New report cites missteps that led to deaths of two Kansas City firefighters
Two Kansas City firefighters killed in an October building fire and collapse died after missteps and misjudgments by their commanders, according to a report released Tuesday by the Kansas City Fire Department.
The department-authored report concluded it was a fatal tactical mistake to allow firefighters John Mesh and Larry Leggio to continue to attack the fire from inside a zone the incident commander had declared an imminent danger.
The report confirms findings by The Kansas City Star in December that the firefighters should not have been in an alley next to the three-story burning building when a wall of bricks fell on them.
The report found:
▪ The Kansas City Fire Department’s culture of aggressively fighting fires may have led to risky behavior on the parts of fire crews and commanders the night they battled the fire at the building on Independence Boulevard.
The most significant failure that night, the report said, was that commanders allowed personnel, including officers, to continue using the alley.
▪ The two firefighters who died and two others who were injured were in the alley not to protect the neighboring grocery store, as previously asserted by a department spokesman, but to protect a pumper truck parked and blocked in the alley.
▪ Fire personnel were so fixated on fighting the fire that they lost sight of the fact that only property was at risk when they entered the danger zone. “When there is little to save, we should risk little,” the report said.
The report said its intent was not to cast blame. But it makes 14 recommendations. Topping the list is that the Fire Department should develop a collapse zone policy. One did not exist prior to this fire. Other recommendations include better training and communications policies.
“I acknowledge that something went wrong at this fire — two good men died,” Kansas City Fire Chief Paul Berardi said in a prepared statement. “The purpose of this report is to lessen the likelihood of that happening again.”
The Star’s investigation in December determined that firefighters were operating in the collapse zone six minutes after it was established.
Industry standards suggest that all fire personnel immediately exit a collapse zone — typically an area 1 1/2 times the height of the building — once one is ordered. The only exception would be to attempt to save someone’s life, which wasn’t an issue in this case.
Mesh and Leggio, and a few other firefighters, were battling the blaze in an alley about 30 feet wide that separated the building from Snyder’s Supermarket.
One of two firefighters seriously injured in the collapse told The Star at the time that he was unaware that a collapse zone had been established. According to the department’s report, communication problems contributed to confusion on the fire ground and a lack of understanding by crews of the danger of operating in the alley where the collapse occurred.
While citing the department’s style of aggressive fire attack as a strength, the report said that “cultural norms that work against the safety of firefighters are and can potentially be disastrous and should not be tolerated.”
Those comments and a series of recommendations calling for new policies and reforms are part of a 68-page report that Berardi had promised would be an unvarnished, “warts and all” account of events leading up to the deaths of the two veteran firefighters.
It is the first official explanation of why Mesh, 39, and Leggio, 43, were in that alley. Residents of the building and grocery store already had been evacuated.
Leggio’s widow, Melissa Leggio, told The Star on Tuesday evening that she was reading the report and would have no comment. Mesh’s widow, Felicia Mesh, could not be reached.
The nearly one-block structure at 2608 Independence Blvd. had businesses on the first floor and apartments on the upper two stories.
Thu Hong Nguyen, who operated a nail salon in the building, is charged with arson and two counts of second-degree murder in the case. She has pleaded not guilty.
On the night of the blaze, firefighters were initially dispatched at 7:27 p.m. and arrived finding heavy smoke coming from the rear of the building. Crews rescued at least two occupants and went inside looking for the origin of the fire, but they had difficulty finding its source as the fierce blaze intensified.
Before commanders ordered everyone out at 7:49 p.m., many firefighters reported that the conditions inside had become so untenable because of the heat that they “were nearly at May-Day conditions.”
A mayday is a plea for help when firefighters fear their lives are in danger.
Everyone got out safely, and a collapse zone was declared at 8 p.m. as firefighters continued to pour water on the building from outside with hoses and aerial streams.
But a pumper truck was at risk, parked in the alley and blocked from exiting by another vehicle in front of it. Flames shot near it.
At this point, 8:04 p.m., a division chief radioed his decision to send firefighters into the collapse zone to protect the apparatus. The incident commander did not acknowledge the decision. Two minutes later, the wall fell.
Prior to the collapse, the building’s east side was not seen as an immediate danger by firefighters, who continued to use it as their primary route between the front and the back of the building.
This was “the most significant” failure on the part of leadership that night, the report said.
“Once this was identified, the incident commander immediately began radio traffic to remove personnel from the alley,” the report said. “Before the communication could be completed, the wall collapsed on the personnel.”
The incident commander, Deputy Chief Todd Ackerson, was one of the 11-member department team that spent three months investigating the incident.
Federal investigators are working independently on their own report. Typically, reports by the National Institute for Occupational Safety and Health are meant to educate the nation’s fire service.
After other fatal collapses nationwide, NIOSH repeatedly has pointed out the dangers of operating within collapse zones.
In its report about a similar building collapse in Philadelphia in 2012 that also killed two firefighters, NIOSH said it was “unacceptable” for firefighters to remain in a collapse zone.