A recent fire known as "Harrow Court" claimed two young Ffs.  This was a fire in a block of flats and when crews arrived they found they had no water save for a 9 litre extinguisher.  Despite being told not to enter, they did and brought out alive one male occupant.  They then re-entered to rfecover a woman but before they could exit a flash over occured and they became trapped in cables that fell from the ceiling. All three died. These cables had been fixed in plastic ducting but not by anything else. Hence as the ducting deformed the cables fell.

HARROW COURT NATIONAL RECOMMENDATION No.1
 
Further to your request for an update on a specific matter I respond as follows:
 
 
1.      National Fire Safety Recommendation No.1: Provision should be made to inform all relevant stakeholders including Local Authorities, Housing Associations and other FRSs of the potential dangers associated with the lack of adequate securing of cables in trunking, particularly any which were installed to the 1988 British Standard.
Action to date: Meetings held with ACO Graham Stag (CFOA FSE Regional Lead Officer), Cath Reynolds (DCLG Fire Research Dept.) and CFO Ian Cox (CFOA FSE National Lead).
Letter dated 22/03/07 sent to CFO Ian Cox for discussion/action at CFOA FSE national committee.
Letter dated 22/03/07 written to BSI technical committee responsible for BS 5839 explaining the importance of securing cables and requesting greater emphasis is placed upon this within relevant standards. Meeting held on 16/05/07 with Colin Todd, BSI Committee member. As a result of this meeting, Colin Todd sent an email to John Fisher (BSI FSH/12/1 secretary) recommending that the forthcoming amendment to BS 5839 has a suitable enhancement of text relating to fire alarm cable support. Draft amendment of sub clause 26.1, 26.2(f) and 46.2(b)(5) was recommended for consideration by FSH 12/1 committee.
 
As a result of this work, BS 5839-1 has had amendments made on 31/03/08:
 
The current and latest edition of the fire detection and alarm standard is
BS 5839-1: 2002+A2: 2008. The following clauses relate to the changes made as a result of the Harrow Court recommendations:
 
26.1(A2)Commentary: Unless cables are supported in such a manner that they remain supported for the duration similar to that for which the cable itself can survive a fire, early failure of the circuit might occur because of strain on terminations as a result of collapsing cables.
 
26.2 Recommendations, (f) Note 9 (A2): Experience has shown that collapse of cables, supported only by plastic cable trunking, can create a serious hazard to firefighters, who could become entangled in cables.
 
46.2(b)(5): Note 2 (A2): Serious shortcomings in cable support that could result in collapse of a significant length of cable in the event of fire should also be regarded as a major non-compliance.
 

This is the Loudoun County Department of Fire, Rescue, and Emergency Management Significant Injury Investigative Report for 43238 Meadowood Court. The Department is sharing the Report in an effort to reduce and prevent firefighter injuries and Line of Duty Deaths (LODDs) across the County, regionally, statewide, and nationally.
On May 25, 2008, fire and rescue personnel from Loudoun County responded to a structure fire at 43238 Meadowood Court in Leesburg, Virginia. During the course of the incident, seven responders were injured. Of those injured, four firefighters received significant burn injuries, two firefighters sustained orthopedic injuries, and one EMS provider was treated for minor respiratory distress. To date, five of the injured personnel have returned to duty. Two firefighters continue to recover from their injuries, including one who was severely burned.
Given the severity of the injuries and magnitude of the event, an independent Investigative Team was assembled to review the incident. The Team was comprised of four Loudoun County personnel, three external members from area fire departments, and two resource/support personnel. The Team was tasked with reviewing “the events leading up to the incident, the incident operation(s), the firefighter MAYDAY(s), and incident mitigation.”
For three months, the Team thoroughly examined the events surrounding the Meadowood Court fire incident and identified the factors associated with the injury of personnel. The Report contains the results of the Investigative Team’s comprehensive review and analysis. All of the information presented is factual and was validated prior to inclusion in the document. Recommendations are provided throughout the Report in an effort to provide a framework to enhance and improve the Loudoun County Fire and Rescue System, as well as protect responder and citizen safety.

The report on OSU Fire Service Training's fatality is below

The United States Fire Administration (USFA) worked with the International Association of Fire Fighters (IAFF) in a project to enhance risk management capability of local fire departments. The goal of this initiative was to enable fire departments to design effective risk management programs based on community hazards and service commitment, enhance firefighter safety, and provide tools for continual evaluation of emergency response systems. The ability of fire departments to design an acceptable level of resource deployment based on risks and service commitment and to provide tools for continual evaluation of emergency response systems is crucial in the enhancement of firefighter operational safety and occupational health. The adequate placement of firefighting resources also supports the reduction in civilian fire fatalities. This study examined critical issues related to adequate resource deployment tying them to the development of effective risk management programs. Geographic information systems (GIS) computer simulation was used to develop staffing and deployment models that will be recommended for department of various sizes serving different populations in varying geographic regions. The first phase of the analyzed retrospective data from the years 2000-2005 to identify and quantify the major factors that contribute to fire fighter line-of-duty death (LODD) in the United States. The identified contributing factors were examined for frequency of occurrence and clustering with other factors. The results are to be used to develop risk management programs for fire departments. This first phase used data compiled from six years of verified firefighter on-duty fatalities from four reputable industry sources. Sources included the United States Fire Administration (USFA) as well as the National Fire Protection Association (NFPA), the National Institute for Occupational Safety and Health (NIOSH), and the International Association of Fire Fighters (IAFF). For each LODD, factors contributing to the death were recorded from Federal investigations and eyewitness reports. The contributing factors were then analyzed for frequency of occurrence and clustering with other factors. Contributing factor clusters identified include the following. Cluster #1 includes incident command, training, communications, standard operating procedures, and pre-incident planning. Cluster #2 includes vehicles, personal protective equipment, equipment failure, and human error. Cluster #3 includes private owned vehicle, accidents, and civilian error. Cluster #4 includes company staffing/crew size, standard operating guidelines and health/fitness/wellness. Clustering information is being used to develop risk management recommendations for local fire departments. From the first phase of this study, the following report, Contributing Factors to Firefighter Line of Duty Death in the United States was developed by the IAFF. This second phase of the study will also address effective risk management programs for the fire service as the same methodology will be used to assess firefighter on-duty injury. Data sources for phase II are being sought. Click the story title to download the report.

As you are aware, Technician (Firefighter) Kyle Wilson of the Prince William County (VA) Department of Fire & Rescue was killed in the Line of Duty when he heroically gave his life at a single family dwelling fire on April 16, 2007. Below are links to all sections of the report including audio, video, fire modeling and related information. Don't BLOW THIS CHANCE to educate all of your members with this outstanding report provided by Fire Chief Kevin McGee & the Prince William Fire & Rescue Department... the audio, the video, the modeling ...all of it can make a significant difference to any and all Firefighters. For example, within the audio, you will hear the chilling radio transmissions of Firefighter Wilson advising that he was trapped, with his words: “Mayday, Mayday, Mayday, Tower 512 bucket, I’m trapped inside, I don’t know where I am, I’m somewhere in the stairwell, I need someone to come get me out!!” By the time firefighters were able to get to Firefighter Kyle Wilson it was too late. Prince William County Fire & Rescue is saving future lives by sharing their LODD Investigative report to honor Kyle, in an effort to reduce and prevent firefighter line of duty deaths at the local, region, state, and national levels. Technician Wilson joined the Prince William County Department of Fire and Rescue on January 23, 2006. Tragically, he died in the line of duty on April 16, 2007 while performing search and rescue operations at a house fire. On that day, Technician Wilson was part of the firefighter staffing on Tower 512 which responded to the house fire that was dispatched at 0603 hours. The Prince William County area was under a high wind advisory as a nor’eastern storm moved through the area. Sustained winds of 25 mph with gusts up to 48 mph were prevalent in the area at the time of the fire dispatch to Marsh Overlook Drive. Initial arriving units reported heavy fire on the exterior of two sides of the single family house and crews had every reason to believe that occupants were still inside the house sleeping because of the early morning hour. A search of the upstairs bedroom commenced for the possible victims. A rapid and catastrophic change of fire and smoke conditions occurred in the interior of the house within minutes of Tower 512’s crew entering the structure. Technician Wilson became trapped and was unable to locate an immediate exit out of the hostile environment. Mayday radio transmissions were made by crews and by Technician Kyle Wilson of the life-threatening situation. Valiant, heroic and repeated rescue attempts to locate and remove Technician Wilson were made by the firefighting crews during extreme fire, heat and smoke conditions. Firefighters were forced from the structure as the house began to collapse on them and intense fire, heat and smoke conditions developed. Technician Wilson succumbed to the fire and the cause of death was reported by the medical examiner to be thermal and inhalation injuries. Virginia Occupational Safety and Health (VOSH) and the National Institute for Occupational Safety and Health (NIOSH) performed independent investigations of the Marsh Overlook fire incident. VOSH’s investigation is complete and closed with no citations or corrective orders being issued. NIOSH’s investigation results are still pending. The major factors in the line of duty death of Technician I Wilson were determined to be: • The initial arriving fire suppression force size. • The size up of fire development and spread. • The impact of high winds on fire development and spread. • The large structure size and lightweight construction and materials. • The rapid intervention and firefighter rescue efforts. • The incident control and management. The weather conditions and construction features resulted in the rapid and catastrophic progression of fire conditions. The organizational preparation and response to incidents of this nature can and are recommended to be improved with the majority of recommendations focused on staffing, training, procedures, and communications. The below links will provide you with significant amounts of information so that our own members can listen, read, learn and study how this happened-and what your FD can do so history is not repeated. PW LODD Report Fact Sheet- http://www.pwcgov.org/vpresentations/fnr/LODDReportFactSheet.pdf PW LODD Investigative Report- http://www.pwcgov.org/vpresentations/fnr/LODDReport.pdf PW LODD Report Presentation- http://www.pwcgov.org/vpresentations/fnr/LODDReportPresentation.pdf PW LODD Report Basic House Model- http://www.pwcgov.org/vpresentations/fnr/LODDReportBasicHouseModelSection1.wmv PW LODD Report Audio and Video- http://www.firecamera.com/index.cfm?Section=4&pagenum=259&titles=0 LODD Death Report Fire Model- http://www.pwcgov.org/vpresentations/fnr/LODDReportFireModelSection3.wmv All of the above links are from: http://www.pwcgov.org/default.aspx?topic=040026000110004566 We, once again have another Fire Department that is stepping up and providing the facts so we can learn...we have no option but to take full advantage of it. Take care-BE CAREFUL. PLEASE DON'T BLOW THIS CHANCE TO EDUCATE ALL YOUR MEMBERS.

Washington, DC, January 30, 2008 - On the first anniversary of a fatal propane explosion at a West Virginia convenience store, the U.S. Chemical Safety Board (CSB) today announced that testing has been completed on a key propane valve and outlined other issues that will be examined in the final investigation report. The accident on January 30, 2007, at the Little General Store in Ghent killed four people and injured six others when propane gas was suddenly released through a liquid withdrawal valve during a changeover between two propane tanks. A volunteer firefighter and an EMT who responded to reports of the leak were among those killed when the propane cloud ignited, destroying the store. The CSB has examined and tested the valve and found that on the day of the accident the valve was stuck in an open position. Investigators are continuing their examination of regulatory and code compliance as well as West Virginia's gas safety practices. 'This investigation is about more than figuring out what went wrong with the valve, it is about getting to the root cause of this accident and preventing a similar incident from occurring,' said CSB Lead Investigator Jeffrey Wanko, P.E., C.S.P. On the day of the accident, a technician working for Appalachian Heating (a company that had a business arrangement with Thompson Gas) was preparing to switch propane service to Thompson Gas from a previous propane vendor, Ferrellgas. As part of the process, the technician was to transfer propane from the Ferrellgas tank to the newly installed one. The Ferrellgas tank was located against the store's outside rear wall. The Thompson Gas tank was located about ten feet away. While preparing for the transfer, propane began flowing out of the liquid withdrawal valve on the Ferrellgas tank located next to the store. Lead Investigator Jeffrey Wanko said, 'The placement of the tank facilitated gas entering the building and the ignition of the flammable gas and contributed to the high number of injuries and fatalities.' The tank did not comply with National Fire Protection Association or Occupation Safety and Health Administration siting specifications which require that a propane tank be placed 10 feet from the building. Investigators believe personnel involved in the installation of a new propane tank at the store removed a metal screw cap on the liquid withdrawal valve, in preparation for removing propane from the old tank. The malfunctioning withdrawal valve leaked, resulting in an uncontrollable release. The technician was unable to stop the flow and placed a 9-1-1 emergency call at 10:40 a.m. CSB investigators found that in common with many states, West Virginia does not require technicians who install propane tanks to receive any formal training. The CSB is also examining the practices of 9-1-1 emergency call centers to provide basic emergency instructions for flammable gas incidents such as proper evacuation procedures. In this instance, Little General employees stayed in the building during the gas release. The CSB's final report and safety recommendations are expected to be complete in mid-2008. The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

This is a the report from the Santa Clara County Fire Department on the death of Fire Captain Mark McCormack, who was electricuted on a structure fire in 2005. On February 13, 2005 at 02:20, the Santa Clara County Fire Department (CNT) responded to a reported large single-family residential structure fire at 15700 Blossom Hill Road in Los Gatos, California. The following resources were committed to the incident. From CNT: 6 engines, 1 haz-mat, 1 truck, 1 rescue, 2 Battalion Chiefs, and 9 volunteers. From Saratoga Fire District (SAR): 1 engine, 1 rescue and an acting Battalion Chief. Mutual aid from the San Jose Fire Department (SJS): 3 engines, 2 trucks, and a Battalion Chief. From the County Overhead Support Team: 4 members. The fire consumed approximately 80% of the main fire building. During the event, CNT Engine 10 Fire Captain Mark McCormack lost his life when he came into contact with a downed 12kv (12,000 volt) power line that had burned through early in the incident. Following contact with the wire, he was immediately extricated from the area, received advanced life support, and was transported to Good Samaritan Hospital.

This is the departmental report of findings from the fatality accident that occurred August 6, 2005 with a Line of Duty Death of the Riverside County, Calif. Fire Department Apparatus Crash-Ejection of Firefighter (download)

(FFCC.com notes: For ALL NIOSH Firefighter Fatality reports, go to: http://www.cdc.gov/niosh/firehome.html ) June 1, 2005-NIOSH has released a report on the death of Thomas Brick, a New York City firefighter, who died in a warehouse fire in December 2003. The fire broke out on December 16 at a furniture and mattress warehouse in upper Manhattan. While entering the building, the crew encountered heavy smoke and no visibility in a stairwell. Brick and his crew continued to the second floor, seeking the origin of the fire. As a result of a recent delivery, inventory was stacked as high as the ceiling in some places. Brick became separated from his crew during the search. An officer ordered the team to leave due to high heat conditions and an announcement was made that a member was missing. But outside, Brick was accidentally accounted for and the emergency message was cancelled. When a final check discovered that Brick was still missing, colleagues went to try and rescue him. He was found face down with the face piece of his respirator off. Brick was flown to a hospital where he was pronounced dead. NIOSH recommends that to reduce the chance of similar incidents, fire departments should: Ensure that pre-incident commanders conduct a risk-versus-gain analysis before committing firefighters to an interior operation, and continue the analysis during the operation Use guidelines and ropes securely attached to permanent objects and/or a bright, narrow-beamed light at all entries to a structure to guide firefighters during emergency exits. Instruct firefighters in the hazards of exposure to carbon monoxide and warn them never to remove their face pieces in areas in which these hazards are likely to exist. Establish a system to facilitate the reporting of unsafe conditions or code violations observed by firefighters during operations.

By Avis Thomas-Lester Washington Post Staff Writer Sunday, May 1, 2005; C01 The fire scene in Oxon Hill was already chaotic when word came that a career firefighter, Lt. Elmer "Dino" Mahaffey, was trapped on the second floor of the brick rowhouse. Already, key information hadn't been shared with firefighters in the house. And the volunteer chief running the scene hadn't set up a rescue team or Mayday procedures for the career and volunteer crews there. Once firefighters learned about Mahaffey, some left their posts without permission, or "freelanced," churning up more turmoil as black smoke billowed and the fire spread, according to a report released last month on the Feb. 22, 2004, blaze. The highly critical report, prepared by top officials of the Prince George's County Fire Department, draws no conclusion on whether the chaos contributed to Mahaffey's injuries. He spent 26 days in intensive care after his throat and lungs were severely burned and has not returned to duty. But it does point to repeated mistakes on the day of the fire and deeper flaws in the department's training and certification process. And it raises broader questions about the working relationship between career and volunteer firefighters in a county that has morphed from rural to urban in the past 25 years. Prince George's has about 1,500 fire service personnel -- 600 career firefighters and paramedics and 900 volunteers, officials said, making it one of the largest hybrid fire departments in the country. Many Washington suburbs operate similar agencies. In Prince George's, volunteer units own 71 of the 93 fire engines and 32 of the 44 fire stations, giving them considerable influence in the department. At times, a volunteer chief can wield authority over career personnel and serve as "incident commander" at a scene. Some career firefighters bristle at this arrangement, suggesting that they are held to higher standards for training and hiring. For them, the turbulent scene described in the Oxon Hill fire report and the criticism the report directs at volunteer commander Darryl E. Lowery validate their concerns. Lowery disputed the report's findings, saying that the scene was no different from others he has run and that he is being used as a scapegoat by the department's career leaders. "This is their way of shifting the blame from themselves to the volunteer firefighters," he said. "This is not the first time that something has gone wrong in incident command, but as a volunteer, you are going to get more criticism than the career side." The report's authors recommended that the department "increase the minimum standards to be an incident commander" for volunteer and career firefighters alike. They also suggested that incident commanders be designated by the fire chief and held "accountable and responsible for their action or inactions." Fire Chief Lawrence H. Sedgwick Jr., who was involved in the investigation before being promoted last year to lead the department, said no one has been disciplined as a result of the probe. But the department has changed its procedures, requiring more of the most senior career firefighters to be on duty 24 hours a day. "What we've done with the report is use it as a training tool," Sedgwick said. For Mahaffey, 35, the implications are personal. He remains at home recuperating from his injuries and is scheduled to have another operation May 20. He worries that he will be forced to retire. He said he has not read the report but believes that poor supervision and substandard equipment -- the department has none of the thermal imaging devices that could have sped the search of the second floor-- contributed to his injury. "There is a lot of freelancing and not a lot of discipline in the firefighters that the department as a whole has known about, but they chose not to correct it," said Mahaffey, his words broken by fits of coughing. "Was it Lowery's fault? Yes, because he could have taken it upon himself to do the right thing. But it wasn't all his fault, because it's just how the department operates." Lowery's role at the Oxon Hill fire was to coordinate the various career and volunteer crews there. Mahaffey's career unit, Quint 21, was charged with search and rescue operations. Within a few minutes on the scene, Lowery notified dispatch: "We have the occupants of the residence out of the house," the report says. But that information was not shared with Mahaffey and his team inside the house. Nor were there any radio transmissions alerting firefighters that flames had moved from the basement to the first floor, the report states. Mahaffey and another firefighter were on the second floor when they noticed the heat. "We go down the hallway to go down the steps, and I see fire on the steps," he recalled. Mahaffey issued a Mayday call on his radio and, receiving no response, opened a window and began waving his arms at firefighters on the ground. Flames burst from a first-floor window below, knocking him back inside. His breathing apparatus became dislodged, leaving him to inhale gases, smoke and heated air, the report says. Career and volunteer firefighters ran from other parts of the house to rescue him, bringing him down a ladder from the window. The report commends the rescuers but criticizes some for leaving their posts without permission. It also faults Lowery, saying he failed to initiate rescue procedures, to ensure that firefighters continued to suppress the fire during the rescue and to adequately supervise the fire scene. The report does not recommend specific disciplinary measures against Lowery or any other firefighters. Earlier this year, Lowery was placed on "non-operational status" in Prince George's after he was charged with misdemeanor theft for allegedly stealing gasoline for his car from county gas pumps, court documents show. On Monday in Prince George's District Court, Lowery agreed to pay $18 to cover the price of the gas, and the county state's attorney declined to prosecute. Lowery, who works as a firefighter for the National Institutes of Health, said in an interview that the historic conflict between career and volunteer firefighters had fueled an effort to falsely accuse and discredit him. "I have worked to save lots of people," he said. Lowery remains on non-operational status pending an administrative review of the gas incident by the county's Public Safety Office. Public Safety Director Vernon Herron said he plans to review policies on background checks, training and performance standards for career and volunteer firefighters. Currently, volunteer chiefs are voted in by their respective stations after meeting certain requirements. Career chief positions are typically filled with the most experienced personnel. Career firefighters are required to take random drug tests, but volunteers are tested only after an automobile crash or other major emergency, officials said. Of the 1.1 million firefighters nationally, about 300,000 are career and 800,000 are volunteers, according to the National Fire Protection Association in Quincy, Mass. More than 80 percent of the nation's 26,000 fire departments are volunteer operations, including those in Southern Maryland. Montgomery, Anne Arundel, Howard, Arlington, Fairfax and Prince William counties operate combination departments; the District has only career firefighters.

October 18, 2003 Numerous government workers trapped in a burning downtown office tower dialed 911 as they tried to make their way through smoke-filled staircases and hallways, officials said. Hours later, 13 were found unconscious amid the smoke, six of them dead. The bodies weren't discovered until after the fire was brought under control Friday evening and firefighters started searching the 35-story Cook County administration building floor by floor, authorities said. Then Chicago Fire Commissioner James Joyce said the people who died appeared to be from one stairwell around the 22nd floor, 10 stories above the source of the fire. Most of the injured were found in the stairways and hallways from the 16th to the 22nd floors, he said. "Searching for all those people, at the same time fighting the fire, is more complicated than it looks from the outside," Joyce said. CLICK HERE FOR THE REPORT: Chicago Hi-Rise "Cook County Office Building" Study

These photos show the Class 3 Engine that was involved in this serious accident. CLICK HERE for the entire report summary with additional details.

These reports were recently added to the NIOSH website. Take a moment and check them out, review them and use them in your FIREFIGHTER TRAINING Program: South Dakota: Firefighter killed during airbag training: http://www.cdc.gov/niosh/face200334.html Memphis Tennessee: 2 Firefighters killed by roof collapse: http://www.cdc.gov/niosh/face200318.html Pennsylvania: Chimney collapse kills firefighter: http://www.cdc.gov/niosh/face200304.html

Firefighters are more likely to die traveling to or from a fire than fighting one, and motor vehicles pose a greater hazard than flames, according to new data from the National Fire Protection Association (NFPA). All told, 105 firefighters died while on duty in 2003, up from 97 in 2002, primarily because of last year's bad wildland-fire season. The entire report is free, and available at this link: http://www.nfpa.org/PressRoom/NewsReleases/FFDeaths/ffdeaths.asp?cookie%5Ftest=1

Report: Fatal fire training drill an error-filled fiasco "...It was a mess built on long-standing problems within the fire department," said Fire Rescue Capt. Jerome Byrd Sr. "You have to understand the egos and the inner workings of the department to comprehend it..." A report issued by Miami-Dade safety officials documents a series of errors that led to the death of a new recruit in a simulator at Port Everglades. BY KRISTEN BOLT AND MARISSA SILVERA Miami Herald-Thu, Jul. 08, 2004 Wayne Mitchell died ten feet away from safety. He spent his last moments wandering alone in a room he should never have entered, suffering heat exhaustion from a 1,000-degree inferno used by Miami-Dade Fire Rescue Department to train recruited firefighters. Mitchell's first live firefight on Aug. 8, 2003 was a tragic series of errors documented in a report released this week by the Miami-Dade County Office of Safety. The department refused to comment on the report, which highlights the department's failures to meet safety standards and seeks structural changes. The report did not recommend criminal or other legal action against anyone involved. But some fire-rescue officials did talk about the report on Wednesday. "Just about everything you could think of went wrong at the same time," said acting Battalion Chief Stan Hills, president of the fire-rescue union. "Any one of those factors could have been overcome, but the combination was deadly." "It was a mess built on long-standing problems within the fire department," said Fire Rescue Capt. Jerome Byrd Sr. "You have to understand the egos and the inner workings of the department to comprehend it." Byrd was one of three assigned training instructors in the fatal firefighting session at the Resolve Fire & Hazard Response Center, a private fire-training school at Port Everglades. Byrd found Mitchell's prone body on the second level of the steel passageway meant to imitate the hull of a ship. The other two instructors had already fled the simulator, complaining of heat exhaustion and malfunctioning equipment. Byrd said that they did not radio him to inform him of their departure. By the time Byrd and the session's other four recruits staggered out and realized someone was missing, it was too late. "They had a group of lives in their hands, and they let one of them go out of sheer negligence," said Mitchell's mother, Jeanne Wilcox. "Someone should be held accountable." "The recruit training department had a closed-door policy," said Byrd. 'They had an `I am God' mentality, and they shut everyone out." "I was complaining almost daily to the training bureau about their philosophy and methods," said Byrd, who had a decade of experience in recruit training before returning to fighting fires. With trainers in demand, however, he volunteered. "They said I was out [of recruit training], but that I could go to this last burn." The report said that the department made "a serious mistake" by excluding the Safety Office from reviewing and assessing the recruit training. Hills agreed. "The Safety Office needs to be someone who can walk into any office, and whose sole job is to target unsafe practices and equipment," he said. Hills said one-fourth of the workforce suffers injuries that cause them to lose at least one day of work every year. Had regulations been followed, for example, an ambulance and a Rapid Intervention Team should have been poised outside the facility. There was no safety plan for the exercise -- an exercise that the report, Byrd and Hills all agree was too complicated for recruits facing their first fire. Hills said the accident pointed up the importance of radios, which the union had been lobbying to get for training exercises. He said he had testified for several years about this need, which was finally filled last month through union contract negotiations. On the day of the fatal exercise, in violation of regulations, no one had walked Mitchell and the other recruits through the simulator before the fires were lit. Mitchell had never seen the structure before he glimpsed it through smoke that made visibility "poor" to "nonexistent" in some areas, according to the report. Complicating matters was a door that was mistakenly left open within the simulator. Mitchell walked through that door, losing precious time. The National Fire Protection Association, the Broward State Attorney's Office, the National Institute for Occupational Safety and Health, and the Fire Standards and Training Division of the state fire marshal are still investigating. LEGALLY REQUIRED PROCEDURES IGNORED According to the Miami-Dade Office of Safety Risk Management Division's investigation of Wayne Mitchell's death, the following items were not followed during the training exercise. The procedures are according to National Fire Protection Association standards, which are also state law: The training simulator was too advanced for a basic recruit to follow on the first time in a live exercise. The live fire training exercise plan was incomplete and included no safety plan. The incomplete training exercise plan was not reviewed by the Miami-Dade Fire Safety Officer. No designated safety officer was provided. Recruits were not given a walk-through of the simulator prior to the exercise. Two fires were burning inside the simulator and recruits were told to walk past one, leaving it behind them. No Rapid Intervention Team was provided for the live fire training exercise. The RIT consists of at least three Fire Rescue personnel with full protective gear to rescue individuals who may become incapacitated. No ambulance was provided for the live exercise. The training cadre had approached top staff and advised of serious issues relating to training philosophy, equipment safety and personnel. The department's safety officer had been ordered not to involve himself in recruit training and did not review the burn exercise plan.