DIVISION OF PUBLIC EMPLOYEE SAFETY AND HEALTH SAFETY AND HEALTH BUREAU INVESTIGATION NARRATIVE REPORTING Garden City DISTRICT: INVESTIGATION ESTABLISHMENT NAME AND SITE ADDRESS TYPE COMPLAINT | Inwood FD X| ACCIDENT. 188 Doughty Bivd PROGRAMMED _| Inwood, NY 11096 MONITORING FOLLOWUP DATE(S) OF INVESTIGATION: [INSPECTION NUMBER OTHER 32/29/14 1015648 SUMMARY An accident investigation was initiated by the NYS Department of Labor Public Employee Safety and Health (PESH) Bureau at the Inwood Fire District, 188 Doughty Boulevard, Inwood, on December 29" 2014. The investigation was conducted by Supervising Safety & Health Inspector Matthew Setteclucati in response to information received on December 24%, 2014 from Joseph Ruvolo, District Manager by phone and email, The purpose of the investigation was to evaluate the circumstances and events leading up to the interior firefighting accident during the response to a house fire at 787 Central Avenue, Woodmere, on December 19%, 2014, which resulted in the eventual death by complications from asphyxiation (near drowning) of Joseph Sanford, jr, employed by the Inwood Fire Department. Mr. Sanford died of his injuries on December 234, 2014, Opening conference Employees at this location are not represented by an employee union. An opening conference was conducted on December 29%, 2014. At this time credentials were presented, the PESH Act, and the scope of the inspection were explained to the Participants, Opening conference attendees were informed that the purpose of the investigation was to investigate the workplace fatality in accordance with NYS Labor Law Article Two Section 27a “Pwrbiic Employee Safety and Health Act" Present during the opening conference Joseph Ruvolo, District Manager, Inwood FD Gaetano Marino, 1 Assistant Chief, Inwood FD The following materials were explained to participants during the opening conference:SH 909 - PESH Act 12 NYCRR ~ Parts 801, 802, 803, 804, 805, and 820 SH 907 ~ Employer's Rights anc Responsibilities pamphlet P-906 - Employee's Rights and Responsibilities pamphlet Log and Summary of Injuries and lilnesses/record keeping information and forms (SH 900, SH 900.1, SH 900.2) P 206 - Consultation Assistance pamphlet SH 908 - PESH poster SH 918 - Penalty Information for Public Employers NYS Right to Know / Hazard Communication information 12 NYCRR Part 800.6 - Workplace Violence Prevention Program rule ‘These materials may be accessed at: ps//www labor.ny.gov/worker; prial htm otection/safetyhealth/inspector%20reference%20mat A “Public Employee Safety and Health Bureau inspection Reference Material” handout was distributed to participants. The following information was obtained from the employer. Personal Data - Victim Name: Joseph Sanford, Address: Date of Birth: 07/24/1971 Date of Death: 12/23/2014 @ 3:51 am Age: 43 Sex: male Job Title: Class A (interior) Firefighter Time in Position: 17 years Training for Job being performed at time of accident: (Nassau Co. Fire Service Academy): Essentials of Firefighting, 1997; SCBA Confidence, 1996; Officer Training, 2000; Department Operations Residential, 2005; Department Operations Commercial, 2005; Department Operations, 2009 Nature of Injury: Death by complications of near drowning, Investigation SEQUENCE OF EVENTS “3 "> s+ On December 19, 2014 at approximately 4:08 AM, Joseph Sanford, jr. was responding to a residential house fire as part of a mutual-aid ladder truck team that was performing search and rescue operations within the residence, when he was discovered unresponsive, submerged in water in the basement of the structure by a hose team from another department. A mayday was called and Mr. Sanford was removed from the structure and resuscitated, He was transported by ambulance to North Shore University Hospital and wasplaced in ICU, where he died of complications related to the incident on December 234, 2014 at approximately 3:51 PM. The following sequence of events has been pieced together from witness interviews with assistance from the Nassau County Fire Marshal's office: On the night of the incident, truck team 313 from Inwood Fire Department was dispatched by Nassau County PireCom and responded as mutual aid to the house fire at 787 Central Avenue, The fire structure was a 2-story residential house with a basement. The team consisted of chauffer Thomas j. Lynch and four interior firefighters: Phillip Johnson, acting Company Officer; Kenyatta Stevens, interior firefighter; Ramel Oliphant, interior firefighter; and Joseph Sanford Jr. (deceased), interior firefighter. Upon arrival at the scene, P. Johnson reported to the Incident Commander and then proceeded with his team of K. Stevens, R. Oliphant and J. Sanford, Jr. to the rear entrance of the building, The Inwood team did not submit accountability tags to the IC (tags are used to indicate who was entering the fire structure). As the team was entering the building through the back entrance, K. Stevens experienced an SCBA malfunction and returned to truck 313, where: Lynch was waiting and assisted him in replacing the defective pack. While K. Stevens was returning to the truck, P. Johnson, R. Oliphant and J. Sanford, Jr. entered the fire structure through the back entrance to the first floor. After initiating a right-hand search of the first floor, the team encountered fire emanating from the floor and wall of the 1-2 corner of the house and a pitched and partially collapsing floor. P. Johnson stated that he then backed everyone out to the back entrance of the house where R. Oliphant remained to assist a hose team from another department. P. Johnson then proceeded to the middle of the first floor where he encountered K. Stevens (who had returned to the house after replacing his pack) and several firefighters from Lawrence- Cedarhurst Fire Department near the top of the basement stairs. He and K. Stevens then Proceeded to search the second floor of the house. Neither man could account for the whereabouts of}. Sanford, Jr. at this time, As they made their way through the front entrance hallway to the second floor stairs, P. Johnson observed a hole in the floor that “did not look large enough for someone to fall through’. The hole was adjacent to the front entrance of the house but left enough room to pass close to the left wall. [Interviews of witnesses who observed the hole after the fire described its size as being roughly between 3-5 feet in diameter.} K. Stevens was following closely behind P. Johnson and did not observe the hole. The 2 firefighters then proceeded to complete a search of the second floor and had just reached the bottom of the stairs back to the first floor when they heard a mayday call come over the adid. ‘They traveled the short distance through the hall to the basement, where they encountered several firefighters from another department attempting to extricate a downed firefighter (J. Sanford, Jr). P. Johnson stated that Mr. Sanford was face-down and unresponsive in approximately 12-18 inches of water near the bottom of the basement stairs. P. Johnson and K. Stevens then assisted several other firefighters in removing J. Sanford from the basement and out of the house. P. Johnson stated that J. Sanford was wearing full bunker gear, including a helmet, gloves and SCBA mask when he was foundJ. Sanford was successfully resuscitated and transported by ambulance to North Shore University Hospital where he was admitted to the Intensive Care Unit in critical condition. Mr. Johnson later died at the hospital on December 23%, 2014 at approximately 3:51 PM, The official cause of death was acute anoxic encephalopathy resulting from the near- drowning incident None of the firefighters from Inwood truck 313 could reliably account for Mr, Sanford’s whereabouts from the time shortly after the initial entry until his discovery in the basement. The Inwood FD 2 Assistant Chief stated that he arrived on scene shortly after the team entered the fire, He stated that when he questioned the incident commander as to the Inwood team’s whereabouts, the incident commander indicated that he believed the Inwood team to bea RIT (Rapid intervention) team and thought they were waiting outside the structure on rescue standby Witness interviews An interview was conducted with Joseph Ruyolo, District Manager, Inwood Fire District, at 188 Doughty Blvd. on December 29", 2014. The witness was asked about the events leading up to, including, and following the accident. An interview was conducted with Gaetano Marino, then First Assistant Chief, Inwood Fire Department, at 188 Doughty Blvd. on December 25, 2014. The witness was asked about the events leading up to, including, and following the accident. An interview was conducted with Thomas Lynch, Class B (exterior) firefighter, Inwood Fire Department, at 188 Doughty Bivd, on February 26%, 2015. The witness was asked about the events leading up to, including, and following the accident. An interview was conducted with Phillip johnson, then acting Company Officer, Inwood Fire Department, at 188 Doughty Bivd, on February 26t, 2015, The witness was asked about the events leading up to, including, and following the accident. An interview was conducted with Dominic Andreno Il, then Second Assistant Chief, Inwood Fire Department, at 188 Doughty Blvd, on February 26t, 2015. The witness was asked about the events leading up to, including, and following the accident. An interview was conducted with Ramel Oliphant, Class A (interior) firefighter, Inwood Fire Department, at 188 Doughty Blvd. on March 18, 2015, The witness was asked about the events leading up to, including, and following the accident. An interview was conducted with Kenyatta Stevens, Class A (interior) firefighter, Inwood Fire Department, at 188 Doughty Blvd. on March 18%, 2015, The witness was asked about the events leading up to, including, and following the accident.Safety/Health Standard Evaluation Employee Training: No records of required annual training within the last 12 months for Respiratory Protection or quarterly In-service Training (Firefighting) for the victim. Mr. Sanford left the Department for approximately six months and rejoined several months prior to the incident. An attempt was made by Inwood FD to acquire records from the other department but none were available Personal Protective Equipment: According to witness statements, the victim was found in full interior firefighting gear, including: bunker pants, bunker coat, gloves, boots, helmet/hood, and SCBA. Respiratory Protection Program: ‘The Department has a compliant Respiratory Protection Program but does not have up-to-date annual training as noted above. Additionally, witness interviews indicated that the victim was not in “constant visual or voice contact" with other firefighters in the IDLH atmosphere for the majority of the interior operation, Violations to be issued as result of accident investigation: Standard: 29 CFR 1910.134(g)(3)(li) Employees entering an IDLH atmosphere must remain in constant visual, voice or signal line contact with those outside the IDLH atmosphere. Conditions observed: According to witness interviews, Incident Command was not made aware that the Inwood Fire Department truck company (including Mr. Sanford) had entered the fire structure, The IC had indicated to others that he thought the Inwood team was standing by as the rescue team, Standard: 29 CFR 1910.134(g)(4)(i) Incerior firefighters must remain in constant visual or voice contact with one another at all times during interior firefighting operations. Conditions observed: When questioned by the inspector, Inwood FD members present at the time of the accident had conflicting accounts of Mr. Sanford's whereabouts after the initial entry into the fire structure, and none could account for his whereabouts for several minutes prior to the mayday call. No attempt was made by the fire team to contact Mr. Sanford during this period, nor was Mr. Sanford assigned a specific partner or task. Standard: 29 CFR 1910.134(1)(2) Interior firefighters wearing SCBA respirators must be fit tested at least annually. =e + Conditions observed: The District could not provide records of an annual SCBA fit test for Mr. Sanford when requested during the opening conference on December 29%, 2014, and again on February 26%, 2015. Fit test records were provided to the inspector by the Department Surgeon during the closing conference on July 3*4, 2015. Due to the untimeliness of the document, the violation will stand but will be considered abated, Standard: 29 CFR 1910.134(k)(5) Respiratory protection training must be performed at least annuallyConditions observed: Training records and employer interviews indicated that Mr. Sanford had not completed respiratory protection training within the last 12 months, Standard: 29 CFR 1910.156(c)(2)/nterior firefighters must be trained at least quarterly, Conditions observed: Training records and employer interviews indicated that Mr. Sanford had not received in-service training on firefighting related topics within the last 3 months. Exit Conference An exit conference was conducted on December 29", 2014. Present during the exit conference: Joseph Ruvolo, District Manager, Inwood FD Gaetano Marino, 1* Assistant Chief, Inwood FD All parties were informed that the investigator's report and proposed violations, ifany were subject to review and approval by the Director, NYSDOL Division of Safety and Health, A closing conference would be conducted after completion of the review and approval process. Closing Conference A closing conference was conducted on July 3°, 2015. Present during the closing conference: George Miller, Commissioner Joseph Ruvolo, District Manager Gaetano Marino, Chief of Department Dr. Jorge Gardyn, District Surgeon Frank Parisi, Department Safety Officer Jaqueline Sanford, wife of victim The following materials were distributed and explained to participants during the closing conference in addition to observations made during the walkaround portion of the investigation, DOSH 904 - Closing Conference Pamphlet Proposed violations, abatemiént periods, and reasonable and adequate.abatement methods were also discussed, ORDERS ISSUED: | CSHONAME(TYPED) DATE X [YES Matthew Setteducati PREPARED. NO st 77/AS DOSH 914 (12-09)