A Baltimore fire recruit who was killed in a February training exercise was not ready to be sent into a burning dwelling, had failed agility tests and had been given old protective gear that frayed and failed to protect her from the intense heat, according to a report prepared for the mayor.
The 121-page report by an independent investigator, obtained yesterday by The Sun, adds new details to the death of Racheal M. Wilson and places much of the blame on her instructor, who investigators say abandoned her in the burning rowhouse, and on other mid-level fire commanders, three of whom have already been fired.
It describes a chaotic scene conducted by instructors who acted with little oversight and concludes that 50 national safety standards were violated during the exercise, more than the 36 previously acknowledged by the city and the department.
Fire Chief William J. Goodwin Jr., who has been criticized for allowing lax standards at the training academy he once headed, is mentioned once in the detailed report, in a paragraph in which investigators note that he was unaware that the live-fire exercises would take place.
Mayor Sheila Dixon, who commissioned the investigation, is expected to release the report publicly Thursday after Wilson's family has had a chance to read it. She refused to discuss the contents yesterday.
The lead investigator, Howard County Deputy Fire Chief Chris Shimer, concluded his report by expressing hope that other departments would learn from the mistakes made by Baltimore firefighters.
"The ultimate sacrifice by Racheal Wilson should serve as a reminder to fire officials everywhere that rules and standards are developed for a reason," Shimer wrote. "The primary reason is to ensure that we keep our personnel safe so they may return home each and every day to their loved ones."
Two previous investigations into the Feb. 9 fire on South Calverton Road have revealed dozens of violations of national safety standards, including the setting of seven or eight fires instead of the one that is permitted, the lack of radios for some instructors, the failure to clear debris from the vacant dwelling and the failure to brief students before the exercise.
The report was based on a six-month investigation into what occurred during the fatal fire, but it also scrutinized other practices, finding "systematic problems" at the training academy.
It includes graphics, photographs and 19 appendices. Toward the end of the report, Shimer concludes that the fire academy is governed by an "unacceptable" view that "recruits must be exposed to heavy fire conditions in order to be adequately prepared for the field.
"These practices are unacceptable and may lead to serious injury and in this case death," the report says.
After the fire, three commanders lost their jobs. Division Chief Kenneth Hyde, who was head of the academy when Wilson died, was fired by Dixon in February. Lt. Joseph Crest, the instructor in charge of the fire, and Lt. Barry Broyles, who was supposed to be in charge of an unprepared rescue team, were fired on the recommendation of a panel of their peers.
Goodwin has said that the Fire Department needs to focus more on safety and has taken steps to improve it. He replaced most of the staff at the training academy, obtained grants for radios, increased the department's safety office operation and started to rotate all midlevel battalion chiefs, in part because of a belief that they had grown too close to their men and were not reporting safety violations.
Investigators noted that Goodwin was interviewed and that the Fire Department was mostly cooperative, with the exception of three key people.
Lt. Eugene Jones, who was supposed to light fires at the fatal burn, would not allow officials from the Bureau of Alcohol, Tobacco, Firearms and Explosives to interview him. Tarnisha Lee, a firefighter paramedic who lit some of the fires in the rowhouse, would submit to only a brief interview with investigators.
Hyde, who was in charge of the training academy, initially cooperated with investigators but stopped participating on the advice of his lawyer, according to the report.
The report examined for the first time a similar training exercise that was conducted Feb. 8 on Sinclair Lane, the day before the fatal burn. Investigators found that national safety standards were violated there, too, something that Fire Department spokesmen have denied.
From watching a video of that fire, investigators determined that instructors lit more than one fire, recruits entered and exited the burning building without being accompanied by instructors and a recruit left the building with what appeared to be burning debris on his or her back and neck.
Instructors were not wearing their face pieces properly, the report says. One recruit, Daniel Nott, was injured after removing his mask and suffering burns to his face. Lt. Sam Darby, an instructor, suffered a burn on his hand at that fire.
"It is obvious to an observer of this video that the fire is beyond the capabilities of a recruit class, especially one with minimal training," the report says.
Problems with class
Even before the back-to-back training fires on Sinclair Lane and South Calverton Road, the recruit class had problems, it says.
As officials were selecting members for Class 19 in November 2006, they overlooked Wilson's having failed one section of a seven-part agility test given to recruits before they can enter the class. Disregarding physical fitness is a common practice, the report says.
In early 2006, Wilson, who was a civilian working in the Fire Marshal's office, applied to the academy. She took an agility test but was rejected.
She took the agility test again in November 2006 and failed. The report says she was 10 seconds too slow on the "tower walk," a timed drill during which recruits wearing weighted vests must climb and descend the steps at the fire academy's six-story fire tower.
Wilson was accepted into the November 2006 class, however, even though the report says she had scored better the first time she took the agility test and did a better job on four of the five stations. That indicates that her physical conditioning had deteriorated from the time she initially applied to the fire academy and was rejected.
Wilson's autopsy found that she was 5 feet, 4 inches tall and weighed 192 pounds.
"Racheal's physical stature may have presented some challenge to her becoming a firefighter," the report says.
Other problems were noticed. Wilson's instructors told investigators that during training she "had a propensity for removing her face piece" and said that she had trouble holding the nozzle of a hose under pressure. Instructors never documented their concerns and allowed her to progress through the academy without mastering those skills, the report says.
Wilson was holding a nozzle the day of the fatal fire, though she had never done so successfully in a live fire. As had occurred during previous training exercises, she was knocked backward when she opened it to spray water on a second-floor fire.
The day of the training fire on Calverton Road, the department issued her a pair of pants that had "significant problems," including worn knee patches and a hole in the fly, the report says.
Wilson's autopsy found that her thigh and leg were seriously burned, and investigators concluded that her turnout gear "was not adequate for interior fire fighting."
The report says that the "crotch had no integrity, and thermal protection in the crotch had diminished. It may have accounted for serious burns in her lower extremities."
The report gives a detailed account of what occurred within the rowhouse.
The recruits had never been given a thorough walk through the building or a clear plan for attacking the fire, and the report says the little information they were given turned out to be wrong. They were told that there would be no fire on the first floor, but when they walked in the back door of the building they were met with fire.
Two recruits said they had questions about what they were supposed to do before entering the building. Their instructor, Capt. Louis Lago, said he did not have time to answer them, "presumably due to the fact that the fires had already been ignited," the report says.
Wilson's crew, led by Ryan Wenger, an emergency vehicle driver, was ordered to take a crew of recruits to the third floor, bypassing a fire on the second level, a practice typically used only if firefighters are rescuing someone.
Wenger told investigators that he had concerns about carrying out that order but suppressed his worries in the belief that if he objected, somebody else more cooperative would be put in his place, the report says.
Wenger was told that the crew behind him would put out the fire on the second floor. That group was delayed as it tried to put out the unexpected fire that had been set in first-floor room filled with debris that included tires, mattresses, branches and a television set, the report says.
"To extinguish the fire, the crew had to place the nozzle under the debris, which materially delayed their response to the second floor," the report says.
When Wenger got his crew to the third floor, he fell to his knees because of the heat.
"The heat was unbearable even while on his knees, but he apparently did not think about retreating and getting his crew out of the building," the report says.
Another recruit, Stephanie Cisneros, approached Wenger and said she thought she should get out of the building. It was then that Wenger began evacuating his team. He did not have a radio and could not call for help.
After Wenger helped Cisneros get out, Wilson said she wanted to leave. Rather than helping her out first, Wenger pulled himself out of the burning building and then tried to pull her out. He lifted her torso, hand and arms but could not get her out.
"He asked her if she could help him, and she replied that she could not help, as she was burning up and could not take the heat," the report says.
Wenger lost his grip, and Wilson fell back into the building. He grabbed her a second time. She remained conscious and talked to Wenger, saying that she was "burning up," according to the report. The skin on her face was blistering from the heat.
Her mask started coming off during the rescue attempts, but investigators say they could not conclude whether she took it off or if it slipped off.
Two other recruits tried to help her out of the building, and Michael Hiebler, an emergency vehicle driver, lifted her legs out.
The initial Fire Department report suggested that Wilson's boot might have become caught in the room's faulty floor, hampering her escape. The report concludes that Wilson's left boot became lost but most likely did not become "entangled" in the debris.
Other recruits and firefighters in the building described conditions that investigators said could have been a "flashover," a dangerous situation in which the heat inside a building becomes so intense that all surfaces ignite.
While a rescue of Wilson was being attempted, an unknown number of firefighters entered the building. At some point, all of the other recruits got out, but nobody sounded an evacuation horn and nobody kept track of who was inside the building and who was outside, so a proper head count was impossible.
After the fire, two top staff members at the academy said that they had expressed reservations about the class.
Crest told investigators that he was "uncomfortable with the majority of the class," the report says.
Capt. Terry Horrocks told investigators that he had asked Hyde not to take the class to the burn.
Neither formally documented their objections, and investigators found no way of verifying that those conversations took place.