CINCINNATI (FOX19) - A year-long investigation into the death of Cincinnati Firefighter Daryl Gordon could lead to major changes within the city fire department.
On Thursday, Cincinnati officials released the 'Daryl Gordon Line of Duty Death Report,' - a 353-page report detailing what led to Gordon's death on March 26, 2015. In the report, fire leaders admit mistakes were made on the morning of March 26, 2015.
The report also takes an in-depth look at how the department can lessen the likelihood of another line-of-duty death.
"This 350 pages is literally this committee beating ourselves up saying what can we do differently to ensure this will never happen again," said Matt Alter, President of Cincinnati Firefighter's Union Local 48.
Gordon died after he fell down an elevator shaft inside a burning apartment building in Madisonville.
The elevator's defective door was the primary contributing factor in Gordon's accidental death, the report found. However, several other factors, including human error, played a part in the incident.
The report's suggested improvements would cost the city approximately $2.3 million each year. The largest change focuses on retraining companies in "basic fire fighting skills."
The report lists seven key recommendations:
- Operations and Response Enhancement
- Fire Prevention
- Fire Investigation
Many of those suggestions have already been implemented by Cincinnati firefighters, Chief Richard Braun said at a press conference Thursday.
The report cites 22 "lessons learned" from the King Tower fire, the first of those lessons being "Complacency." Responding companies initially treated the fire as another routine call, the investigation found.
Fire fighters engaged in "freelancing" while battling the blaze, the report claims. Freelancing means firefighters do what they want, when they want to do it, resulting in failure to complete plans and tasks.
Crews also faced issues deploying fire hoses. Engine 49's primary attack line never made it to the fire apartment, the report reveals.
The report stressed that firefighters who battled the apartment complex blaze alongside Gordon are not to blame for shortcomings found in the investigation.
"Each and everyday, firefighters in the City of Cincinnati perform in the same manner as firefighters did on did on March 26, 2015, all while risking their lives protecting lives and property," it said.
FOX19 NOW is reviewing the report and will continue to update this story.