VANnAL" AVE

03121/01
SUMMARY
On December 18, 1998 at 0452 hours, the Brooklyn Fire Communications Office ofthe New York City
Fire Department received a telephone alarm, reporting a fire and smoke condition on the 10
th
floor of 17
V andalia Avenue. .
Units ofthe New York City Fire Department were dispatched to the location. The fire was on the 10tb
floor of a 10 story, Class I multiple dwelling measuring approximately 250 x 50 feet. The building was
equipped with a partial'sprinkler system that'protected all ofthe public hallways and the elevator lobbies
throughout the building. The building also was protected by a standpipe in the exposure four stairs and a
hose outlet on each floor on the exposure two side ofthe building. Battalion 58 transmitted a 10-75 signal
at 0459 hours.
The dispatcher notified all responding units that an elderly woman was trapped in apartment 10-E. Fire
Department standard operating procedmes were initiated. Engine Companies stretched hand-lines;
Ladder Companies forced entry, implemented ventilation and conducted searches.
Members ofLadder Company 170, the first-to-arrive Ladder Company, entered the fire building to
perform their assigned duties. While operating on the 10
th
floor in the public hall, three members of
Ladder Company 170 - Lieutenant Joseph Cavalieri, Firefighter Christopher Beopp and Firefighter James
Bohan - were fatally injured. This occurred when heavy fire, smoke and gases, driven by wind, pushed
out into the ball from apartment # 10-D. .
All three members were found at different locations on the 10
th
floor. They were located between the fire
apartment and the elevator lobby doors. These irgured members were removed by Firefighters assigned to
Squad 252, Rescue 2 and the two FAST Units - Ladder Company 175 and Ladder Company 120. Fire
Department personnel, assigned to the Bureau ofEMS, treated the injured Firefighters and removed them
by' ambulance to area hospitals.
1
THE INVESTIGATION
The members ofLadder 170 responded to a reported fire at 17 V andalia Avenue in the Borough of
Brooklyt;lon December 18, 1998, at 0454 hours. While operating at this fire, Lieutenant Joseph Cavalieri,
Firefighter Christopher Bopp and Firefighter James Bohan incurred serious injuries that resulted in their
deaths.
Battalion Chief Robert Busch was the chief on duty in the Safety Battalion. He responded to the :fire on
the second alarm. He arrived at 0545 hours and was informed that members had been seriously injured.
Battalion Chief Busch started the initial stages ofthe investigation. He instituted the Safety Battalion
standard operating p r ~ u r e s for firefighter fatalities, which included activation of all off-duty Battalion
Chiefs assigned to the Safety Battalion. He also arranged with the City Wide Dispatcher to assign all on
duty Battalion Chiefs with Safety Battalion experience to respond to the Box location to assist in the
investigation. He established a logbook and instituted the fatal fire investigation checklist.
These Chiefs were assigned to conduct interviews of all personnel who were at this operation at the time
ofthe mishap. During the course ofthe investigation, the Safety Battalion conducted additional and
follow-up interviews with members ofthe Fire Department, 90 in total.
The following items, records and documents were collected, examined and evaluated:
1. Building and enforcement records from the City ofNew York Department ofBuildings, FDNY
Bureau ofFire Prevention and the Administrative Company - Engine Company 290.
2. Fire Report, Preliminary Report on Death made to the Fire Commissioner and the report ofthe
Bureau ofFire Investigation.
3. Communications records, including the incident history and Fire Department radio
transmissions.
4. Response records from Emergency Medical Service.
5. Medical examiner autopsy and report of findings.
6. Photographs ofthe :fire building, adjacent a r e a s ~ member's protective clothing and equipment.
7. Duty roster identifying all personnel who responded to the incident.
8. OffiCial weather reports.
9. Newspaper articles.
10. Injury reports and burn charts.
Additionally, the following resources were used:
1. FDNY Audio-Visual Unit
2. FDNY Bureau of Fire Communications
3. FDNY Forensic Unit
4. FDNY Graphics Unit
5. FDNY Mask Service Unit
6. FDNY Technical Services
7. FDNY Bureau ofFire Investigation
8. FDNY Bureau ofFire Prevention
9. Department of Investigation ofthe City ofNew York
2
Information from the photographs, witness statements, videotapes, physical evidence and flow tests was
analyzed and a time sequence chart was used to reconstruct the events leading..to.1heiatalities_As : w i 1 h _ ~ ~
any investigation of this gravity and magnitude, there were a number ofinconsistencies and conflicting
. statements obtained from the personnel interviewed. It is the opinion ofthe Safety Battaiion that these
inconsistencies and_conflicting statements._resulted from varying memories, differing perspectives and
emotional factors.
3
ENGINE COMPANY 290 - BUILDING RECORDS
The Building Inspection Card (A-119) indicates that annual inspections were conducted on April 24,
1996, May 12, 1997 and April 6, 1998. A second Building Inspection Card (A-119) shows that there was
a semi-annual inspection conducted on August 23,1983. Another entry on card refers to_the ___
standpipe in the east wing being out of service on September 24, 1984. Beneath that is an entry for
September 25, 1984, noting that the west wing standpipe can be used. Both of these cards note, that there
are sprinklers in the hallway. Multiple Dwelling Inspection Fonns (A-291) are filed in the folder and
indicate inspections were conducted on April 6, 1990, March 20, 1991 and April 15, 1992. Multiple
Dwelling Inspection Fonns (A-291) dated April 16, 1990 and March 20, 1991 have the section that .
applies to standpipes a.nd sprinklers filled out. There are two Fire Prevention Inspection Checklist forms
(A-IO)) indicating that inspections were conducted on March 29, 1995 and April 24, 1996. These fonns
indicate that the inspectors noted sections that apply to the standpipe, sprinkler system and alann system.
There are also two Refuse Chute/Compactor Survey Forms (A-291-B) in the folder and one is dated April
15, 1992. One additional Multiple Dwelling Inspection Fonn (A-291) and one Refuse Chute/Compactor
Survey form are unreadable. It should be noted that the Safety Battalion only has photostats ofthe
company records. The originals were delivered to the Department of Investigation. There is no record of
any violations on any ofthe inspection forms in the folder and there are no copies of any violation orders
in the folder.
The building record folder contains two Standpipe Out Of Service Forms (BBC T-292). These forms
show that on January 24, 1984, the standpipe riser on the east side ofthe building was out ofservice and it .
was repaired on January 28, 1984.
The Critical Infonnation Dispatch System (CIDS) Card (CD-201) attached to the Building Record Card
(A-119) is dated March 10, 1984. The information contained on the card indicates that this building is a
nine-story residence for senior citizens, with a total of21 apartments for handicapped people. These
apartments, lettered "J" and "R", are closest to the elevator. Housing Police also have keys to these
apartments. This is the only CIDS information contained in the company building record folder. The
written cms information differs with the cms information that was transmitted by the dispatcher to
responding units on 18,1998. The fact that the hallways and elevator lobbies are equipped with
sprinklers is not noted in the transmitted cms information.
A further review ofthe company building record folder disclosed that there were eight previous structural
fires at 17 V andalia Avenue. Four of these fires were for food on the stove and two were compactor fires.
The remaining two fires occurred on May 27, 1994 in.apartment 5L and on April 15, 1997 in apartment
3R A civilian was seriously injured at the fire on May 27, 1994 and a civilian fatality occurred at the fire
on April 15, 1997.
The only time a sprinkler was listed as a factor on any ofthe fire reports contained in the company
building record folder was for a compactor fire. At this fire on October 27, 1991 the sprinkler was present,
but the fire was too small to operate the sprinkler.
5
THE MISHAP
The Officer and members of Ladder Company 170 'responded to a telephone alarm for a fire reported at
17 Vandalia Avenue in the Borough ofBrooldyn on December 18,1998 at 0454 hours.
The Officer, Lieutenant Joseph Cavalieri, and the Forcible Entry Team ofLadder 170, Firefighters
Christopher Bopp and James Bohan, took the elevator to the ninth floor. The Officer, Nozzle and Back
up positions ofEngine 290 went into the elevator with them. These companies then went to the lOth floor
via the exposure #2 stair. Engine 290 Door and Control positions, who had walked up the exposure #2
stair, rejoined them. )'be Officer ofEngine 290, using his handie-taIkie, contacted his Chauffeur to find
out where the fire wasJocated. The Chauffeur ofEngine 290 told him that the fire was on the top-floor
rear, near the exposure #4 side. The Officer of Engine 290 informed the Officer of Ladder 170 about the
, location of the fire and he acknowledged this information. The Officer and Forcible Entry Team of
Ladder 170 then entered the elevator lobby. This was the last time that the Officer and Forcible Entry
Team ofLadder 170 were seen until after the mishap occurred. The Officer and members ofEngine
Company 290 went back down to the ninth floor and moved their line to the exposure #4 stair and
stretched up to the fire floor from the standpipe located in that stair.
The Officer and members ofLadder 170 Forcible Entry Team probably searched the elevator lobby,
located the fire apartment and searched the public hall on the exposure #4 side ofthe elevator lobby. At
some point, the members ofLadder 170 Forcible Entry Team opened the door into apartment 10-D and
the fire, driven by the wind, swept into the public hall, trapping the Officer and Forcible Entry Team of
Ladder 170 in the lOth floor hall. Because of interviews conducted and information developed by the
timeline, the Safety Battalion believes that Firefighter Christopher Bopp, the extinguisher position of
Ladder 170, transmitted three separate mayday messages at this time.
Firefighter Christopher Bopp was recovered at 0518 hours and removed to the ninth floor. Firefighter
James Bohan was recovered at 0525 hours and taken to the eighth floor. The remaining member,
Lieutenant Joseph Cavalieri, was recovered at 0528 hours and he was taken to the ninth floor. Fire
Department personnel, assigned to the Bureau ofEMS, initially treated these injured members when they
were removed from the fire floor. Firefighter Bopp and Firefighter Bohan were removed to Brookdale
Hospital and Lieutenant Cavalieri was taken to Kings County Hospital. All three members were -"
transported to area hospitals via Fire Department ambulance and they were pronounced dead at the
respective hospitals.
6
FINDINGS
In an interview conducted by the Bureau of Fire Investigation, the building security guard on duty at the .
time of the fire stated that the interior alarm transmitted at approximately 0450 hours. The guard took the
elevator to thelOth-tloor, verified the source ofthe alarm and then..called itin on his cell-phone. The
advanced fire condition on arrival indicates there was a delay in transmitting the alarm.
The eIDS information given to the responding units on their printout, as it pertained to the standpipe, was
incorrect. The cms information listed the location ofthe standpipe in the "B"stair on the exposure #2
side ofthe building. The hose outlet in the public ball was located on the exposure #4 side ofthe building.
In reality, the standpiPe is located in the exposure #4 stair on the exposure #4 side ofthe building and the
hose outlets are located in the public hall on the exposure #2 side ofthe building. Information concerning
the sprinkler system in the building was not contained in the CIDS information.
The public halls on eachfloor are sprinkled, but the sprinkler system was not functioning at the time of
the:fire. Inspection ofthe system by personnel from the Bureau ofFire Prevention on December 18, 1998,
disclosed that section valves were in the closed position. There were three section valves, which
. controlled the system in the following manner: one valve controlled the sprinklers in the public hall on the
exposure #2 side of the building; a second valve controlled the sprinklers on the exposure #4 side ofthe
building; a third valve controlled the sprinklers in the elevator lobby itself. These section valves were
located on the first floor in the ceiling. The access panels to these valves were painted over.
Tests on the building sprinkler system were conducted by the Bureau of Fire Prevention on the morning
ofDecember 18,1998. The results of these tests indicated that the sprinkler system failed to provide water
to the sprinklers in the 10
th
floor public ball and elevator lobby. The valves located in the ceiling ofthe .
first-floor lobby were in the closed position. At the time ofthe fire, responding units were not aware of
the sprinkler system in the building because the information about the sprinkler system was not included
in the transmitted cms.
In an interview conducted by a member ofthe Bureau ofFire Investigation, the occupant ofapartment
10C stated that he awoke at approximately 0500 hours when he smelled smoke. He opened the door into.
the public ball, saw smoke and a glow coming from the area of apartment 1 He saw the occupant of
100 on the floor in the ball. There was no one else in the hall and he pulled the victim into his apartment
and closed the door. He also stated that when he opened the wiridow in his apartment to vent it, he
observed flames ,out the window of apartment 100.
Engine Company 290 and Ladder Company 170 entered the building at approximately 0500 hours. The
east elevator, located on the exposure #4 side ofthe elevator lobby, was out of service. Along with the
Forcible Entry Team ofLadder 170, the Officer, Nozzle and Backup positions ofEngine 290 entered the
west elevator, located on the exposure #2 side ofthe elevator lobby. These members of Engine 290 also
took their hose, which consisted of five lengths of2 Yz..inch hose and two lengths of 1 %-inch hose, into
the elevator. Tbese units took the elevator to the ninth floor. Engine 290 Door and Control positions
walked lip to the fire floor in the exposure #2 stair.
On arrival, Battalion 58 noticed that there was smoke coming from windows located on the 10
th
floor in
the front middle section ofthe building. The Safety Battalion believes that the smoke Battalion 58
observed was from apartment 1 OJ. This would that the door to that was open. It would
also indicate that the door to the fire apartment was at least partially open. Damage to the interior of .
18
7
apartment 10J was done mostly by smoke. The smoke detector located on the ceiling just inside the
apartment door was distorted by heat. damage in the-apartm.ent.
Smoke also was seen coming from apartment 10J by different members of various companies, including?
Squad252,_Battalion 44, Division 15, Ladder 175, Engine 225, Ladder 107 and Ladder 120.
In interviews conducted by the Safety Battalion, Ladder 170 OVM stated that fire was reported on the
top-floor rear with "Nothing coming out ofthe fire apartment windows". Ladder 1 03 OVM stated that
"fire was pulsing in and out ofthe fire apartment windows". Both Outside-vent (OVM) positions went to
the rear ofthe fire building when they arrived at the scene. Ladder 170's OVM then went inside the
building and immediately went to the roof. Ladder 103' s OVM remained in the rear to assist the
Chauffeur placing Ladder 103' s aerial ladder. in operation.
The Chauffeur of Ladder 170 went to the fire floor via the exposure #4 stair, as did Ladder 103 Roof.
Ladder 170 OVM and Roof positions went to the roof via the exposure #2 stair. Ladder 170 Roof found
the roof door, at the head ofthe exposure #2 stair chocked open with a brick. Ladder 170 Roof opened
and chocked the bulkhead door over the exposure #4 stair. He then notified the Officer of Ladder 170 that
the roof was open, but did not receive a reply. Ladder 170 Chauffeur confirmed that he heard this
transmission.
The bulkhead windows in the exposure #4 stairs on the exposure #4 side were vented by Ladder 170
OVM after he checked the perimeter ofthe building from the rooflevel. At the time he vented the
windows in the bulkhead, there were heavy smoke and heat coming out ofthe bulkhead.
Ladder 103 Chauffeur and OVM repositioned their apparatus at the rear of 17 Vandalia Avenue, where
they raised the aerial to the 1Olh-floor window adjoining the fire apartment. .
After their arrival on the ninth floor, the Officer from Engine 290 and the Officer and Forcible Entry
Team from Ladder 170 went to the 10
1b
floor via the exposure #2 stair. The Nozzle and Backup positions
of Engine 290 rejoined Engine 290 Door and Control positions after they walked up to the ninth floor.
These members proceeded to connect their hose lengths to the outlet in the ninth-floor public hall and
stretch their hose lengths in the exposure #2 stair to the 101h floor.. .
Engine 290 Nozzle told his Officer that he thought the fire was on the other side ofthe building. The
Officer of Engine 290, using his handie-talkie, contacted his Chauffeur to find out where the fire was
located. The Chauffeur ofEngine 290 told his Officer that the fire was on the top-floor rear, near the
exposure #4 side. The Officer of Engine 290 then told the Officer ofLadder 170 that the fire was onthe
other side. The Officer of Ladder 170 acknowledged the Officer ofEngine 290.
At the time ofthis exchange between the Officers, the Officer and Forcible Entry Team of Ladder 170
were on the exposure #2 side ofthe building, just outside ofthe door leading into the elevator lobby. The
Officer and Forcible Entry Team of Ladder 170 opened the elevator lobby door and the Officer of Engine
290 observed that there was a light smoke condition in the elevator lobby. This was the last time the
Officer and Forcible Entry Team ofLadder 170 were seen until after the mishap occurred.
Engine Company 257 arrived on the ninth floor after waiting for the elevator that was used by Engine
to return to the lobby. They walked toward the exposure #4 side ofthe building, entered the exposure #4
stair and went up to the fire floor. Hete, they started to hook up to the standpipe outlet on the 10lb floor
and flake out their hose-line, which consisted ofthree lengths of2 'l2-inch hose. Engine 257 was unable
19
to remove the cap to the standpipe on the 10tb floor because they could not fit a spanner on the cap.
Insulation on amla missing-vaLve wheel on the standpipe-were the reasons.
Ladder 103 Roof entered the building and walked 'Up to the fire floor via the exposure #4 stair. At the
floor the Lieutenant of Engine 257 was .crouched down at thtuioor to-the public hall. .
pushing out from the closed door. Ladder 103 R90ftalked to the Lieutenant of Engine 257 and told
about the wind condition and that he was going up to vent the roof. The Chauffeur ofLadder 170 then .
came up onto the landing and started to go up to the roof. The Lieutenant opened the door to the
hall and heavy smoke filled the stair. Engine 257 Control was in the process ofhooking up to the
standpipe on that floor. Ladder 103 Roof and Ladder 170 Chauffeur then went down to the ninth floor
and crossed over to the exposure #2 stair instead of continuing up to the roof in the exposure #4 stair.
The Officer of Ladder 103 had determined the location ofapartment 10E by checking the floor layout on
the ninth floor. The Officer of Ladder 103 and the Irons position removed a woman in a wheelchair from'
apartment 10E. This apartment was directly across from the exposure #4 stair door to the public hall.
After they removed her from the apartment, they took her down to the ninth floor via the exposure #4
stair. At the time ofremoval, the heat condition in the hall was not hot enough to warrant taking the
woman out ofher wheelchair, but the smoke condition was heavy and down to the floor. This smoke
condition indicated that the door to the fire apartment was at least partiaUy open.
In an interview conducted by Investigators from the Investigative Squad ofthe New York City
Department of Investigation, the occupant ofapartment 10E stated that when the firefighters took her out
ofher apartment into the hallway, it was really hot.. She did not see any fire, just smoke.
Ladder 170 Chauffeur assisted members ofLadder 103 who carried the woman in the wheelchair down to
the ninth floor. He then started to cross over on the ninth floor to the exposure #2 side ofthe building and
he attempted to contact the Officer ofLadder 170. He thinks he received a response, "Ladder 170 havi,ng
difficulties trying to get in door." He cannot be sure if it was the Officer ofLadder 170.
Whenever the door from the stair to the public hall was it allowed heat and smoke to enter the
exposure #4 stair. This hampered the efforts ofEngine 257 to accomplish their hook-up to the standpipe
on the 10tb floor. Engine- 257 never succeeded in their attempt to hook up to the standpipe.
After determining the fire's location, Engine 290 stopped their efforts to stretch their line between the
ninth and 10tb floors in the exposure #2 stair. They then moved their partially connected line across the
ninth floor to the exposure #4 stair. Here, they successfully connected one length of 1 %-inch hose and
two lengths of 2 Y2-inch hose to the standpipe outlet on the ninth floor. The remaining hose that they had
moved over from the exposure #2 stair was left in the public hall on the ninth floor.
Ladder 170 Chauffeur and Ladder 103 Roof then left the 10tb floor exposure #4 stair and dropped down to
the ninth floor to cross over to the exposure #2 stair. They both saw Engine 290 bringing their partially
connected line from the exposure #2 stair. Ladder 170 Chauffeur returned to the exposure #4 stair when
he heard, on his handie-talkie, Ladder 170 Roofs report that the roof was open. Ladder 103 Roof
continued over to the exposure #2 stair. He went up the stair and stopped briefly at the 1Olb-floor landing.
He looked into the public hall and noted that there was a light smoke condition. He did not look down the
public hall. He then continued to the roof and transmitted a warning over the handie-talkie aboutthe wind
condition. The Officer ofLadder 103 acknowledged this message. Fire was coming over the roof of the
building and shooting parallel to the roof at this time. Ladder 103 Roof then crossed over toward the
exposure #4 side ofthe roof. He observed that the bulkhead over the exposure #4 stair was open and
20
heavy black smoke was coming out of it. He then went to the rear ofthe fire building directly over the
and the fire was in the apartment. He did
not feel any heat coming out ofthe apartment window and there was little smoke coming from the
bedroom window. Fire did come out ofthe windows from the fire apartment, once or twice, while he was
looking-at the..apartment.
Engine 257 Officer was unable to have his line connected to the standpipe on the 10
th
floor. He contacted
Engine 290 to find out if they had hooked up their line to the standpipe outlet on the floor below. Engine
290 stated that Engine 257 had Engine 290 bring their line up to the 10
th
floor. Engine 257 assisted
Engine 290 in stretching their line up to the 10
th
-floor landing.
Battalion 58 arrived on the ninth floor and observed Engine 290, assisted by Engine 257, stretching a line
to the top floor. Battalion 58 then entered apartment 9B. He saw that the fire had vented out ofthe fire
apartment window on the 10
th
floor and transmitted this information over the handie-talkie.
Engine 290 started their stretch up the stairs as the woman in the wheelchair was being brought down
from the 10
th
floor. They were forced to move to 'the side so the woman could be removed.
After their arrival, Engine 332 entered the building, took the elevator to the eighth floor and then went up
the exposure #2 stair to the 10
th
floor. The Officer of Engine 332 opened the door to the public hall and
saw that the smoke was black and down to the floor. This would indicate that the elevator lobby doors
were opened after the Officer of Engi:p.e 290 left Ladder 170 at them. The Officer then went back down to
the ninth floor and took his 'company over to the exposure #4 stair.
The Officer and members of Squad 252 arrived on the scene and went to the ninth floor via the exposure
#2 stair. They stopped briefly on the seventh floor to determine the layout ofthe apartments. Squad 252
Roof continued to the roof.
Engine 283 took the elevator to the eighth floor and hooked up their line, which consisted offour lengths
of 2 %-inch hose, to the standpipe outlet on the eighth-floor landing ofthe exposure #4 stair. The Officer
of Engine 283 went to the ninth floor and then had his company stretch to that point. He then moved the
uncharged line and the company up the stairs to the 10
th
floor. The stair was very crowded and stretching
the line was extremely difficult due to the woman being removed in the wheelchair, the number ofFile
Department personnel and the amount of hose in the stair. It is estimated that, at this time, there were
approximately 15 members in the stair or on the landings between the ninth and the 10
th
floor. At least
three uncharged lengths of2 %-inch hose from Engine 257, one charged length of 1 %-inch hose and one
charged length of2 %-inch hose from Engine 290, and one charged length of2 %-inch hose from Engine
283, were also located in that same stair.
Engine 283 Officer heard the first mayday while his company was advancing the line between the ninth
and lOth floors. This was prior to Engine 283 getting water in their line.
When Squad 252 arrived on the ninth floor in the exposure #2 stair, they entered the public hall and
started to cross over to the exposure #4 stair. The Officer of Squad 252 heard the mayday when he got
near the exposure #4 stair. It was very crowded and he heard Battalion 58 acknowledge the mayday. He
started back toward the exposure #2 stair and heard another mayday.
Ladder 103 Roof called on his handie-talkie to the Officer ofLadder 103 and told him that they were not
going to vent and aSked him to advise when they were in the apartment. He did not receive an
acknowledgment from the Officer ofLadder 103. He then looked over the front of the building and saw
21
black smoke drifting out ofthe apartment near the elevators. He returned to the rear ofthe building and
heard the first ofthe maydays. .
The Officer of Engine 290 heard the first maydayjust before he reached the 10
th
floor landing. Engine
290 moved their charged line up to the stair door to the public hall. The door was opened and Engine 29Q
was hit with a tremendous blast ofheat that drove them off the 10
th
floor landing and partially down the
stairs. They did not operate their line on that attempt to enter the public hall.
Engine 290 regrouped and made a second attempt to enter the 10
th
-floor public hall. This attempt als9
was unsuccessful because ofthe extremely high heat condition. They did not operate their line on this
;<
second attempt. The of Engine 290 called for a second line and Engine 283 brought the second
line up to the lOth-floorlanding.
A third attempt was made to enter the hallway by Engine 290 in conjunction with Engine 283. When
Engine 290 and Engine 283 were ready to advance into the public hall, Engine 290 Nozzle opened the
nozzle and then the door was opened into the public hall. Both companies succeeded in their effort to
make their way out into the public hall and began to extinguish the fire. Engine 283 was on the left side
and Engine 290 was on the right side of the public hall, slightly behind Engine 283, as they made their
way toward the fire apartment. Engine 290 operated their line above and ahead of Engine 283.
When the Officer of Rescue 2 arrived on the ninth floor, Battalion 58 ordered him to locate Ladder 170
Can. Because ofmayday messages, he also ordered the of aramedics to treat the possibly
injured firefighters. 1'/
The Safety Battalion believes that use of a lead length of '. ch hose by Engine 290 had no bearing
on the mishap, since it occurred before the line was in operation. However, the use of an 1 %-inch lead
length substantially reduced the flow ofwater from their line. This added to the amount oftime that it
took to control the fire, effect final extinguishment, and remove the victims ofthe mishap.
According to statements made in interviews conducted by tlie Safety Battalion, the extremely high heat
condition that existed in the hallway as Engine 290 and Engine 283 advanced their lines down the public
hall, made moving the lines extremely difficult.
Officer of Rescue 2 heard a mayday as he entered the fire building and the 10-84 time for Rescue 2 is
05:10:16 hours. The Officer of Ladder 175, the FAST unit, heard a maydayjust after arriving at the fire
building. They transmitted signal 1 0-84 at 05: 1 0:53 hours. Division 15 also heard the maydayjust as he
walked up to the front door ofthe building. He had transmitted signal 1 0-84 at 05:08:58 hours, got out of
the car, took his bunker gear from the trunk. and walked to the front entrance.
Ladder 175 was just coming up the walk to the front ofthe building and Division 15 ordered them to the
lOth floor to find the reason for the mayday. Ladder 175 proceeded to the fire floor Via the exposure #4
stair.
Division 15 tried to ascertain information from the person transmitting the mayday, but was unsuccessful
because handie-talkie communications were a problem. Division 15 later established a relay system with
the radios to improve communications, but it remained a problem throughout the operation.
Engine 283 Door heard a mayday as he chased kinks in both lines on the stair, before Engine 283 had
water in their line. Engine 283 Control heard a mayday while still connecting to the standpipe outlet on
22
the eighth floor. Battalion 58 heard a mayday and tried to determine the location and identity of it. He also
orderedEngine 283 to stretch a second line. Squad 252 Roof also heard a mayday. The-Officerof-Engine
332 heard a mayday while he was in the exposure #4 stair on the ninth floor. Battalion.44 heard the
mayday and ordered Engine 332 to go back to the exposure #2 stair.
The Safety Battalion believes that a total ofthree mayday messages were heard and all three were
transmitted by Ladder 170 Can. The time of the :first mayday was approximately 0511 hours. The second
and third were transmitted at approximately 0512 hours.
The Vibralerts on Engine 290 SCBA started to sound approximately six minutes after they entered the
10
th
-floor public hall to extinguish the fire. Engine 283's Vibralerts sounded just after Engine 290's.
Engine 290 Officer and Door continued to operate after their SCBA were expended. The Safety Battalion
estimates that Engine 290 ran out of air at approximately 0517 hours and Engine 283 at approximately
0520 hours.
Rescue 2 was able to continue to operate because they were using SCBA cylinders with a 45 minute
rating. Rescue 2 Forcible Entry initially backed up Engine 290 and then relieved them when they were
unable to continue. Rescue 2 Officer,.Can and Floor Above Hook positions initially backed up Engine
283 on the 2 Yz-inch line and relieved Engine 283 when they ran out of air.
Battalion 44 ordered Engine 332 to hook up to the hose outlet located on the ninth floor in the exposure
#2 stair and stretch their line up to the public hall on the 10
th
floor. This line consisted ofthree lengths of
2 Yz-inch hose. This line was charged and did not reach the elevator lobby because ofthe distance from
the outlet in the public hall on the ninth floor. Battalion 44 contacted Engine 225 on the handie-talkie and
ordered them to bring their line to the top floor. Engine 225 added two lengths ofhose to Engine 332's
line. This line was not charged again.
The Officer of Squad 252 found Firefighter Christopher Bopp, the Can position from Ladder 170 .
. Firefighter Bopp was found on the exposure #4 side ofthe elevator lobby door, next to apartment 1.OJ. He
was in the prone position with his feet facing the elevator lobby door. The Officer ofSquad 252 pulled
Firefighter Bopp's legs and started to remove him to the exposure #2 stair. The Safety Battalion estimates
that this recovery started at approximately 0518 hours.
The Officer of Squad 252 initially received help from other members of Squad 252 and the Chauffeur of
Rescue 2 in the removal. Additional help was provided by Ladder 175 Chauffeur and Ladder 103 OVM
when they encountered the removal effort in the hallway between the exposure #2 stair door and the
exposure #2 side ofthe elevator lobby door. Firefighter Bopp was removed to the exposure #2 stair and
taken down to the ninth floor.
While helping the Officer of Squad 252, the Chauffeur of Rescue 2 discovered Firefighter James Bohan,
Ladder 170 Irons position, when he moved around toward the head and shoulders ofFirefighter Bopp.
Firefighter Bohan was found in the supine position with his legs facing the elevator lobby doors. He was
not removed at this time due to the effort being expended on the removal ofFirefighter Bopp.
Ladder 120, the second FAST unit assigned to the fire, transmitted signal 10-84 at 05:21:14 hours. They
entered the building and were ordered to the fire floor by Division 15. The members ofLadder 120 saw
members working on a firefighter on the ninth floor. Based on interviews, the Safety Battalion believes
that Firefighter Bopp was on the ninth floor at this time.
23
','
Rescue 2 Chauffeur encountered the Officer ofLadder 175 in the public hall on the exposure #2 side
the elevator lobby on the lOth floor and told him thatthere were two firefighters
Officer and Forcible Entry Team ofLadder Company 175 then continued to move toward the elevator
lobby in the public hall on the 10
th
floor. For safety purposes, the Officer ofLadder 175 ordered the
position to remain at the elevator lobby. Ladder 175 Officer and Irons position then continued to the
exposure #4 side ofthe elevator lobby. Here, they found the body orfirefighter James Bohan and
to move him toward the exposure #2 stair. The Safety Battalion believes that this recovery occurred at
approximately 0525 hours.
'Battalion 44 ordered Ladder 120 to enter the hallway and search for downed firefighters. Ladder 120's
Officer and Forcible EJ:1try position started down the hallway toward the elevator lobby door. When they
reached the elevator lobby, they encountered the members ofLadder 175 removing Firefighter Bohan.
They then assisted Ladder 175 take Firefighter Bohan to the eighth floor.
Lieutenant Cavalieri was found when the Officer ofRescue 2 heard a PASS device sounding as he was
operating a line into the fire apartment. He left the line and found Lieutenant Cavalieri in the supine
position with his feet toward the fire apartment. The Safety Battalion believes that he was located
between the "H" and "}" apartments, but closer to the "J" apartment. The Officer ofRescue 2 initially
started to remove Lieutenant Cavalieri toward the exposure #4 stair and was successful in moving him
approximately 15 feet. He then realized he needed help, so he left Lieutenant Cavalieri and returned to
where the line was operating. The Officer of Rescue 2 had Rescue 2 Irons Floor Above position return
with him to Lieutenant Cavalieri. Together they moved the Lieutenant toward the exposure #2 stair. The
Safety Battalion estimates that the time ofrecovery was approximately 0530 hours. Ladder 120 assisted
after encountering them in the 1Oth-floor public hall. Lieutenant Cavalieri was taken to the ninth floor.
The occupant of apartment 10J stated in his interview that when his smoke detector first sounded, he
disarmed it and opened the door from his apartment to the public hall to find the cause. Heavy smoke
came into the apartment and he closed the door. He did not recall ifhe closed the door fully, but he
knows that he did not lock it. This would mean that the door to the fire apartment had been open, leaving
the smoke condition present in the hallway.
Inspection ofthe door to the fire apartment on the day ofthe fire showed that the pins to the self-closing'
binges were not in place. Subsequent examination ofphotographic evidence supports that inspection.
The self-closing hinges failed to operate properly because the pins were not in place.
Interviews conducted by a member ofthe Bureau ofFire Investigation indicate that the fire loading in the
apartment was heavy. The occupant had just put new carpeting and foam padding on the floor in the
apartment and the furniture had foam rubber cushions.
The'interior ofthe outside wall in the apartment had sheetrock placed over foam insulation. This foam
insulation contributed to the fire load in the apartment.
The windows in the public hall on the exposure #2 side ofthe building and the windows in the elevator
lobby were vented by the Officer of Engine 332. The Safety Battalion never discovered anyone who
admitted to venting the windows in the public hall on the exposure #4 side ofthe building.
According to an interview conducted by a member ofthe Bureau of Fire Investigation, the ,occupant ofthe
fire apartment tried, unsuccessfully, to extinguish the fire' when it first started. In addition, the occupant
24
opened the window above the couch where the fire started in an effort to relieve the smoke in the
apartment.
Ladder 1.03' s and Ladder 170' s OVMs both went to the rear of the :fire building when they arrived.
Ladder 103 DVM stated in his interview that the:fire was pulsing in and out -Of the fire apa.rtrilent. Ladder
170 OVM, stated in his interview, that he reported that the fire was on the top-floor rear. The fire that
Ladder 103 DVM saw was from the window left open by the occupant. The pulsing in and out was the
result ofthe gusting wind conditions that night. The differing reports can be attributed to the fact that
both firefighters viewed the apartment for different lengths oftime. Ladder 103 OVM remained in the
rear, waiting for the Chauffeur ofLadder 103 to bring the apparatus to the rear ofthe building. Ladder
170 OVM observed t h ~ fire, then entered the building and went to the roof.
Members ofLadaer 103 removed the female occupant of apartment 10E at approximately 0508 hours.
The occupant was taken, in her wheelchair, directly across the hall from her apartment to the exposure
four stairs. At the time of removal, the conditions in the public hall included a heavy smoke condition and
some heat. These conditions suggest that the door to the fire apartment was at least paitially open when
the woman from apartment 10E was taken out of her apartment.
According to the timeline, the Officer and Forcible Entry Team ofLadder 170 were last seen at
approximately 0503 hours. The next time they were heard from again, according to the timeline, was
approximately 0511 hours when the mayday was transmitted. The operations that Ladder 170 conducted
during that time are speculation. The Safety Battalion believes that the members of Ladder 170 Forcible
Entry Team probably searched the elevator lobby and the public hall on the exposure #4 side ofthe
elevator lobby and found the fire apartment. The Safety Battalion discovered no physical evidence that
the members ofLadder 170 operated in the fire apartment.
The Safety Battalion believes that at some point after Ladder 103 removed the woman in the wheelchair
from apartment 10E, the members ofLadder 170 Forcible Entry Team opened the door to the fire
apartment. It is unknown at what point the windows in the:fire apartment failed completely. However, .
the wind speed on the night of the mishap was 17 miles per hour and it's direction was from the
northwest. This wind had the necessary force to push the fire in the apartment out into the public hall.
When that happened, the members ofthe Ladder 170 Forcible Entry Team, operating in the public hall,
were trapped and burned by the heat and flames from the :fire.
Battalion 58 ordered Ladder 107 to relieve members operating on the lines. Ladder 107 relieved Rescue 2
Irons Floor Above position on the 1 %-inch line. Ladder 107 then relieved members of Rescue 2 on the 2
%-inch line. Rescue 2 Floor Above Hook position switched lines with. the members ofLadder 107 on the
1 %-inch line. The fire in apartment 10D was extinguished by the joint efforts ofRescue 2 Floor Above
Hook position operating the 1 %-inch line and Ladder 107 Officer and Forcible Entry Team operating the .
2 V:z-inch line.
All three members ofwere transported to area hospitals via Fire Department ambulances and where they
were pronounced dead.
Firefighter Bopp and Firefighter Bohan were removed to Brookdale Hospital. Lieutenant Cavalieri was
removed to Kings County Hospital.
I
The cause of death for Firefighter Christopher Bopp was determined to be bums ofthe head, trunk and
arms involving approximately 15% ofbody surface area andsmoke inhalation.
25
Firefighter James Bohan's cause odea'lh-W3S-burns ofthe head, trunk and extremities involving
approximately 20% body surface area and smoke inhalation.
Lieutenant Joseph Cavalieri's cause ofdeath was burns ofthe head, trunk and extremities involving
approximately 300/0 body surface area and smoke inhalation.
On December 30, 1998, members oftheSafety and Inspection Service Command conducted flow tests of
the standpipe system at 17 Vandalia Avenue, from 0445 hours throUgh 0615 hours. The tests used hose,
fittings and stretches similar to those that were used by units operating on December 18, 1998, the day of
the mishap. The follo:yying flow results were obtained:
Three lengths of2 ~ - i n c h hose with a lead length of 1 %-inch hose stretched from the ninth-floor
standpipe produced a flow of 154 gallons per minute.
Four lengths of2 %..inch hose stretched from the eighth floor produced a flow of 290 gallons per
minute.
Both ofthese hose-lines were operated simultaneously and the output was measured by pitot
gauge as the water was discharged out ofa 10
th
-floor window.
A member detailed to the Safety Battalion was assigned to verify the following:
TASK TIME TAKEN
to have the elevator go to the fire floor and return to
the lobby
Approximately one minute to the fire. floor, and one
minute to return to the lobby
to cross over from one stairwell to the other on the
same floor
Approximately one minute
to walk. up to the ninth floor Approximately three minutes
26
.J
1
CAUSES OF THE MISHAP
DIRECf:
The attempt to stretch and operate a hand-line from the standpipe outlet located in the stair on the same
floor as the fire and the failure to get the initial line charged and operating.
Inadequate communication and coordination amongst units operating in the stair and the unit operdting
out on the fire floor. Engine 290 was the only unit that knew where the members of Ladder 170 were
operating.
Members ofLadder 170 operating in an atmosphere that contained high heat, heavy smoke and other
products of combustion.
Members ofLadder 170 operating in the hallway without the protection of a 2 ~ - i n c h hand-line when
heavy fire, heavy smoke and toxic gases vented from apartment 10-D .
. Failure by units operating in the exposure #4 stair to inform Ladder 170 of the seriousness and extent of
the escalating fire conditions.
INDIRECT CAUSES:
Wind gusting from 17 to 25 mph and blowing directly into the fire apartment
Delayed. alarm caused by the occupant's attempt to extinguish a couch fire in the apartment and the
building security guard going up to the 10
th
floor to verify the cause ofthe interior alarm going off before
notifying the Fire Department.
Fire forced by the wind into the 10
th
-floor public hallway trapped members and inflicted fatal injuries.
Failure of the sprinkler system to operate.
CONTRIBUTORY CAUSES:
. High heat release rate of the fire loading in the fire apartment. All ofthe furniture was made of foam
rubber and the occupant had just installed new carpeting. The foam insulation between the exterior wall
and the sheetrock wall also contributed to the heavy fire load.
Failure of the building's maintenance personnel to maintain and inspect the sprinkler system to determine
its operability.
Failure ofthe administrative unit to verify and check the accuracy of CIDS card information and include
information about the sprinkler system ..
Insulation on the standpipe outlet on the 10
th
floor in the exposure #4 stair prevented proper hook-up of
hose to the standpipe.
27