SPRINGFIELD, Ill. (WCIA) — Illinois labor officials are issuing a series of statewide recommendations to improve firefighter safety following a two-year investigation into the death of a Chicago firefighter.

Mashawn Plummer, 30, was critically injured the morning of Dec. 16, 2021, while battling an apartment building fire. Just six months after graduating from the Chicago Fire Academy, Plummer died five days after the fire. A civilian woman who was pulled out of the fire also died.

Investigators with the Illinois Department of Labor’s Division of Occupational Safety and Health (IL OSHA) found the primary cause of Plummer’s death was a catastrophic malfunction of his self-contained breathing apparatus. The hose connecting Plummer’s mask to his air tank tore in two places, rapidly depleting his only source of breathable air in heavy smoke conditions. It remains unknown why the air hose tore during the fire; the SCBA passed an inspection the day before.

However, IL OSHA identified several factors that contributed to Plummer’s death, which influenced their recommendations. They found that when Plummer’s SCBA malfunctioned, he was alone and most of the firefighters at the scene didn’t hear the mayday call Plummer made due to several radio channels being used.

Both of these factors were in violation of the Chicago Fire Department’s written policy and standard operating procedure, which states:

• Firefighters must enter a structure together, stay together and exit together.
• Company officers must ensure that all firefighters under their command are on appropriate tactical radio channels.
• Personnel on scene, including battalion chiefs, company officers and firefighters, must monitor tactical radio channels for critical reports.

Plummer’s company and the battalion chief that took over incident command did not follow these procedures, IL OSHA said. Not only was Plummer alone for 10 minutes, but the CFD’s main dispatch center was aware of his mayday call before the chief was, due to a radio call on the wrong channel.

It took five minutes for the chief, who at one point told dispatch a mayday emergency was not happening, to realize that Plummer was missing and a mayday emergency was in fact happening.

Other contributing factors in Plummer’s death, IL OSHA found, include:

• Plummer was not closely supervised as a rookie firefighter should be.
• The SCBA’s malfunction was so serious that it was unlikely to be corrected inside the burning building. It also left Plummer with only minutes to find another source of air or leave the building
• Plummer’s mayday call did not include a unique identifier, such as his name.
• At least one firefighter heard Plummer’s personal alert safety system (PASS) going off, but dismissed it as a false alarm.
• Once located, Plummer did not receive emergency breathing air.

Following their investigation, IL OSHA cited the Chicago Fire Department for four offenses and recommended the following procedures during fires and during mayday emergencies. The recommendations are for not just the CFD, but all fire departments in the State of Illinois:

• Firefighters entering burning buildings should:
  • Perform a radio check before going inside.
  • Enter with their team, stay together and exit together.
• Firefighters in distress should say their name during a mayday call and repeat their call until the incident commander acknowledges them.
• Firefighters searching for downed firefighters should immediately provide said firefighter with emergency air, with one firefighter assigned as the “air firefighter.”
• Company officers should ensure
  • Close supervision of inexperienced firefighters.
  • That firefighters going into a burning building are on the appropriate radio channel.
• Incident commanders should
  • Establish radio contact with firefighters going into burning buildings.
  • Have zero tolerance for firefighters operating inside buildings alone.
  • Ensure all personnel receive emergency or mayday calls immediately.
  • Treat any potential mayday call as an actual mayday call until proven otherwise.
  • Ensure that PASS alarms are treated as firefighter distress alarms and combat the prevalence of false alarms at fire scenes.
• Fire department leaders should
  • Program portable radios with an emergency button that alerts firefighters to a firefighter in distress.
  • Ensure company and command officers serving in acting roles are trained at the levels they are temporarily operating at.

IL OSHA said they hope their incident report on Plummer’s death serves as an educational resource for Illinois fire departments to follow to ensure other firefighters remain safe on the job. It can be viewed in full by clicking here.