A series of firefighter errors, faulty breathing gear, and the late arrival of backup led to the 2014 death of Joyce Craig, Philadelphia’s first female firefighter to die in the line of duty, according to a federal report released today.
Investigators from the National Institute for Occupational Safety and Health’s Fire Fighter Fatality Investigation and Prevention Program made 10 recommendations to ensure the Philadelphia Fire Department avoids ever repeating the perfect storm of errors they say contributed to Joyce’s Dec. 9, 2014, death. Some of the recommendations — like putting on protective gear before going into a fire and ensuring backup arrives in time to help — seem like basic common sense, while others — like outfitting firefighters with the latest in safety gear — come with a pricetag.
Fire Commissioner Adam Thiel said the department already has made some of the recommended changes and plan to make more. The NIOSH findings echo many of the same conclusions city investigators made in their probe, which also was published online today. Thiel met with Craig’s family earlier today to discuss both reports.
“Joyce Craig’s death was devastating to her family and to the department,” Thiel said. “We hope the lessons learned in these reports will prevent such tragedies in the future.”
Andrew Thomas, who heads the firefighters’ union, didn’t immediately return a request for comment.
Craig, a 37-year-old career firefighter and EMT, suffocated after becoming separated from her crew and running out of air in a blaze that destroyed an 89-year-old, two-story brick row house on Middleton Street in West Oak Lane.
Federal investigators listed eight factors as contributing to her death: Fireground tactics (best practices weren’t followed); crew integrity (firefighters unfamiliar with each other and the neighborhood worked that night); uncontrolled ventilation that enabled the fire to spread; firefighters’ insufficient mayday training; a hose on Craig’s self-controlled breathing apparatus burned through; firefighters failed to don needed protective equipment before going inside the burning home; backup firefighters took 22 minutes to arrive after they were dispatched; and dispatchers failed to activate a “rapid intervention team” as best practice demands in such quickly moving fires.
Craig normally was assigned to Engine 64 in Crescentville, but she volunteered to work an overtime shift for Engine 73, which was based at Ogontz and 76th avenues.
The fire that killed her that night was the kind firefighters dread — a basement blaze, which can create a “chimney effect” tunnel of upwardly billowing, blinding smoke, and scorching flame. Engine 73 arrived on the scene at 2:53 a.m., and within two minutes, Craig and her partner were in the kitchen trying to douse the blaze.
But it worsened, and at 3:02 a.m., the chief ordered those inside to evacuate. Craig somehow became separated from her lieutenant and partner firefighter — and firefighters didn’t realize she was trapped inside. Craig called for help five times over 13 minutes.
At 3:06 a.m., she made her last mayday: “Engine 73 can’t breathe. I can’t breathe. Engine 73 Pak.”
Her colleagues found her at 3:15 a.m. collapsed in the first-floor dining room, suffering from smoke inhalation and burns. Visibility was so bad that one firefighter who crawled through a window hunting for Craig climbed right over her, not noticing her at first, according to the NIOSH report. Doctors declared her dead at the hospital at 3:33 a.m.
Craig, who had been on the force for 11 years, was promoted posthumously to lieutenant in January 2015.
Last December, Craig’s family sued the companies that manufactured her safety equipment, saying the single mother of two would have survived if her gear had functioned properly. She was wearing the face mask of her Self-Contained Breathing Apparatus (SCBA), but there was no air in her tank and a Personal Alert Safety System (PASS) failed to notify responders to her location, according to the lawsuit, which alleges negligence, product liability, and wrongful death.
The NIOSH report confirms that a hose on Craig’s SCBA, which was at least seven years old, burned, and her PASS device “may have ceased to function intermittently from extreme heat exposure.”
Attorneys from the Saltz, Mongeluzzi, Barrett & Bendesky firm, which represents Craig’s family, issued this statement in response to NIOSH’s findings:
“This report appears to advance our arguments regarding the liability of the equipment manufacturer and affiliated defendants, but it is far from the final word on what happened, why and how those responsible should be held accountable. Those questions will ultimately be answered at trial by a jury.”
The NIOSH report also assigned some blame to two controversial policies that resulted in firefighters forced to work with colleagues they didn’t know in neighborhoods unfamiliar to them. The first — a “brownout” policy adopted in 2010 and discontinued in 2015 — was intended to save money by temporarily removing an engine or ladder company from service and redistributing its staff. The second, a “firefighter rotation” policy instituted in 2013 and dumped in 2016, imposed involuntary transfers of senior firefighters to other stations. Its stated goal was to ensure that all firefighters have equal opportunity to work various assignments and acquire diverse skills.
But federal investigators suggested both policies backfired.
“An important aspect of being a firefighter is being able to work as a member of a team, and the skill of an officer is to develop that team,” they wrote in their report. “The subtext to every activity that firefighters do is that they are doing it in coordination with others.”
Investigators never did determine what started the fire, which ignited in some combustible material in a basement recreation room.
NIOSH investigators made 10 recommendations:
Fire suppression should be initiated on the floor where the fire is.
Fire officers and firefighters should be trained in the latest fire behavior research affecting fireground tactics.
Fire departments should maintain crew integrity.
All firefighters and officers should be trained how to use hose nozzles and manage hoselines.
All firefighters and officers should be trained in mayday techniques and communications.
Fire departments should upgrade SCBA and PASS gear to the latest national standards to ensure thermal protection.
Rapid intervention teams should be on scene and activated before interior firefighting begins.
Backup must respond in a timely manner.
Firefighters must put personal protective equipment on before entering a structure.
A stationary command post should be established to ensure the command team communicates effectively.
Thiel said the department already has implemented some of the recommendations. Specifically, he said, the department has updated SCBA and PASS gear, stationed battalion chiefs in the dispatch center to improve communication during incidents, and created a new position of “field incident safety officer” to improve communication and safety on the fire ground.
The department budgeted for 30 new firefighters and four additional training officers in its 2018 budget, Thiel added.