DIVISION OF SAFETY

SAFETY
OPERATING
BATTALION
INVESTIGATIVE REPORT
FATAL FIRE AT
79 WORTH STREET, MANHATTAN
June 5, 1994 Case No. 35/94
VOWME I
SUMMARY
On June 5th, 1994 at the 1819 hours, the New York city
Fire Department Bureau of Communications for the borough
of Manhattan received a E.R.S. ( Emergency Reporting
system) alarm from an unidentified male caller, reporting
a fire in the lobby of a commercial building at 79 Worth
st.
Units of the P.D.N.Y. were dispatched to the location
and found multiple fires within the building. On the first
floor main entrance hall there was two separate fires, one
was in some rubbish and the other was in some clothing and
other materials. These two separate fires were
extinguished by the operating sprinkler system and the
first arriving Fire Department members.
The fire fighting forces then discovered several fires
on the fourth floor, which required the use of two hand
lines and the of the sprinkler system to
extinguish those flres. During the process of taking up
from the fourth floor , fire was discovered in the
sub-cellar area of the commercial building. It was in the
course of the extinguishment of the sub-cellar fire, that
Lieutenant George W. Lener in command of Ladder Co. 6
sustained fatal injuries.
Lieutenant Lener was found unconscious, floating face
down in approximately eleven inches of water, in the rear
of the sub-cellar. He was removed from the fire building
to the rear yard, where cardiopulmonary resuscitation was
initiated. He was transported to Downtown Beekman hospital
by Emergency Medical Service personnel where he was
initially treated. Lieutenant Lener was later transferred
to Jacobi Hospital in the Bronx where he was treated
within the hyperbaric chamber. He remained at Jacobi
hospital life sustaining treatment until he
succumbed to hlS fatal injuries on July 20, 1994.
Page 1
FINDINGS:
On the evening of June 5th, 1994 at 1819 hours a fire
in the lobby of 79 Worth st. Manhattan was reported to the
Manhattan Bureau of Communications office by an Emergency
Reporting System caller. units were dispatched to the
scene and the first arriving unit, Ladder Co. 8
transmitted a 10-75 for the fire.
The unit forced entry and discovered that they had two
separate fires on the first floor of the main hallway. A
few sprinkler heads had fused and they contained the fire.
A line from Engine Co. 7 was stretched to the entrance
door, but not used. The Officer of Ladder Co. B sent one
of his members to the cellar to shut down the sprinkler
system. The member proceeded to the sprinkler control room
located in the cellar and shut down the water supply to
the system.
As members were checking the upper floors of the
building, they discovered a fire on the fourth floor.
Civilians within the building, almost simultaneously,
notified other members that there was a fire on the fourth
floor. The fire on the fourth floor required the
stretching of two hand lines, and the charging of the
sprinkler system by Eng. Co. 7 to contain and extinguish
the fire. All Hands was transmitted, and additional units
were special called to the scene.
The fire was knocked down and the sprinkler line being
supplied by Engine Co. 7, was shut down. The upper floors
were searched and examined for extension, and the fire on
the fourth floors was extinguished. The fire was now in
the overhauling stage and under control. Units were
starting to take up the lines and the rest of the building
was being checked.
Two members from Ladder Co. 8 descended to the cellar
-s,stem. shut down two
other valves on the system and were eXlting the cellar,
when ther noticed some smoke coming from the slib-cellar.
They notlfied Division 1 and the officer of Ladder Co. 10
of the conditions in the sub-cellar. Ladder 10 was
directed to search the sub-cellar for fire. Rescue Co. 1
was directed to return to the building and Ladder Co. 6
was special called to the fire.
The officer of Ladder 10 and his unit descend to the
sub-cellar stretching a search line from the first floor
down. There was heavy smoke and no heat in the slib-cellar
area. Using their search line they feel their way around
the front area of the cellar when some of the members low
air warning devices sound. The officer exits the
sub-cellar area with his unit to change cylinders.
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Rescue Co. 1 and Ladder Co. 6 arrive at the scene
almost together. The Rescue unit is assigned to locate the
fire in the sub-cellar and Ladder 6 is ordered to stand
fast. The Rescue Co., with a search line and their thermal
imaging camera, descend to the sub-cellar, and begin to
search for the fire. The Division orders the sprinkler
system to be recharged and an additional line hooked up to
it. Battalion 1 is also in the cellar along with the
officer of Engine Co. 10.
Rescue Co.1 locates the fire in the rear of the
sub-cellar in the sub-cellar ceiling and the Officer
notifies the Division. Division 1 transmits a second alarm
for the fire and orders Ladder 6 to the sub-cellar, to
work with Rescue 1 and Battalion 1. The sprinklers are
operating through some 29 fused heads in the sub-cellar,
and they cool the smoke and create steam. The fire is not
being extinguished by the sprinkler system as the heads
are mostly standard uprights. The fire is burning in the
bas of the sub-cellar ceiling beams, above the tin
ce11ing, and out of the effective reach of the sprinklers
discharge.
The Rescue Co. officer has two of his men go the rear
of the building on the exterior to open the iron shutters.
The two rescue members are joined by some members of
Ladder Co. 1, they also operate on the iron shutters. The
opening of the rear shutters to ventilate the sub-cellar
is extremely difficult and requires the use of power saws.
The smoke condition on the floor is still heavy.
Lieutenant Lener and his unit are following the search
line into the sub-cellar. The are equipped with 30 minute
S.C.B.A. cylinders and they search the front of the
sub-cellar. They enter the oil burner room and then work
their way back to the rear. The chauffeur of Ladder Co. 6
vibra alert goes off and he exits for another cylinder.
Lieutenant Lener and the other three members work their
way to the rear. The visibility is a little better in the
rear, as one or two of the shuttered windows have been
opened, and Ladder 6 starts to pull ceilings. Lieutenant
Lener tells his members that if they get in trouble, the
window to get out is right there. He physically shows at
least one member where the windows are.
Division 1 has ordered Engine 10 to the sub-cellar
area-via the interior 'stairs, they a-re-helped by En9ine
7's members who are spread out on the stairway feed1ng the
line down. Engine Co. 55 is directed to stretch a line
down to the sub-cellar to the rear. They stretch their
line down the main interior stairway to the cellar level
and out to the back of the cellar to the rear fire escape.
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The Division ordered fans to be used as smoke ejectors, be
placed in operation at the front freight elevator shaft,
to help ventilate the sub-cellar.
Battalion 4 is operating on the cellar level and
directs Eng. Co. 55 to the rear. He also operates with
Ladder Co. 10 who is starting to cut the flooring in the
rear of the cellar level close to exposure four side of
the building. Engine 24 stretches a line to the cellar
level and works with Ladder Co. 10.
Two members of Engine Co. 10 run low on their air
supply and they leave to change their cylinders. They
leave the sub-cellar without notifying their officer. Saws
are being used to cut the flooring of the cellar to vent
the subcellar and saws are also being used to vent the
rear iron shutters. The noise of -the saws,
hose lines and noise common in firefighting 1S extremely
loud and disorienting.
Members of Ladder 6 operating in the sub-cellar have
run out of air and go out the rear windows into the rear
yard. They go in and out of the sub-cellar to pull
ceilings. The smoke is very heavy and they can't stay in
very long. Engine 10 has the line in the rear and is
operating on the ceiling fire as the truck pulls the
ceiling. The members of Ladder 6 who are out of air decide
to get fresh cylinders and go to the front of the fire
building for full cylinders. Lieutenant Lener did not
exit the cellar with his members and remained in
the sub-cellar. There is still limited ventilatlon in the
sub cellar. only two windows can be opened fully and the
third just partlally.
Engine 10 moves their line out to the rear windows and
direct their stream inward toward the front of the
sub-cellar and up into the ceiling bays.
Lieutenant Lener becomes disoriented and transmits a
MAYuDAY for bel p. Members-=_who hear the transmi ssioDuhear
many messages that run from ( I am out of air), ( I am
lost and don't know where I am ), ( I am by the fire and
burning), ( I am in the sub-cellar ), (oI am in the
stairway). Members hearing the MAY DAY try to locate
where he is and begin searching the buildin9. The noise
level from saws, generators and operations 1S high. It
adds to the difficulty of locating the member and his
identity.
Car 9 - A is on the scene and transmits an additional
alarm for the fire. Just as the May Day is heard at this
time. The 7 th Battalion transmits a 4th alarm for the
fire.
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Division 1 takes over the handie-talkie frequency and
tries to locate the member in trouble and tries to have
him identify himself. He directs Ladder Co. 15 the FAST
truck, to search sub-cellar. They go down to the sub
cellar level and work their way to the rear. Visibility is
still poor and the Officer removes his mask momentarily
and He immedi-ately feel the effect of carbon monoxide. He
replaces his mask and cautions his Company not to remove
their masks.
The 4 th Battalion is operating in the sub-cellar
stairs and the cellar floor. He finds a disoriented fire
fighter, stumbling around the cellar. He takes him out of
the building to the street, and then Battalion 4 returns
to the cellar. ( The member is a detailed member looking
for his detail unit.)
Eng. 55 had stretched a line through the cellar
floor and out to the rear fire escape. While on the cellar
level the Officer of Eng. Co. 55 heard of a MAY DAY. He
has his unit stretch down the rear to the sub-cellar level
and they direct their stream through the a window on to
the fire which was located in the ceiling joists in the
rear of the sub-cellar. Once the fire is darkened down
the officer moves into the sub-cellar level to see if he
can bring his line in and get the rest of the fire.
Some members operating in the rear yard had heard the
member was found and the MAY DAY was canceled.
As the Officer of 55 moves in on the sub-cellar
floor he sees a light sh1nning through the water, he
reaches down for the light and f1nds Lieutenant Lener
floating face down in about a foot of water. He gives a
MAY DAY and then calls for help. He has a difficult time
trying to hold the unconscious Lieutenant out of the
water. As he is yelling for help, other members zero in on
h im __ him-XelllOve' the member out to-tlle--rear.
S.A. Deputy Chief of the 3rd Division arrives at the
rear to assume command of exposure 3, and he hears a MAY
DAY. He directs the searches going on in the rear and
calls for medical assistance.
Once Lieutenant Lener is out in the rear yard which is
very narrow and litt-ered-with rubbish and other
obstructions, the members begin to administer first aid to
him. His mask is removed and the Officer of Rescue Co. 1
noted that it was the number 4 mask and that the cylinder
gauge indicated it was empty.
Page 65
There was some difficulty in determining who the member
was initially and if any other members were also missing.
A roll call was initiated and the sub-cellar thoroughly
searched. The injured member was removed through an
adjoining building to the front and was transported to
Downtown Hospital for treatment.
The multiple fires within the building are arson
related and the automatic alarm system had been sabotaged
preventing earlier detection. An alleged perpetrator has
been arrested and charged with the cr1me.
After conducting many interviews, reviewing evidence and
analyzing operations several items of concern were noted.
They are as follows:
(1) The Personal Alarm Safety System device of member was
functional but not on.
(2) Two SCBA face pieces were found floating in the water
at the sub-cellar level
(3) A plastic SCBA adapter Cheater was found floating in
the water in the sub-cellar.
(4) Several of the interviews indicated that there were
many members in the cellar and sub-cellar areas without
their SCBA being used correctly. Some members operated
with out their face pieces on, some took hits from their
face pieces and evidently some were using cheaters.
(5) Members were not leaving the contaminated area when
their masks ran low. Many continued to stay and work
without the protection of the SCBA.
(6) Some members left the area when their air supply ran
low and did not notify officer.
(7) Several members individually reporting to the scene
did not report in to the command post. Members went to
find detail units within the fire building. Thisaction
places members in serious jeopardy_
(8) There was a high level of noise during the MAY DAY
calls. They significantly interfered with the
rescue efforts.
(9) There was a cancellation of the MAY DAY by members in
the rear, and it may have been pre-mature and
unauthorized.
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(10)There was some confusion because of different
terminology. ( Basement, cellar, sub- basement,
sub-cellar ).
(11)During the member interviews, some members commented
on the level of Carbon Monoxide in the sub-cellar level,
and the effects that it had upon them. Blood gases taken
on Lt. Lener indicated a Carbon Monoxide level of 41 %
taken at the N.V Downtown hospital and according to
captain Fago of Eng. Co. 7 he had a Carbon Monoxide level
of 25 % when his blood gas was taken. This was indicative
to the high levels of CO. in the sub-cellar.
(12) Two members being interviewed stated that they had
become entangled with some unknown objects in the
sub-cellar during the extinguishment operations and the
training of the mask confidence course at the Division of
Training helped them get out of a precarious situation
Page 67
CAUSES
DIRECT
Member operating in below grade area (subcellar) in an
atmosphere containing smoke, high concentrations of
carbon -monoxi-de and t-oxic products of combustion.
Lack of compliance, by member, with some provisions of
AUC 220, Self Contained Breathing Apparatus Policy.
PASS device not properly utilized by member.
INDIRECT
Flooded condition in subcellar area (depth of water 10" to
11")
Ineffective operation of sprinkler heads in subcellar,
due to location of fire above the heads.
Limited ventilation at subcellar level due to iron
shutters and rubbish in rear yard.
Arson related fire. Several separate fires on various
floors.
Size and configuration of subcellar
Tampering with automatic alarm system negated early
discovery of fire.
Premature shut down of entire sprinkler system.
Building construction - previous fire damage repair
.nand ar--e.a
while interior operations were ongoing.
EARLY
May Day procedures Terminology .
Communications problems - noise levels.
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RECOMMENDATIONS
1. PERSONAL ALERT SAFETY SYSTEM
1.1 Personal Alert Safety System devices that presently
are in service are not being used to the extent that was
intended. The present device leaves much to be desired.
New integrated PASS devices are being developed and
hopefully will meet our needs. A -conmli-ttee should be
formed to work with interested manufacturers to develop a
user compatible safety sounding device. Until such devices
become available it should be mandatory that we use the
ones we now have to the fullest extent. ( See Tools 18
PASS section 12 of appendix ).
1.2 Provide the training for the use of such devices to
ensure that all field members are thoroughl familiar with
the operation, uses and testing of such dev1ces.
(2) SELF CONTAINED BREATHING APPARATUS
2.1 Self contained Breathing Apparatus to be worn as
prescribed in All Unit Circular 220 ( SEE APPENDIX SECTION
13 ) which establishes the Departments policy for such
use. The Training Bulletin Mask (SEE APPENDIX SECTION 11)
is specific in the use and limitations of the self
contained breathing apparatus.
2.2 The improper use of the SCBA facepieces taking hits
or having the regulator disconnected from the worn
facepiece can be extremely dangerous.
The use of adapters, (so called cheaters) is strictly
forbidden. Any infraction of such requirements shall be
considered a serious breach of discipline.
2.3 Consideration of modifying section 1.5 of All Unit
circular 220. When members are operating in cellar or
scms-ideredas-operatinq. in
confined spaces. If any of the unit's personal get low on
air, ( Vibralert Alarm sounds) all members of the unit
including the officer shall leave the contaminated area.
The necessary relief of such units shall be strictly
controlled by the incident or sector commander.
2.4 The establishment of a Mask Safety Officer. The
express purpose of this officer would be to monitor the
members operating in the confined space, or contaminated
area. The officer would control time limits, and be aware
of what members that are in the contaminated area.
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This designated officer could a close staging
areas for relief and air supplles, in addition to keeping
the Incident Commander informed of relief and supply
needs.
2.5 units assigned to the 1st and 3rd Divisions are
supplied with 45 minute cylinders except, the 4th and the
10 th Battalions. units in those battalions are equipped
with 30 minute cylinders. It is recommended that for fires
in cellars and sub cellars in commercial buildings in
those divisions, only 45 minute cylinder equipped
Firefighters be allowed to work in those structures.
2.6 Establishment of realistic time rating for the SCBA
cylinders. The 30 minute cylinder does not last 30
minutes, the 45 minute cyllnder does not last 45 minutes
and the6D minute cylinder does not last 60 minutes,
during firefighting use.
The escape times are all different and calculated at
20 % of the rated time. ( viz. 30 min cylinder has 6
minutes escape time, 45 minute cylinder has 9 minutes of
escape time and the 60 minute cylinder has 12 minutes of
escape time.)
Man individuals use different amounts of air because
of physlcal and psychological make up, and the rated times
are often confusing and misleading.
2.7 Repeated formalized training in the use of SCBA is a
necessity. The use of the Fire Academy's mask training
courses to be used when ever possible. The providing of
trailers to be used as portable mask confidence courses
that could be rotated throughout the Divisions is
suggested. The primary purpose is to increase the members
proficiency in the use of the SCBA.
3. COMMUNICATIONS
3.1 The installation of voice actuated recorders in all
Battalion vehicles for the purpose of automatically
recording all handie-talkie communications ( Tactical
channel ) at the fire / emergency scene. This could
provide invaluable information by allowin9 the Incident
Commander to review critical tactical radlO messages,
generally right from the early stages of the operation.
This would also be a valuable tool when investigating
fire ground mishaps.
3.2 Purchase of recording device for the Field
Communications Unlt to be used as a back for their
regular recorder and to be utilized in thelr spare
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apparatus when necessary.
3.3 Consult with Bureau of Communications and have them
research the feasibility to:
(A) Provide electronic identifier on our handie-talkie
radios that would allow us to identify the unit and
possible the user under emergency conditions.
(B) Provide a distinctive tone alert to be used by Chief
Officers when taking control of the radio frequency
because of an emergency.
4. MAY DAY PROCEDURES
4.1 The noise level at the operation was extremely high
because of the use of several saws and the running of a
few <1enera-ter-s i-n the immediate area. The noise level made
it d1fficult to hear radio transmissions, and interfered
with receiving and transmitting critical information.
Amending the Communications Manual directing the
shutting down of all machinery except those that are
critical to the operations, ( If deemed necessary by the
Incident Commander ) which may allow members to hear
important information as to unit, name or location of the
May Day user.
4.2 Provide hands on drills for May Day procedures and
Roll Call procedures.
5 TRAINING NEEDS
5.1 Terminology was a problem during the operations at
this fire. The terms used ran from basement, sub-basement,
cellar, sub-cellar, second basement, cat walk in the rear,
a fire in a taxpayer, my PASS alarm went off so I left to
change m cylinder indicates a need for education and a
standard1zation of terms.
5.2 Sprinkler system operations:
(A) Suppling sprinkler systems
( B) Shutt1ng down the systems.
(C) Isolation of the floors by use of floor valves.
(D) Communications of valve shut downs to the Incident
Commander.
(E) Procedures when shutting control
valves.
(F) When supplying the systems the use of flow gauges can
provide the members with valuable information.
5.3 Unit cohesiveness, is a concern that should be
addressed. The many details, mutuals, and overtime tours
bring a lot of unfamiliar members together in sometime
I
Page 71
J
unfamiliar areas of the city. The Officer takes care of
and accounts for his members, who is taking care of and
accounting for the officer? This situation is apt to
happen when the officer is not familiar with the members,
or the members are not familiar with the officer, be it
covering or overtime.
5.4 Discipline should be stressed at our operations,
because there is to much free lancing going on ie ..
(A) Members decide to change cylinders and leave the area
without notifying their officer.
(8) Members ended up reporting to the fire ground and
going into the structure on their own accord.
5.5 Provide training on the effects of gases and chemicals
that we frequent-ly encounter while operating at fires. The
effect of carbon monoxide and how it effects you
6 MISCELLANEOUS
6.1 This and in previous investigations the cooperation
from Emergency Medical Services has not been forth coming.
Information that could provide us with valuable data is
not given. The liaison should be handled at the executive
levels, or a procedure set up in place to gain the
information that is needed to conduct a thorough
investigation.
6.2 Provide Divisions with Carbon Monoxide meters to have
them more readily available for use at fire and emergency
scenes.
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