Feds Issue Final Report On Fallen-Firefighter Blaze

Four years after city firefighter Ricardo Torres, Jr. died while responding to an early-morning house fire on Valley Street, federal investigators have released a 33-page report detailing the scene — including that a bookcase blocked the building’s front door, Torres got separated from his colleagues, and an officer who called for help wound up needing to be rescued himself.

The report also issued a spate of recommendations, around Mayday training and preserving ​“crew integrity,” to help prevent another such tragedy from happening again.

Those details and many more are included in the report, which came out on Tuesday and was published by the National Institute for Occupational Safety and Health (NIOSH).

Also on Tuesday, city Fire Chief John Alston, Mayor Justin Elicker, and fire union President Miguel Rosado, among others, held a press conference at fire headquarters on Grand Avenue to discuss the report’s findings.

The report can be read in full here. It shines a light on the final moments of Torres’ life, as he struggled for air on the second floor of a two-story house at 190 Valley St. while fighting a fire in the early hours of May 12, 2021. Torres ultimately died from asphyxiation. The state Office of the Chief Medical Examiner ruled that his death was accidental. Firefighters rescued a woman from the building’s ground floor as part of their response to the blaze. 

Lt. Samod Rankins was also seriously injured during the response to the blaze, and two other firefighters suffered minor injuries.

The report describes a number of factors that contributed to the fire turning fatal, including:

• A bookcase that the building’s occupant had placed behind the front door to protect from intruders, and that ultimately made it more difficult for firefighters to enter and administer water; 

• Torres becoming separated from his firefighting colleagues on the second floor as the fire continued to rage and he ran low on air; 

• Rankins calling for help for Torres as a ​“firefighter down,” and then needing to be rescued himself because Rankins’ ​“facepiece and helmet got dislodged;” 

• The depletion of the air of the firefighters who went back in the building to try to rescue Torres and Rankins, after they had used up some of their air and energy fighting the fire earlier in the incident. 

The report concludes with nine recommendations, ranging from better training for responding to basement fires to ensuring firefighter response crews have a dedicated and trained incident safety officer (ISO) to making sure that ​“initial and ongoing size-ups and risk assessments are conducted throughout the incident” to bolstering local firefighters’ training in issuing and responding to Mayday calls.

“It broke my heart. This is a tragedy,” Chief Alston said about his biggest takeaway from the report. He, Elicker and Rosado all stressed how this report, four years in the making, has been a long time coming. ​“Four years is a long time to wait for a report like this,” Alston said. Hopefully, added Elicker, this will begin to provide some form of closure for a family, a department, and a city that has long mourned Torres’ death.

Elicker and Alston said that the department has already implemented or is in the works of carrying out all nine recommendations included in the NIOSH report.

The report states that the first 911 call about the house fire came in at 12:44 a.m. on May 12, 2021. The fire began in the basement; state police investigators were unable to determine the cause of the fire. 

Car 34, Engine 1, Engine 9, Engine 6 — which included Torres and Rankins — Truck 4, Truck 1, Rescue 1, Special Operations Command 1, and Emergency 2 all responded to the fire, starting at 12:51 a.m.

At 12:58 a.m., Engine 9 rescued a woman from the building’s first floor. ​“The 1st floor apartment was only accessible via the rear door,” the report reads, ​“because the occupant had placed a bookcase in front of the entrance door.” The basement and attic were used for storage, and the basement storage area was described by state police investigators as ​“excessive storage.”

At 1:02 a.m., three firefighters from Engine 6 — including Torres and Rankins — got to the building’s second floor via the front stairs. Rankins reported ​“heavy smoke conditions and high heat” on the second floor; the incident commander instructed Engine 6 to get to the ​“Side Charlies/Side Delta corner and open up the walls.” Rankins asked to have the ​“hoseline charged.”

“The End of Service Time Indicators (EOSTIs) for the Engine 6 firefighters began to sound and Engine 6 Lieutenant [Rankins] told Engine 6 Pipe and Engine 6 Hydrant [Torres] that they needed to leave to change air cylinders,” the report’s executive summary states.

One firefighter on the second floor ​“left the hoseline and exited the 2nd floor.” The two remaining firefighters, Rankins and Torres, then ​“became separated. In this confusion, Engine 6 Lieutenant’s [Rankins’] facepiece and helmet became dislodged.”

Eventually, Torres ​“ran out of air, became disorientated, and was trying to get out of the room.” He ​“walked/crawled” and got between a radiator and a couch in the living room underneath two windows. He was running low on air and called a ​“Mayday” at 1:16 a.m.

At 1:17 a.m., Rankins called the incident commander and said, ​“I have a firefighter down on the 2nd floor.” 

At 1:18 a.m., Rankins called a ​“Mayday.” Rankins was then rescued by fellow responding firefighters. ​“The firefighter found Engine 6 Lieutenant [Rankins] in the living room near the entrance to the kitchen. Engine 6 Lieutenant [Rankins] had his facepiece off and was standing when the firefighter found him. He said, ​‘Help me,’ and then fell into the firefighter. Engine 6 Lieutenants’ [Rankins’] helmet was found in the Side Alpha/Side Bravo corner near Engine 6 Hydrant [Torres] and his gloves were off.

At around 1:21 a.m., another firefighter ​“made his way into the living room” and found Torres ​“lying prone near a couch with his facepiece on, but he was out of air.” Two firefighters tried to get Torres out of the building through the front windows, but were unable to and ultimately had to leave for being low on air. 

Another firefighter then went in and was able to bring Torres down the front stairs to the outside at 1:33 a.m.

Both Torres and Rankins were transported to the hospital at 1:36; Torres was declared deceased at 2:12 a.m.

The report includes a total of nine recommendations for the city fire department to adopt to help prevent this type of tragedy from happening again.

Those recommendations include: 

• Ensuring that firefighters conduct ​“size-ups and risk assessments” throughout their response to a blaze like this one. ​“At this incident, the initial focus of the first-due companies was to rescue the female occupant located on the 1st floor,” the report reads. ​“There was no initial scene-size-up or risk assessment conducted that was communicated to IC,” or the incident commander. 

Continuous communication, size-ups, and risk-assessments allow all personnel on the scene, including the commander in charge, to be aware of changing conditions and to ​“adjust to avoid hazards or mitigate risks.” 

An incident safety officer (ISO) can then ​“stop or suspect incident operations based on imminent threats to firefighter safety.” The ISO should be separate from the incident commander, operations, or accountability positions, the report states, ​“so they can focus on their responsibilities and the primary objective of continually assessing all on-scene hazards to firefighter life and safety.”

• Maintaining ​“crew integrity” when operating in a ​“hazard zone.”

“It is the responsibility of every firefighter and company officer to always stay in communication or contact with crew members by visual observation, voice, or touch while operating in the hazard zone,” this recommendation reads. ​“All firefighters should maintain the unity of command by operating under the direction of their company officer. The ultimate responsibility for crew integrity and ensuring no members get separated or lost rests with the company officer. A Mayday should be called if any member cannot be accounted for during a personnel accountability report.”

• Making sure that firefighters and fire officers are properly trained and then properly use ​“the principles of air management and fireground survival procedures.”

Air management, with the help of the self-contained breathing apparatus (SCBA), takes place at the individual firefighter level, crew level, and command level, according to the report. 

“A low-air emergency for one crew member should be treated as an emergency for the entire team, requiring the entire team to exit simultaneously, maintaining crew integrity. If they are not out of the IDLH [immediately dangerous to life or health] atmosphere and go into their emergency reserve air, they need to immediately communicate this emergency with their crew and IC. Firefighters should not wait until their EOSTI [end-of-service-time indicator] alarms activate or they are out of air to communicate or address this situation.”

• Making sure firefighters and officers are trained in Mayday operations. ​“Firefighters should be trained and have confidence in how to call a Mayday when in danger,” the report reads. ​“Any delay in calling a Mayday reduces the chance of survival and increases the risk to other firefighters trying to rescue the ​‘downed’ firefighter.”

• And making sure that fire department operations include standard operating procedures for responding to basement fires. ​“At this incident, the fire department had no defined tactics for fighting a basement fire.”

This part of the report continues: ​“Early identification of basements and their access points are critical during the initial on-scene size up and a component of the 360-degree size up. If the use of basements is a common component of building design within a particular community, then a basement should be considered as part of the scene size-up. The presence or lack of a basement must be communicated to everyone involved to minimize or eliminate the opportunity for fire crews to end up working above a basement without their knowledge. The immediate dangers include falling through the floor and working in the exhaust portion of a flow path.”