NIOSH Review: Baltimore Recruit Firefighter Death 2007

Introduction and Background

When errors in judgment occur and correct firefighter safety practices are violated, accidents, injuries, and even deaths can result. In the case of the February 9, 2007 fire training exercise at 145 South Calverton Road, many National Fire Protection Association (NFPA) guidelines were ignored or violated, resulting in the death of recruit Racheal Wilson. Though tragic and heartbreaking — not just for Wilson's colleagues but for her family, her two children, her friends, and her loved ones — incidents like these can serve as a tool for improving safety practices in the future. So that Wilson's death will not have been in vain, this report reviews and analyzes the facts of the case based on Baltimore City Fire Department (BCFD) regulations and on proper procedures for training exercises as laid out in NFPA 1403, Standard on Live Fire Training Evolutions, 2002 Edition.

What went wrong, why it went wrong, who was in charge, why standard safety procedures were not followed, and what changes need to be made for safe future live fire training exercises are all addressed in this paper. It should be stated at the outset that among the failings of the leadership involved in this tragedy, paper documentation pertaining to the structure in question and its NFPA-approved preparation were not produced prior to the live fire event. In addition, proper documentation of the event was not provided in a timely manner during the investigations that followed. The failure of fire department management to produce these documents highlights one aspect of the BCFD that must be addressed: the need to follow basic procedural steps.

Since the employee culture at the bottom of the chain of command tends to reflect the level of competency, consistency, and adherence to structure maintained at the top, an organization is generally a reflection of its leadership. When management disregards important policy steps, it sets a damaging example for those in lower positions. Learning from tactical, strategic, and procedural errors can be useful in correcting them. A sober but honest assessment is far more relevant to this discussion than recriminations and uninformed finger-pointing. This paper is presented with the constructive philosophy that making errors is human and understandable, but when those errors result in the loss of life, a careful reconstruction of the facts — along with recommendations for future mitigation — must be part of the process.

Sequence of Events at 145 South Calverton Road

According to the report presented by the Baltimore City Fire Department (BCFD), titled Preliminary Investigation into the Line of Duty Death of Recruit Racheal M. Wilson, 24 members of FPA Class 19 were involved in this training exercise.

Three fires were set at 145 South Calverton Road at 11:35 hours. The vacant building was a three-story "end-of-group" row house owned by the Housing Authority of Baltimore City. Weeks earlier, this same row house had been used for a training exercise, but at that time no fire was set in the building. Four minutes after the three fires were set, a "simulated dispatch of units" began suppression activities.

The hoses were not "charged" (containing high-pressure water) when Wilson and others entered the front door of the building. On the second floor, Wilson and others encountered fire in the hallway, and when Wilson opened the nozzle she "was knocked backwards by the pressure of the water that was now flowing." PM Stephanie Cisneros then helped Wilson to her feet; meanwhile, EVD Ryan Wenger extinguished the hallway fire. The remainder of the second-floor fire was left burning, according to the BCFD report.

Wilson was again given the pipe (hose) and the team advanced to the third floor. Wilson began to put out a fire directly to her right, with Wenger within three feet of her. Cisneros was on the upper level of the split-level stairs and "begins to receive burns to her left leg from heat coming from the fire in the second floor rear room" (BCFD). The fire from the second floor was burning through the wall into the stairwell. Cisneros moved to the top of the steps and saw Wenger sitting on the windowsill; she told Wenger she was rushing to exit the building. Wenger exited first through the window onto the roof of the second floor and helped Cisneros out.

Wenger looked back through the third-floor window to check on Wilson, who appeared to have all protective gear in place, but Wilson had dropped the hose line. Wilson attempted to escape through the third-floor window "but was unable to do so because of the unusual height of the windowsill [41 inches from the floor]." Wilson "ended up lying on the windowsill at chest level. Wenger attempted to pull her up and out of the window but was unsuccessful" (BCFD). While help arrived from team members on the roof of the third floor, Wilson momentarily slipped off the windowsill back into the building. As she tried to climb back up, her face piece had fallen off and her helmet "was hanging to the side of her head by the neck strap, but her hood was still on." Wenger witnessed Wilson's face "starting to burn."

The next attempt to get Wilson out through the window also failed. Wilson's left foot was apparently "entangled in wire mesh" exposed through the wall just below the window. Wilson soon "goes limp and loses consciousness," according to the BCFD report. She was helped through the window and CPR was administered on the second-floor roof while other team members used the hose Wilson had abandoned to extinguish the third-floor fire. Wilson was missing her left boot; she was placed on a backboard "and into a stokes basket" and lowered to the ground by an aerial ladder. CPR was administered continuously as she was rushed to the Shock Trauma Center. Dr. Thomas Scalia pronounced Racheal Wilson dead at 12:50 hours (BCFD).

Beyond the wealth of data and institutional changes outlined for the BCFD, the Independent Investigation Report (IIR) presented to Baltimore Mayor Sheila Dixon adds an important environmental footnote. Led by R. Chris Shimer, Deputy Chief of Howard County Department of Fire and Rescue Services (HCDFRS), the IIR noted that the temperature that day at Baltimore Washington Thurgood Marshall International Airport was 26 degrees Fahrenheit. Wind was gusting up to 25.3 miles per hour and was otherwise steady out of the northwest at 17.3 miles per hour. Reports from the live fire incident indicate that the wind was out of the southwest at 20 miles per hour. That wind speed "contributed significantly to the fire growth and propagation," likely pushing smoke and heat toward the rear of the structure and hastening the growth of all three fires that had been set.

Works Cited

BCFD Preliminary Investigation Into The Line Of Duty Death Of Recruit Racheal M. Wilson On February 9, 2007. (2007). Retrieved November 12, 2009, from http://www.minnesotafireservice.com/pubs_open/20070226bcfd_wilsonreport.pdf.

Goodrich, Art. (2007). Baptism by Fire or Death by Diversity? Retrieved November 12, 2009, from

Independent Investigation Report. (2007). The Baltimore City Fire Department Live Fire Training Exercise 145 South Calverton Road. Retrieved November 12, 2009, from http://www.baltimorecity.gov.

Linskey, Annie. (2009). Claim Denied in Death of Cadet: Fire Department Did Not Send Paperwork to Support Benefit to Her Kids, U.S. Says. Baltimore Sun. Retrieved November 13, 2009, from http://www.baltimoresun.com.

Linskey, Annie. (2007). Union Officials Blame Supervisors in Baltimore Recruit's Death. The Baltimore Sun. Retrieved November 13, 2009, from http://www.firerescue1.com.

Sledgeski, Bob. (2009). Compounding Failure: Our View: A Fire Cadet Dies Tragically in a Poorly Supervised Training Exercise, and Now Missing Paperwork May Cause Her Children to Be Harmed Too. Baltimore Sun. Retrieved November 12, 2009, from http://www.baltimoresun.com.