HAMILTON, OH (FOX19) - Hamilton fire officials on Monday announced safety improvements after a firefighter died in the line of duty more than three years ago.
Their internal investigation identified five contributing factors into the death of Firefighter Patrick Wolterman on Dec. 28, 2015.
- Arson: The fire was intentionally set by the owner and a relative using gasoline and in a manner to delay the discovery of the fire. “Ironically, Patrick died in the line of duty trying to save those people who had conspired to set the fire which took his life,” Fire Chief Mark Mercer wrote in a statement.
- Communications: All current practices were followed at the time, but improvements in timing, alarm information, and fire ground communications were necessary
- Size-up did not reveal the location of the fire: Due to weather conditions and the initial incorrect report of occupants in the structure, the cellar fire was not identified
- Openings were made or enlarged prior to entry: The cellar doors were opened providing fresh air to the undiscovered fire
- Equipment: Not all available communications equipment was used by firefighting personnel during the fire
Wolterman, 28, fell through the floor of the burning home on Pater Avenue.
The dispatcher advised at 1:14 a.m. two elderly people may be in the house and smoke was coming from the basement in the back of it, according to a report after a federal investigation into Wolterman’s death.
These last two transmissions were on the dispatch channel and not simulcast on the tactical channel, reads the report from the National Institute for Occupational Safety and Health (NIOSH).
As Wolterman crawled into the family/living room, the floor collapsed and he immediately fell into the basement, according to the report.
A mayday was called at 1:23 a.m. Command ordered fire crews at 1:25 a.m. to locate the missing fire fighter in the basement.
Wolterman was found, removed from the basement and treated on scene by paramedics and then taken to a hospital, where he was pronounced dead just before 2:30 a.m., according to the NIOSH report.
“This report is not a simple overview. We needed to delve into the issues that contributed to Patrick’s’ death,” wrote Fire Chief Mark Mercer in a prepared statement.
"Where we identified areas that needed improvements, we made those improvements. There have been significant changes in the following areas; officer development and training, operational policies, live fire training drills, and a systematic approach to revamp our alarm and fire ground communications.
"We have constructed response models which improve our overall fire response. We have addressed communications gaps in our system and improved the expectation to identify, share, and receive emergency communications. We are committed to continuous improvement to ensure the safety of our firefighters and citizens alike. "
The city participated in an investigation conducted by NIOSH, through the Firefighter Fatality Investigation and Prevention Program to determine the fire ground conditions which contributed to the fatality.
That is a standard investigation practice through which the fire service identifies ways to reduce fatalities while working on one of nation’s most hazardous duties, protecting our citizens from the dangers of uncontrolled fire.
NIOSH issued the report of the fire on July 14, 2017 .
It determined the following contributing factors:
- Arson fire
- Incomplete scene size-up
- Wind-driven fire
- Lack of tactical priorities (incident action plan)
- Lack of resource status management
- Lack of command safety
- Ineffective dispatch center operations
- Lack of a written professional development program
The union that represents Hamilton firefighters said in a statement it found “inaccuracies and issues" with fire department’s report.
They say it “ignores key contributing factors” and call the process to create the report “flawed” and “inconsistent.”
"In early 2016, the department created a committee to investigate the factors that contributed to the death of Patrick Wolterman. A draft internal report was completed in late 2016. It was later amended by members of fire administration without consensus of the full committee. The report that was released today, has certain contributing factors that were downplayed or omitted altogether, including but not limited to:
- The internal report took nearly three and a half years to complete, much longer than most internal reports.
- For reference, the NIOSH report was completed in July 2017 and released in December 2017.
- The committee makeup changed due to fire administration involvement in the process and changes were made to the report that excluded certain committee member’s points of view.
- Engine 22 (E22) closure in 2013
- Station 27 (Quint 27) closure in 2013
- A significant increase in response time to this area of Pater Ave. due to the closing of Station 27 was completely omitted from the report
- Average response times for 1st arriving fire units was 2 minutes and 59 seconds prior to Station 27 closure and increased to 6 minutes and 23 seconds after closure.
- Delayed Rapid Assistance Team (RAT) response is an ongoing safety issue
- RAT teams are dedicated units to rescue downed firefighters. The RAT team on this night (E21) did not arrive on-scene until 10 minutes and 16 seconds after dispatch, only 42 seconds before the mayday occurred.
- Lack of a Safety Officer was highlighted on the NIOSH report and in this report, but no resolution has been found and we continue to operate on dangerous scenes without a committed safety officer.
“The cuts to Hamilton Fire Department in 2013, closing Station 27 (Quint 27) and Engine 22, continue to play a major factor in day-to-day emergency operations and certainly factored into this night,” the statement reads.
"Our inability to respond in a timely manner, dedicate proper resources to RAT and Safety and provide the best and safest practices for our citizens and firefighters are ongoing problems. While we appreciate the work that went into it, this is not a complete and full report. We acknowledge the improvements in officer development, scene size-up and fire tactics.
"There is more work to be done, as an increased focus on training for all members should be a priority. We will continue to work to find resolution for all of these issues as we seek to never have this happen again. We owe this to the memory of our fallen Brother Patrick, our citizens and our firefighters. "