The release of a damning investigative report into a January fire that claimed the lives of three Baltimore firefighters has led to the resignation of Baltimore Fire Chief Niles Ford.
The 182-page report, compiled by a panel that included emergency services officials from Prince George’s and Howard counties, Washington, D.C., and Baltimore, looked at the city’s responsibility surrounding the Jan. 24 fire in the 200 block of S. Stricker St. that was one of the deadliest for first responders in the city’s history.
Lt. Paul Butrim, Lt. Kelsey Sadler and EMT/firefighter Kenny Lacayo were killed and firefighter/EMT John McMaster seriously injured after a vacant home partially collapsed as they attempted to battle a blaze from inside.
The investigation found:
- the city lacked policies on vacant buildings at the time of the fire and failed to fully implement those proposed more than a decade ago;
- a battalion chief on scene was overloaded with duties and missed critical information on busy radio channels;
- and an early assessment of the fire missed key factors, including the building’s lengthy vacancy, damage from a previous fire and exposure to the elements.
“The absence of critical building information to responding units and the lack of a visual cue on the building was detrimental to the outcome of this fire,” the report states.
Mayor Brandon Scott said in an interview Friday with The Baltimore Sun that several items noted in the report have been ongoing problems for the department during Ford’s tenure.
“There’s some stuff that remains which I just can’t accept,” said Scott, who did not elaborate. “This is about us moving forward and turning the page.”
Ford, who has served as Baltimore’s fire chief since 2014, resigned effective immediately, city officials said. The chief announced the move to staff midday Friday. He could not be reached for comment.
The report also found, among many other things, that a “sense of rivalry and competitive culture” in the city’s fire department is a pervasive problem. The authors stopped short of blaming that culture for the deaths of the three firefighters but warned of its danger.
“The satisfaction of arriving first to the scene of a fire has a rewarding effect on the members,” the report states. “Currently, many of the personnel have described the competition as reaching a point of distraction from the focus of the important tasks presented at a fire and the importance of good decision making.
“Pride and dedication are the cornerstone of a successful unit; however, it is the responsibility of the unit’s officer to control the competition and rivalry,” the report stated. “The importance of a strong incident assessment and team approach cannot be neglected.”
Members of Engine 14 were the first to arrive at the Stricker Street fire in response to a 5:50 a.m. call. Sadler, who was promoted posthumously from acting lieutenant to lieutenant, was in command of the scene until a battalion chief arrived, according to a report from the Maryland Occupational Safety and Health division. She and her crew ran into the house, along with Butrim and two other members of Engine 36. They doused flames on the first floor before the collapse.
The report noted there were signs of a previous fire and structural instability when firefighters arrived, yet they used an “interior attack” despite those conditions, the report said.
The investigation found there was no policy in effect at the time of the Stricker Street fire to notify firefighters of buildings that were vacant and unsafe. The report recommended reinstating Code X-Ray, a city program begun in 2010 to mark dangerous vacant buildings with “X” placards. While the program was never formally ended, use of the placards was halted by 2012 amid complaints from residents and community leaders that the signs were tarnishing the reputations of certain communities.
The city restarted the program in October, ahead of the report’s release, placing signs on the first of more than 500 vacant homes that have been identified as unsafe based on the stability of the building’s structure and roof, previous fire damage and signs of a collapse.
The report also recommends the fire department develop a risk management plan that includes a proper “size-up” of a fire scene prior to interior firefighting on all sides of a home. Specific to vacant buildings, the report suggests a standard operating procedure for entry and training.
The investigation found a battalion chief on the scene was overwhelmed by too many responsibilities, compromising the safety of firefighters. The chief, who was unnamed, told investigators he knew he was missing radio transmissions and was struggling to organize the response.
The report found responding firefighters didn’t use “talk groups” to relieve congestion on the primary radio channel, causing the incident commander to “completely miss or mis-prioritize critical information.”
Investigators recommend following a national fire standard of dedicating an incident command technician to assist each battalion chief. The report notes that city fire officials have added a sixth engine to respond to fire calls in the incident’s wake, but the additional personnel do not address the “root problems” regarding incident command.
“It is not practical or efficient to obtain a trained Incident Command Technician after arrival at an incident scene,” states the report, quoting from National Fire Academy research. “On-scene firefighters are untrained and more importantly inexperienced. Their involvement in tasks such as accountability, while well-intentioned, cannot always be trusted.”
Josh Fannon, president of the city’s fire officers union, said the city currently has six fire battalion chiefs per shift and there are four shifts. Currently, only one has the assistance of an incident command technician.
Scott pledged to create an accountability program to implement the report’s recommendations.
Fannon said implementation of the plan “will lead to greater accountability and safety for all of our members.”
The investigation is the latest response to the deaths of Butrim, Sadler and Lacayo, which led almost immediately to calls for the city to better mark and record the locations of hazardous vacant buildings. The New Southwest/Mount Clare neighborhood where the fire occurred has the sixth most vacant houses in Baltimore, a city with about 16,000 vacants.
A Baltimore Sun investigation showed vacant homes in Baltimore burn at twice the national rate, but gaps in record-keeping have limited what firefighters know before proceeding inside.
The report echoed these concerns, adding that the city’s slapdash approach to labeling fires and inconsistent data collection methods often led to the number of fires being underreported or misclassified, hampering reform efforts.
The Evening Sun
Ford has served under several administrations but was originally the choice of Mayor Stephanie Rawlings-Blake. After beginning his career as a dispatcher in Alabama, he served as a paramedic and firefighter. He was deputy chief in Fulton County, Georgia, and fire chief of Lincoln, Nebraska, before coming to Baltimore.
Ford also served a two-year stint as city manager of Chamblee, Georgia, a town of about 10,000 people. Chamblee City Council issued a preliminary resolution saying its members had lost confidence in Ford and began proceedings to terminate him. Ford resigned.
Scott, then a member of Baltimore City Council, opposed Ford’s hiring in 2014 and questioned why an internal candidate was not selected. The mayor said Friday that Ford’s departure has nothing to do with past disagreements.
“This isn’t anything about how many umpteen years ago,” he said. “This is about this moment in the city and how we can move forward as a department.”
Ford was paid $229,000 in fiscal year 2021, the most recently available year in the city’s salary database.
A group of city fire commanders, including Assistant Chief Charles Svehla, Assistant Chief Chris Caisse and Assistant Chief Dante Stewart, will rotate as acting chief on an interim basis, city officials said.
Baltimore Sun reporter Lia Russell contributed to this article.
This article has been updated to correct the date of the fire.