A Baltimore fire recruit who was killed in a February training exercise was not ready to be sent into a burning dwelling, had failed agility tests and had been given old protective gear that frayed and failed to protect her from the intense heat, according to a report prepared for the mayor.
The 121-page report by an independent investigator, obtained yesterday by The Sun, adds new details to the death of Racheal M. Wilson and places much of the blame on her instructor, who investigators say abandoned her in the burning rowhouse, and on other mid-level fire commanders, three of whom have already been fired.
It describes a chaotic scene conducted by instructors who acted with little oversight and concludes that 50 national safety standards were violated during the exercise, more than the 36 previously acknowledged by the city and the department.
Fire Chief William J. Goodwin Jr., who has been criticized for allowing lax standards at the training academy he once headed, is mentioned once in the detailed report, in a paragraph in which investigators note that he was unaware that the live-fire exercises would take place.
Mayor Sheila Dixon, who commissioned the investigation, is expected to release the report publicly Thursday after Wilson's family has had a chance to read it. She refused to discuss the contents yesterday.
The lead investigator, Howard County Deputy Fire Chief Chris Shimer, concluded his report by expressing hope that other departments would learn from the mistakes made by Baltimore firefighters.
"The ultimate sacrifice by Racheal Wilson should serve as a reminder to fire officials everywhere that rules and standards are developed for a reason," Shimer wrote. "The primary reason is to ensure that we keep our personnel safe so they may return home each and every day to their loved ones."
Two previous investigations into the Feb. 9 fire on South Calverton Road have revealed dozens of violations of national safety standards, including the setting of seven or eight fires instead of the one that is permitted, the lack of radios for some instructors, the failure to clear debris from the vacant dwelling and the failure to brief students before the exercise.
The report was based on a six-month investigation into what occurred during the fatal fire, but it also scrutinized other practices, finding "systematic problems" at the training academy.
It includes graphics, photographs and 19 appendices. Toward the end of the report, Shimer concludes that the fire academy is governed by an "unacceptable" view that "recruits must be exposed to heavy fire conditions in order to be adequately prepared for the field.
"These practices are unacceptable and may lead to serious injury and in this case death," the report says.
After the fire, three commanders lost their jobs. Division Chief Kenneth Hyde, who was head of the academy when Wilson died, was fired by Dixon in February. Lt. Joseph Crest, the instructor in charge of the fire, and Lt. Barry Broyles, who was supposed to be in charge of an unprepared rescue team, were fired on the recommendation of a panel of their peers.
Goodwin has said that the Fire Department needs to focus more on safety and has taken steps to improve it. He replaced most of the staff at the training academy, obtained grants for radios, increased the department's safety office operation and started to rotate all midlevel battalion chiefs, in part because of a belief that they had grown too close to their men and were not reporting safety violations.
Investigators noted that Goodwin was interviewed and that the Fire Department was mostly cooperative, with the exception of three key people.
Lt. Eugene Jones, who was supposed to light fires at the fatal burn, would not allow officials from the Bureau of Alcohol, Tobacco, Firearms and Explosives to interview him. Tarnisha Lee, a firefighter paramedic who lit some of the fires in the rowhouse, would submit to only a brief interview with investigators.
Hyde, who was in charge of the training academy, initially cooperated with investigators but stopped participating on the advice of his lawyer, according to the report.
The report examined for the first time a similar training exercise that was conducted Feb. 8 on Sinclair Lane, the day before the fatal burn. Investigators found that national safety standards were violated there, too, something that Fire Department spokesmen have denied.
From watching a video of that fire, investigators determined that instructors lit more than one fire, recruits entered and exited the burning building without being accompanied by instructors and a recruit left the building with what appeared to be burning debris on his or her back and neck.
Instructors were not wearing their face pieces properly, the report says. One recruit, Daniel Nott, was injured after removing his mask and suffering burns to his face. Lt. Sam Darby, an instructor, suffered a burn on his hand at that fire.