breathing air.
-Following their investigation, IL OSHA cited the Chicago Fire Department for four offenses and recommended the following procedures during fires and during mayday emergencies.
Firefighters entering burning buildings should:
-Perform a radio check before going inside.
-Enter with their team, stay together and exit together.
-Firefighters in distress should say their name during a mayday call and repeat their call until the incident commander acknowledges them.
-Firefighters searching for downed firefighters should immediately provide said firefighter with emergency air, with one firefighter assigned as the “air firefighter.”
-Company officers should ensure
-Close supervision of inexperienced firefighters.
-That firefighters going into a burning building are on the appropriate radio channel.
-Establish radio contact with firefighters going into burning buildings.
-Have zero tolerance for firefighters operating inside buildings alone.
-Ensure all personnel receive emergency or mayday calls immediately.
-Treat any potential mayday call as an actual mayday call until proven otherwise.
-Ensure that PASS alarms are treated as firefighter distress alarms and combat the prevalence of false alarms at fire scenes.
-Program portable radios with an emergency button that alerts firefighters to a firefighter in distress.
-Ensure company and command officers serving in acting roles are trained at the levels they are temporarily operating at.