Federal report cites mistakes that led to deaths of two KC firefighters

Kansas City firefighters now take two simple safety steps that might have saved the lives of two colleagues in a 2015 building collapse.

The steps were among the recommendations in a federal report released Thursday.

Emergency tones are sounded, as they were two years ago, when firefighters are ordered out of a collapse zone. But now heads are counted to make sure everyone got the message — which was not done before.

Fire Chief Paul Berardi acknowledged those steps might have saved the lives of John Mesh and Larry Leggio, who perished at a fire scene on Independence Boulevard.

The federal report cites a series of operational failures that contributed to the firefighters’ deaths. The report said the two men should not have been in an alley next to the three-story building after all personnel were directed to pull back because of fears the walls would collapse.

Six minutes after that order was given, they died in an avalanche of bricks.

Poor communication and the failure to establish and maintain a collapse zone around the building were among the key failings contributing to the deaths noted in the report from the National Institute of Occupational Safety and Health.

None of its conclusions are surprising. The document underscores conclusions reported by The Kansas City Star two months after the deaths of Mesh and Leggio, as well as the findings from the Kansas City Fire Department’s own internal investigative report published in the spring of 2016.

While not assigning blame — NIOSH reports never do — federal investigators noted a number of contributing factors that played a role in the double fatality. Among them was commanders’ failure to keep track of firefighters’ locations throughout the fire. Also, there was no designated safety officer on duty until after the wall collapse, and commanders did not act quickly to evacuate the perimeter of the building after ordering the establishment of a collapse zone.

Berardi acknowledged previously that his department did not have a collapse zone policy at the time of the tragedy, but adopted one several months later during a review of all department policies. That resulted in a number of other systemic changes that, had they been in place at the time of the collapse, might have averted the deaths, he told reporters Thursday.

“We don’t want to make excuses for what occurred that night,” Berardi said. “We want to say it occurred and we want to correct it so that it doesn’t happen again.”

In an investigation spurred by the deaths, The Star found that the Kansas City department was not unusual among fire departments. In case after case, departments across the country often fail to heed the lessons they should have learned from others’ fatal mistakes. For instance, NIOSH had long recommended departments adopt collapse zone policies.

The new report notes that a communication breakdown was partly to blame for the fact that Mesh, 39, and Leggio, 43, were still working within a few feet of the burning building after the order to evacuate the collapse zone was declared.

Berardi acknowledged Thursday that one of the men’s superiors directed them to pour water on the flames through an alleyside window after that order was given. That officer noted their location in a radio broadcast, but his message wasn’t acknowledged by the commander in control on the scene to indicate that he had heard.

Some firefighters also reported later that they did not hear the collapse zone order, even though the radio system was operational.

The report said the department should have had a system in place to account for all firefighters’ whereabouts after a collapse zone has been declared.

All that has changed, Berardi said. Now, emergency tones sound over the radio when a collapse zone is declared. Then company officers do a headcount of their firefighters to ensure that everyone is outside of that area and the boundary is marked off.

Prosecutors say the Oct. 12, 2015, fire was arson and have charged the operator of the nail salon where the fire started, Thu Hong Nguyen, with two counts of second-degree murder and causing a catastrophe. She pleaded not guilty and a trial is set to begin in July 2018 in Jackson County.

Federal investigators began their probe a week after the blaze that killed Mesh and Leggio and finished it in July. Family members and department officials reviewed it before it was published online Thursday morning.

It was around 7:30 p.m. Oct. 12 when the first alarm was sounded on reports of thick black smoke and flames at a combination apartment and retail building near the corner of Independence Boulevard and Prospect Avenue.

The first firefighters to arrive rescued several occupants and struggled to contain the blaze as more units were requested. Before it was over, more than 110 firefighters and other emergency personnel responded to the scene, the report said.

But about 20 minutes into the operation, the fire was burning out of control and all personnel were ordered out of the building. As firefighters were removing their hoses and other equipment, parts of the interior began to collapse, which was a signal that the exterior might also fall.

At 8 p.m. the incident commander ordered the establishment of a collapse zone.

“All companies move back,” a dispatcher announced over the radio. “All companies move back. Create a collapse zone.”

At a minimum, that would have meant retreating a distance equal to one and half times the height of the building.

But according to the federal report not everyone on the scene heard the order and some firefighters, including Mesh and Leggio, continued to work in the alley on the east side that was just 30 feet wide.

Seeing this, the incident commander was about to reiterate his order to get out when, at 8:06, a chain reaction began, the report said. The interior floors of the burning building collapsed, leading to the failure of the east exterior wall by the alley.

The wall weighed nearly 70 tons, federal investigators said.

Mesh and Leggio were buried completely and died of blunt force trauma. Two other firefighters were injured. The falling bricks forced one to his knees and under a fire truck and another was buried to his waist with debris.

The federal report does not address why the men were still working in the alley after the collapse zone was ordered. But the fire department’s internal report from last year said they were attempting to protect a pumper truck that was blocked from exiting the alley.

A company officer ordered his crew to aim a hose stream into the windows showing fire on the east side of the building to protect the apparatus.

“The hose was placed in the position of maximum effectiveness, which placed the crew within the collapse zone,” the department’s investigative report said. “This action should be noted as an effort only to protect the fire apparatus and was to be a temporary placement. The building showed no signs of imminent collapse, which factored into this decision by a number of experienced personnel.”

But citing one of the federal investigation’s chief consultants, Christopher Naum, the NIOSH report says that too often the possibility of a building collapse is overlooked or minimized by firefighters “until the catastrophic conditions present themselves with little to no time to react accordingly.”

NIOSH, whose duty is to investigate firefighter fatalities, has said again and again in its reports that no property is worth a life. The Kansas City department’s report also acknowledged that.

NIOSH has no enforcement power, but made 16 recommendations in its report. In addition to recommending that all fire departments adopt and follow a collapse zone policy, the agency’s suggestions focused on improving communication and command procedures, taking greater care in accounting for the whereabouts of firefighters at chaotic fire scenes and suggested requiring sprinklers in all apartment buildings.

“There are some things that are incomplete,” Berardi said, “but every single one of their recommendations we have at least made progress on.”