OSHA releases final report on fatal Ramos fire

STERLING – The Occupational Safety and Health Administration Monday made public its final incident report outlining errors made during the Dec. 4 fire that took the life of Sterling firefighter Lt. Garrett Ramos.

Sauk Valley Media obtained the initial report in April and reported on its findings.

Sterling and Rock Falls paid a combined $36,000 in fines for “lapses” in each department’s policies and procedures, lapses that contributed to Ramos’ death from “asphyxia caused by inhalation of products of combustion due to a structure fire,” the report said.

While the direct cause of Ramos’ death was “exposure to respiratory hazards,” the indirect causes were a failure “to identify the presence or absence of a basement,” and a failure to ensure that firefighters entering the interior “were operating on the designated fireground frequency,” among others, OSHA said.

The only difference between the initial report and the final report, which “was produced as a learning tool for firefighters in Illinois and nationwide,” OSHA said, is a page of response from the cities on some of the criticisms levied by OSHA, and the agency’s responses, which it included “in the interest of accuracy.”

Ramos, 38, died fighting a fire on Ridge Road in Rock Falls when the floor of a one-story ranch house collapsed and he fell into the basement. He was unresponsive when found, the alarm on his empty air tank sounding. He could not be revived.

According to the Illinois OSHA report, firefighters were to work in pairs inside the building, but Ramos and his partner had split up. No one checked to make sure firefighters entering the interior were operating on the designated radio frequency, according to the report.

Incident command did not know the home had a basement, did not properly log the response to calls for all firefighters on scene to identify themselves and so failed to realize Ramos was missing and failed to identify his mayday call, which was not transmitted on the designated frequency, according to the report.

Thirty-three minutes after the first mayday call, it finally was realized Ramos was unaccounted for. Once found, Ramos wasn’t given emergency air, and the first two attempts to remove him from the basement failed, according to the report.

When the initial report was made public, the two cities issued a joint statement that read in part:

“While IDOL agreed to review some inaccuracies contained in the documentation, the fire departments recognize the report identifies lapses in the execution of standard operating procedures and standard operating guidelines, that when combined, created a situation in which a line of duty death could, and ultimately did occur.”

Those inaccuracies are addressed in an appendix to the report released Monday that includes the page number on which the statements are found. With parenthetical notes from SVM, it reads:

The following observations were presented to IL OSHA by the employers (the cities) during the informal conference after the citations and incident report were issued. In the interests of accuracy, IL OSHA wants to provide these observations and an associated response.

Page 4: The employers observe that the accountability officer was from FD #1 (Rock Falls), not FD #2 (Sterling). IL OSHA agrees.

Page 5: About the statement: “It was initially thought that a firefighter from FD #2 (Sterling), other than the victim, initiated the mayday as he was not accounted for, but he was quickly located.”

(Cities response) The employers observe that this firefighter was not quickly located. There is no definitive timeline available that details the actual length of time that this other firefighter was not accounted for. Statements show that two firefighters performed a search of the first floor of the home with negative results.

Page 6 and 7: The employers observe that due to factors such as construction and time of day, that it was difficult to identify the presence of a basement during the size up. The basement windows on the “Alpha” (front) side were covered by the homeowner.

A mutual aid department also performed a size up upon arrival and noted no basement windows.

Additionally, the stairs to the basement were in the back of the garage and the garage was the point of origin of the fire.

(Cities response) While these factors may have made size up more difficult, a basement window was present on the “Charlie” side (rear) of the home, and the occupants were at the scene to provide detailed information about the structure.

Page 7: The employers observe that in reference to indirect cause #2, all evidence reflects that firefighters on scene were on the designated fireground frequency.

(Cities response) IL OSHA’s review of the evidence does not show that radio checks were performed between command and interior crews prior to entry.

(Cities response) It is unknown what frequency the victim’s radio was on prior to entering the building.

(Cities response) It is known that the victim’s radio was not on the designated fireground frequency when transmitting the mayday call.

Page 8: The employers observe that in reference to indirect cause #10, a mutual aid department performed the rapid intervention team entry.

(Cities response) While true, IL OSHA standards require the employer to provide for effective emergency rescue regardless of who is assigned to a rapid intervention team. If an employer intends to assign their employees to interior structural firefighting, they must ensure that the team assigned for emergency rescue are trained and equipped for that mission. If a mutual aid department(s) provides the team then the employer should train with the other department(s) to ensure that department(s) can provide effective rescue during an incident.

Page 13: The employers observe that in reference to the hazard alert letter that references “problematic fire department radio communications” the letter does not consider that the dispatch center and radio system are under the control of the county, not the employers.

(Cities response) While the radio system and dispatch center are not under the control of the employers, the employees of the employers are exposed to the problems with the system.

(Cities response) IL OSHA realizes that the employers may have influence, but not total control of over the radio system. This is reflected in the fact that a hazard alert letter was issued for this problem instead of a citation.

Rock Falls was issued two willful violations, one serious violation and one hazard letter, and fined $12,000. Sterling was issued three willful violations, two serious violations and a hazard letter, and fined $24,000.

In addition to 11 indirect causes of the incident, the report provides 15 recommendations to reduce the chances of future firefighter deaths.

The Sterling and Rock Falls fire departments were issued citations for violating the Illinois Occupational Safety and Health Act, two classified as willful violations that carry monetary penalties.

Rock Falls was fined $12,000; Sterling $24,000.

“The municipal fire department employers have since addressed and abated the violations and the inspections were closed by IL OSHA,” the agency said in a news release regarding the report, which never names either department, Ramos, or any of the other firefighters involved by name.