Baltimore City

Chief calls for reforms after report on firefighter's death

Baltimore Fire Chief Niles R. Ford called for reforms to reduce "inadequacies of accountability" after a veteran firefighter died and remained unnoticed for hours inside a vacant rowhouse where he had fallen while responding to a blaze last November.

In a report released Friday, investigators said fire personnel took "a haphazard approach" to ventilating the house where Lt. James Bethea died of smoke inhalation. According to the report, commanders "ordered ventilation but failed to specify the tactics to be used."


"No one attempted to open two front basement windows that were secured with plywood," the report stated.

Tests performed by investigators showed "that opening only one of the basement windows very likely would have effectively ventilated the basement in a short time and may have mitigated" the hazards that killed Bethea, who was a fire safety officer.


The report also notes a lack of clear policy for the Fire Communications Bureau, saying many personnel seemed to be confused or unaware of basic procedures, and that the department "did not have a strong culture of training."

First responders didn't arrive on the scene for an hour and a half after the first 911 call from an auxiliary firefighter who spotted Bethea's car, though investigators believe Bethea died hours earlier.

Bethea, 62, was found seated upright, near walls smeared with blood where he tried to find his way out. He likely died within 30 minutes because of high levels of carbon monoxide in the house, according to the report.

Bethea, a firefighter with 41 years of experience, was responsible for making sure firefighters followed proper safety procedures at a dwelling fire on North Avenue. He also was in charge of alerting firefighters to potential hazards. He was in the vacant home next door to the blaze when he fell to the basement.

Ford said the 108-page review was "comprehensive" and intended to ensure "it never happens again." The board of inquiry included members from the city Fire Department as well as from the Howard and Anne Arundel county departments. The report outlines more than 20 policy reforms the department plans to implement before Dec. 1.

Some reforms have already been put in place, such as requiring the last departing units to report to dispatchers that they have left the scene.

The report states that Bethea entered the home not realizing the air quality was dangerous. He was not wearing a self-contained breathing apparatus, also known as SCBA, nor did he have air-monitoring equipment.

Ford said the department SCBAs have a personal alert safety system, which sounds when a firefighter stops moving. Ford said he wants to require all personnel at fire scenes to wear one.


"Normally they do not enter into a hazardous situation. That's not normally what they do. But it's a possibility that this kind of thing happens," Ford said. "We're going to have to develop an accountability system that's adaptive."

The report said Bethea did have his radio, and it was tested the morning he was found by the medical examiner, who determined it was working but it had not used. The report said it is unclear why Bethea did not send an emergency message by radio.

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An off-duty auxiliary firefighter called 911 to report the departmental Ford SUV sitting in the middle of the street, with no one inside, and "no one around."

That initial 911 call came in at 6:47 a.m., more than three hours after the scene had been cleared. Units did not arrive on the scene until 8:12 a.m. Bethea's body was found about 8:45 a.m.

The report says a lack of written guidance might have contributed to "the mishandled information, and inappropriate/slow reactions" to the call from the auxiliary firefighter.

And when investigators asked one fire captain in the unit about when dispatchers should redeploy units from a fire scene, the captain couldn't give an answer, according to the report.


The report did not name the battalion chief of the communications bureau, but quoted him as saying, "The unfortunate thing in my bureau, you have to be very nitpicky with when you tell people things. I mean, I had to send out an email to tell people how to sit in a chair properly."