Anatomy of a tragedy: OSHA’s timeline of the Ramos fire

STERLING – Calls for help that weren’t properly investigated. A burning structure that was not properly assessed.

Policies and procedures – including one that requires at least two firefighters in hazardous situations be in voice or visual contact with each other at all times – were not followed.

Here’s a look at the last hour and a half of 38-year-old Lt. Garrett Ramos’ life, as told by the report from the Illinois division of the Occupational Health and Safety Administration.

According to the incident report, which did not provide names of those involved:

A resident of 10031 Ridge Road in rural Rock Falls, a one-story ranch with a full basement and an attached garage, called 9-1-1 at 11:04 p.m. Dec. 3 to report a fire in the garage. The house is about 6 miles from the Rock Falls fire station, and has no hydrant coverage.

Rock Falls and Sterling fire engines were dispatched. The Rock Falls chief, who also the incident commander, was first on scene at 11:18 p.m. The garage was fully involved and the fire was moving into the house.

The chief attempted to provide dispatch of a “size-up” — an assessment of the fire and the structure — on the primary radio frequency three times, but got no response, likely because dispatch was busy notifying other departments of his call for more responders, known as a request for a Mutual Aid Box Alarm.

Ramos and another Sterling firefighter arrived. Those two and a Rock Falls firefighter entered the home and saw the the entire attic space was on fire. It was reported that three exited the building after the low-air alarms on their breathing apparatus went off.

After an air bottle change, Ramos and the other Sterling firefighter were sent back in; they split up and went to different rooms to pull down ceilings.

The other firefighter pulled down ceilings until he “completely ran out of air” and then went to rehab. He met up with the Rock Falls firefighter who initially went into the home with him and Ramos.

Ramos did not arrive at rehab.

During this time, the accountability officer had Ramos on the board as being inside the house with two other firefighters. A team of three firefighters were told to go inside and report to Ramos for their interior assignments.

At the same time, firefighters from multiple departments were moving in and out of the house, fighting the fire. One determined that a fire was burning below him; he exited the house and told the operations chief.

At about 11:54 p.m., which was 35 minutes after they arrived on scene, the operations chief stated that the fire was under control.

At about 12:01 a.m., a report of a partial floor collapse was heard on the fireground frequency (that is, the radio frequency used by firefighters on the scene to communicate with one another).

At 12:04 a.m., “several members stated that they heard ‘mayday, mayday, mayday’, but the call was not transmitted on the designated fireground frequency ... At least one additional ‘mayday, mayday, mayday’ was heard by members on scene, but it was unclear who made the call.”

The maydays may have been made on the dispatch frequency.

After the maydays were transmitted, the operations chief told the others to clear the radio for emergency traffic to allow the firefighter calling the mayday to communicate further.

There was no response.

More attempts to contact the firefighter were made on both frequencies, but again, no response.

A rapid intervention team was assembled and sent to look for a Sterling firefighter, not Ramos, who was thought to be the victim; that firefighter quickly was identified, though, and the operations chief initiated a Personnel Accountability Report (or, PAR).

“We have PAR” was heard over the radio, but a total accountability of all firefighters in the hazard zone did not occur.

The operations chief radioed the incident commander that all interior crews were accounted for, and the accountability officer marked that on the board, then operations resumed “although some members on the scene stated that they believed the PAR was not properly conducted.”

At that point, 40 minutes in [about 12:34 a.m.], deteriorating conditions indicated there was a basement fire. Command had not confirmed there was a basement. The incident commander checked with the homeowners and learned that there was.

Two Sterling firefighters were sent into the basement, but debris from the floor collapse, which happened at 12:01 a.m., stopped them at the bottom of the stairs.

At 12:37 a.m., 33 minutes after the first mayday, firefighters in rehab realized Ramos was not accounted for and notified command.

Command called Ramos on the radio several times but didn’t get a response. A search began, with command telling searchers of the basement. Again, debris stymied their entrance.

A hole was cut into the floor and search crews used a ladder to get to the basement, which was full of thick smoke but no visible fire.

Searchers heard the sound of a breathing apparatus alarm and they called for the emergency medical services crew to be on standby.

Then they found Ramos. His helmet was on and his face mask intact. But he was unresponsive — not breathing — and out of air.

Two attempts to get him out of the basement failed.

He finally was lifted out. At that point the EMS team took over and he was taken to CGH Medical Center, where lifesaving measures continued, but to no avail.

Ramos was pronounced dead at 1:41 a.m.

The direct cause of his death was “Exposure to respiratory hazards. The victim’s breathing air supply was completely depleted. According to the coroner’s report, death was attributed to asphyxia cause by inhalation of products of combustion due to a fire.”

The report cited the indirect cause of Ramos death:

• The initial “size-up” of the structure did not identify the presence of a basement.

• Firefighters were not checked to see they were operating on the designated fireground frequency.

• Interior firefighter team continuity was not maintained.

• It appears the incident command team made the assessment that the fire was under control when it was not, leading to a higher risk than perceived. The incident command team didn’t reevaluate its strategy after learning of the partial roof collapse nor after the mayday call.

• The mayday call did not include a unique identifier, and the mayday caller was not identified by command.

• The PAR report was not properly recorded. Neither was the breathing apparatus “on air” times for crews inside the burning home.

• Once located, Ramos was not given emergency air and two attempts to remove him from the basement failed.

• “While everyone on the incident command team was responsible that day for firefighter safety, no one on the team exercised assertiveness (spoke up) to ensure that the victim was identified and rescued in a timely manner.”

Both cities are facing fines, Sterling of $24,000 and Rock Falls of $12,000, but some of OSHA’s finding are being disputed, and the cities had until April 20 to choose whether to accept the findings and correct the violations OSHA identified, have an informal conference with OSHA reps to discuss the citations, which may reduce the fines or change the date by which corrections must be implemented, or contest the penalties and corrections through a formal legal process.

Both city managers, the state Department of Labor and members of the Ramos family met informally Tuesday to discuss the findings.

The results of that 4-hour meeting are being discussed and information will be released “early next week,” Sterling City Manager Scott Shumard said Thursday.

The cities are contesting two findings: that the incident report misidentifies the “accountability officer” at the scene, and that an email the city administrator sent to the Department of Labor that actually was part of an unrelated DOL inspection that had taken place earlier in the year.

The latter was mentioned in a hazard alert notification letter sent to the city of Sterling citing a delay in the required reporting of Ramos’ death to the DOL and other items that it said “should be voluntarily corrected in the interest of public safety.”

According to the letter, the Sterling fire chief notified the DOL via voicemail at 8:36 a.m. Dec. 4. OSHA sent an email Dec. 6 requesting he make a formal report via the agency’s intake phone number.

On Dec. 6. the OSHA inspector assigned to the case got an email for the Sterling city administrator that said “this issue has taken a back seat for the moment. Please allow the SFD some additional time to complete the required task before revisiting with them if at all possible. It’s the most extenuating of circumstances.”

This is the unrelated email the city is disputing.

On Dec. 8, four days after Ramos’ death, OSHA sent a second email requesting a formal report of the fatality, the letter continues.

OSHA finally received the formal notification at 10:55 a.m. Dec. 10, the letter said.

“Any city employee could have reported the fatality. The city has a responsibility to report fatalities promptly so that an investigation can be opened as soon as possible, if warranted.

“Because of the city’s actions, the investigation was not opened for six days. It is recommended that a formal reporting process be implemented for the city of Sterling.”

OSHA noted that the countywide 911 system can’t receive portable communications from outlying areas and that command staff failed to document critical events at the scene of the fire, including the time of the mayday, when Ramos was designated as missing, when he was found, and when he was removed from the basement.

Both cities said in a joint statement that some of the report’s suggestions for the Sterling Fire Department already have been initiated, including reviews of standard operating guidelines and policies and provisions for additional training.

In addition, “prior to receiving this report, the Sterling and Rock Falls fire departments jointly reached out to the University of Illinois Fire Service Institute to update and schedule training for emergency scene accountability, rapid intervention teams, 2-in-2-out policies and mayday procedures ... Portable radios have been reprogrammed to avoid accidental changes between primary and tactical channels,” said the statement, which is signed by Sterling City Manager Shumard and Rock Falls City Administrator Robbin Blackert.

The two cities also have asked Whiteside County adopt the report’s recommendations to improve communications coverage, the statement said.