REPORT: No Single Cause Led to Firefighter's Death
The 84-page document offers observations and recommendations for battling future fires following the January 2011 death of volunteer firefighter Mark Falkenhan.
Requiring all fire personnel to have a portable radio when entering a life-threatening situation and ensuring that teams entering those situations remain together were two of the recommendations to come out of the final report investigating the death of volunteer firefighter Mark Falkenhan.
The 84-page report by the Baltimore County Fire Department comes more than 14 months after Falkenhan, a Middle River native and member of the Lutherville Volunteer Fire Company, died in the line of duty while battling a four-alarm apartment fire on Jan. 19, 2011 in Hillendale.
Investigators concluded that a frying pan with oil that was left unattended on a stove in a first-floor apartment caused the fire, according to the report.
Baltimore County Fire Department Chief John J. Hohman wrote in the report that he was “unsettled by the reality” that there was no single factor that led to Falkenhan’s death.
“The tradition of the fire service is to find the problem and either fix it or prevent it in the future,” Hohman wrote in the report. “This rule cannot be applied in this case since the outcome was the result of minor issues that alone, are recoverable ... but stacked up, were catastrophic. The report leads me to conclude that while there is always room for improvement, there was no single cause, no single reason for this death.”
The report provided the most in-depth look at the fatal fire, which occurred at 30 Dowling Circle and led to the first line of duty death by a Baltimore County firefighter since three men died in 1984 battling the Shiller’s Furniture blaze in Dundalk.
The report was developed by an investigation team, which consisted of fire department members, including representatives of the local firefighters' union, along with the Baltimore County Volunteer Firemen's Association.
Investigators included interviews, site visits, photographs and the use of a computer-generated re-creation of the fire by the Bureau of Alcohol, Tobacco and Firearms when developing conclusions for the report.
A detailed timeline of the tragedy, from the time the initial call went out until Falkenhan was rescued from the third floor of the building, was included in the report.
This timeline also included transcripts of the radio transmissions between Falkenhan and radio operators as he sought assistance in escaping the building.
According to the report, Falkenhan and his partner entered the apartment and made their way to the third floor of the building in search of victims. At 6:41 p.m., crews were ordered to evacuate the building and a minute later Falkenhan called for a Mayday emergency alert. At 6:50 p.m., firefighters found Falkenhan unconscious and rescued him from the building before he was declared dead at the hospital.
Among key recommendations from the report to reduce the chances of future firefighter deaths:
- Company officers shall ensure that crew integrity is maintained at all times by all personnel operating in an [“immediately dangerous to life or health”] environment. [Falkenhan and his partner separated while searching the third floor]
- No personnel should operate in an “immediately dangerous to life or health” environment without a portable radio. [Falkenhan's partner did not have a portable radio].
- Develop ways of reducing inadvertent radio interference, including developing a rubberized cover for the push to talk buttons on radios which would reduce the chances of accidentally pushing it.
- While performing operations above the fire, notify command of changing conditions, and immediately request resources to support your function. [Firefighters conducting search and rescue operations on the second floor noticed a fire in the corner of the apartment shortly before coming across a victim. While removing the victim, "the room reached its ignition point and flashed as they were exiting the apartment, according to the report.]
But the report concluded that while Falkenhan’s death was tragic, there is little need for massive changes to the department’s rescue protocols.
“[If] current policies and procedures are adhered to, the opportunity for catastrophic problems may be reduced …” according to the report. “It would be easy if one particular failure of the system could be identified as the cause of this tragedy.
“We could fix it and move on. Unfortunately, it is not that simple. No incident is 'routine.' Mark’s death and this report reinforce that fact.”
Gladys Falkenhan, Mark's widow, received an advanced copy of the report and read it over with Homan earlier this week. She said the report provided a sense of closure as she and her family try to recover.
"The most important thing that we all need to remember is that we need to learn from this tragic event and that we need to move on," Gladys Falkenhan said. "That is what Mark would want us to do."