TOLEDO, OH (Toledo News Now) - On January 26, 2014 two Toledo Firefighters died fighting a fire on Magnolia Street in north Toledo.
Now 15 months later a federal report outlines what went wrong that day.
The report was compiled after an investigation by the National Institute for Occupational Safety and Health or NIOSH. It points out possible errors which contributed to the deaths of Privates Steve Machcinski and Jamie Dickman.
The report is not intended to place blame on anyone for what happened at the scene of the fatal fire. It is meant to point out areas where the Toledo Fire Department lacked and where changes should be made to prevent a similar tragedy.
The report states Private Machcinski and Private Dickman were assigned to attack when they arrived on scene that day. Both firefighters entered the burning building through a second story front window. Crews believed the fire was concentrated on the second floor or “division 2.”
The NIOSH report gives a list of contributing factors that led to the two firefighters losing their lives. Arson is at the top of the list.
Ray Abou-Arab, the owner of the Magnolia Street building, is facing murder charges after investigators say he started the fire.
Crew staffing is also listed as a factor. The report points out there were 10 probationary firefighters on the scene of the fire out of 25 total fire staff. A probationary firefighter is one with less than a year of experience on the line or responding to fires.
Sources say that historically in Toledo, probationary firefighters should be teamed up one on one with an Officer such as a lieutenant or captain of the department.
According to the NIOSH report there were only 6 officers and 10 probationary crew members on scene that day on Magnolia Street.
Listed next on the report is an inadequate water supply. The report says a permanent water supply was not established in a timely manner, and that National Fire Protection Association standards were not followed for pumping water. NIOSH states the pump operator needed to be trained and certified to provide sufficient water supply.
The report says privates Machcinski and Dickman had an “uncharged line” with them inside the building. That means hoses did not immediately have water being pumped through them. NIOSH says attack crews should always enter a hazardous environment with a charged hose line.
Another issue, according to the report, was ventilating the building. NIOSH says firefighters failed to coordinate ventilation, which contributed to Machcinski and Dickman's deaths. The report says a second story door and window were open as well as a door on the first floor and later a garage door.
NIOSH points out that adding air to fire without applying water in the appropriate time frame will cause the fire to grow and put firefighters at risk.
According to NIOSH, TFD did not have a full time safety officer at the scene of the fire from the start. A firefighter was assigned to be the safety officer on scene just 4 minutes before the first mayday call. NIOSH says firefighter were already inside the building fighting the fire when the safety officer arrived.
A safety officer is in charge of assessing risk at a fire scene. His or her main job is to keep crews safe. TFD once had full time safety officers, but WTOL 11 has uncovered that the full time dedicated positions were eliminated in the 2012 contract.
Toledo Firefighters Local 92 President Jeff Romstadt says he is not surprised by the findings in the NIOSH report.
He says although the official and final report will be out in the next day or so, this version was shared with the families of both the fallen firefighters.
Romstadt says he hopes all the recommendations will be implemented and that this released NIOSH report finally lets firefighters know what happened.
According to Romstadt, the city conducted their own investigation and generated their own report, but the union and its members were not able to see it.
The NIOSH report was the unions first look at what went wrong that tragic day.
"They did not share the department as a whole, so we really haven't critiqued the fire, or know what we've done wrong for the past 16 months and we at the local, we had a problem with that," said Romstadt.
Other firefighters says they know the report is out and they're curious to read it. They say they have read NIOSH reports for other incidents and that they use them not to assign blame, but as a learning tool for the future.
See the full NIOSH report
Tune in to WTOL 11 and FOX Toledo now for more.
Read more on Toledo's Fallen Heroes here.