Lt. Samuel Darby sat on the roof of the burning building with a power saw.

It was a live-burn exercise in a vacant West Baltimore rowhouse, and he was teaching cadets how to cut holes in the roof to give smoke and fire a way to escape. The heat scorched two knuckles on his right hand.

Darby said his protective gloves were wet and didn't offer proper protection. An independent report raised the possibility that he might not have been wearing them at all. Either way, he was sidelined. So was one of the cadets, who was burned in the face when he broke safety protocols and removed his air mask.

The injuries did not raise any flags. But had fire commanders probed, they might have learned that there were numerous safety violations. The fire set Feb. 8 on Sinclair Lane "was much too large for the class to handle," an investigative report later concluded.

But those concerns were not raised back in February, and instructors held another live-fire training exercise the next day, Feb. 9, on South Calverton Road. Filling in for Darby was Ryan Wenger, whose job is to drive a firetruck. He had no experience training recruits. In fact, he told investigators he was "helping out for the day."

Cadet Racheal M. Wilson was killed in the exercise, which investigators later concluded violated 50 national safety standards.

A series of investigations, culminating with the latest report released last week by the mayor's office, revealed that instructors set too many fires inside the abandoned rowhouse and failed to have water charged in the hoses of firefighters assigned to help should something go wrong.

The report found that Wilson had been sent into a burning building with an inexperienced instructor who didn't have a radio, wearing old protective pants with holes that frayed in the heat. She was ordered to climb above fires before putting them out, ultimately becoming trapped at a third-floor window when the flames below raged out of control.

Wilson's family and friends called the findings criminal. Mayor Sheila Dixon said in a written statement yesterday that she had reviewed the report and that she was "deeply troubled by the circumstances that led to [Wilson's] tragic death."

Dixon said that while some changes have been made - she has fired the head of the training academy, and two other commanders were dismissed by the Fire Department this month - more are needed.

"I hope that by reforming the training academy, another individual committed to keeping our city safe will not perish so needlessly ever again," Dixon said.

Problems started well before the fatal training exercise, with doubts about whether the department should have allowed Wilson to enter the class - she failed a physical agility test by a narrow margin and could not hold a hose charged with water without falling down.

Part of training at the city fire academy requires recruits to battle real-life conditions.

The investigative report noted that it typically takes 60 days to plan a live burn. Battalion Chief Kenneth Hyde rushed though that process, alerting the department's safety office only the day before the exercise was to be held, the report says.

When recruits and instructors arrived on South Calverton, they hauled a dozen wooden palettes and 11 bales of excelsior - thin wood shavings - into the building. Two firefighters went though the house with flares lighting multiple fires on the second and third floors, violating a safety regulation that permits only one fire in such a training exercise.

The weather Feb. 9 was chilly: It was below freezing at noon, with wind gusts up to 25 mph. That, too, should have given instructors pause. "The effect could have contributed significantly to the fire growth," according to the report.

Outside the dwelling, cadets were assigned to instructors. Those assigned to Capt. Louis Lago were confused.

Tina Strawsburg, one of his recruits, asked if she could walk though the building before it was burned, a safety requirement.

"I was told 'no' ... that we didn't need to," she said in an interview with investigators.

The report says that cadets repeatedly questioned their instructors on safety issues, only to be rebuffed.

Another cadet in Lago's crew, Jason Neisser, told investigators that he didn't know how many fires were to be set or where they would be. "We had questioned the captain of the engine company on several things, and his response was, 'There's no time,'" he said in the report.

Nearby, Wenger was meeting for the first time his crew of four cadets, including Wilson and Stephanie Cisneros, a medic who wanted to move to the fire-suppression side of the department.

Cisneros noted that Wenger was not wearing his PASS device, a tool that enables firefighters to find someone who becomes stranded. "I told 'em you better grab yourself a device," she said to an investigator. "He said, 'Oh, I'm fine.'"

Also, nobody gave Wenger a radio, and he didn't ask for one. This became a disastrous oversight when events got out of control, the report concluded.

Lt. Joseph Crest told Wenger that he should take the recruits past a fire on the second floor, to put out the blaze on the third floor. The order contradicted a basic fire-fighting tenet, according to the report: Never get above a fire.

One of the recruits thought it was odd. "I figured we'd go in and take the first floor and then Engine 2 would go up to the second floor and so on," said Angel Perez. "But he said, 'No, we're just going straight up to the third floor.'"

Wenger had questioned the dangerous order, checking with Crest to be sure it was correct. Crest confirmed it.

Wenger didn't notice the first-floor fire. It was in the back, and he was in the front. Nobody had told him about it.

The team climbed to the second floor. The fire there was much bigger than they had expected. "I knew we were supposed to go to the third floor, but I mean, I decided to stop 'em there and I didn't feel comfortable proceeding to the third floor until we at least darkened [or sprayed] that hallway down," he said to investigators. Wenger ordered Wilson to open the hose. She fell to the floor.

"She wasn't getting up too fast," Cisneros said to an investigator. "And that is something that keeps sticking in my mind. ... I don't know whether at that point she was overwhelmed already."

Wenger took over the hose and sprayed the fire. It appeared to him that the fire was mostly out. It wasn't.

He and Wilson continued to the third floor, while Cisneros was on the stairs helping to pull the hose from the second floor to the third floor.

She noticed that the fire on the second floor was reigniting. "I hollered up to [Wenger], 'It's coming back, you need to hit this.'"

The crew that was supposed to come in behind them was delayed, trying to put out the unexpected fire on the first floor.

Cisneros' legs and arms were starting to burn. "I realized the situation wasn't going well," she said in the report. "I started thinking, '[Expletive] that fire, that hose is going to burn. ... I hope we don't lose water.'"

"This isn't good," she recalled thinking. "If I don't make a decision, I could very well perish right here."

The report criticized Wenger for not appropriately assessing the fire and the recruits' capabilities. It was Cisneros, with flames coming off her gear, who decided it was time to end the drill.

Wenger poked his head out a window. "I told him to get the rest of the way out the window, I needed to get out. I said, 'I'm burning up,'" she said.

"He busted himself out of there, and, and the window, it wasn't a big window ... but it was high. But I must have just had the will to get it done because it didn't take me long to get out of that house."

Cisneros tumbled onto the second-floor roof, and her mask came off. She watched Wenger struggling to pull Wilson out of the window and wanted to help. But she couldn't. There was too much smoke and she had lost her air supply.

Wenger was yelling that he needed help. Cisneros looked around and found a radio lying on the roof. She said: "This is not a drill. We have a trapped firefighter. Oh, please Lord. We need help up here now," according to the transcript.

She watched as Wenger tried to pull Wilson out of the window. Wilson stood 5 feet 4 inches tall and weighed 192 pounds. The window was unusually high off the ground, nearly 3 1/2 feet, adding to the difficulty.

"I'll tell you what, Ryan [Wenger], he never stopped. I swear to you he just, he tried so hard. He just kept trying and trying."

Wenger and others finally got Wilson through the window and onto the roof. She was unconscious, and her mask was off.

She was taken to Maryland Shock Trauma Center, where she was pronounced dead.

Later, her classmate Cisneros told investigators: "I'm very sorry that it happened, and I wish I could have done something differently. But you'd have two funerals, probably."

annie.linskey@baltsun.com