The Inwood Fire Department violated federal safety and training standards when it allowed a firefighter to enter a burning house in December without an assigned partner, a state report investigating the firefighter's death has found.
Only a mayday issued later alerted authorities that Joseph Sanford Jr. was missing in action, according to the state Labor Department's Public Employee Safety and Health Bureau, which monitors volunteer fire departments.
Sanford, 43, and four other Inwood firefighters rushed to the Woodmere blaze before dawn on Dec. 19, but the men did not give the Woodmere incident commander their "accountability tags" -- ID tags used in roll call when firefighters are ordered out of collapsing buildings and other dangerous conditions, the six-page report said.
The partner rule -- known as "two in, two out" -- requires every firefighter entering a burning building to have a designated colleague for "constant visual or voice contact," the report said.
"Inwood FD members . . . had conflicting accounts of Mr. Sanford's whereabouts after the initial entry into the fire structure," state investigators wrote, "and none could account for his whereabouts for several minutes before the mayday call.
"No attempt was made by the fire team to contact Mr. Sanford during this period, nor was Mr. Sanford assigned a specific partner or task."
Fire officials Friday said Inwood violated fundamental safety tenets taught in fire academies.
The state issued four citations for the violations in July. Newsday obtained a copy of the report Thursday.
Inwood officials, who have already submitted a corrective action plan, have accepted the violations but don't believe Sanford's death was caused by them.
No fines will be levied unless Inwood fails to follow the plan, the state said.
During the fire, it remains unclear whether the Inwood team knew their assignment had changed from searching for occupants to remaining outside as standby to rescue firefighters, the report said.
The confusion became apparent when Sanford was found in the basement, and the fire scene commander was surprised to learn Inwood firefighters had entered the house, the report said.
Sanford was a respected 17-year veteran who was once assistant chief and head of training. "This was a freak, freak accident," said Anthony Rivelli, who was chief at the time. "Joe was good, Joe was quick. Joe knew what he was doing."
Fire officials across the Island were anticipating the report to learn more about what happened and prevent further tragedies when several departments respond to a fire. They want uniformity in equipment and policies among the departments, from hoses to training.
Sanford's file did not show he had completed certain training, so Inwood was also cited for failing to train everyone annually on respiratory protection gear and quarterly for members who may be assigned to enter burning buildings.
Gaetano Marino, who became Inwood chief this year, said yesterday the department has pledged stricter enforcement of training and safety rules. Firefighters who flout the rules would get a verbal warning the first time, followed by a written one, then suspension and expulsion in rare cases, he said.
"You take it and you work with it," Marino said of the state's findings. "You show as a chief officer that you're there to change something so it doesn't happen again."
The house was under renovation and the blaze started when a bag of staining materials in a first-floor hallway spontaneously combusted, creating a hole in the floor, according to the Nassau County fire marshal's office. Sanford was found facedown in up to 18 inches of water and partially covered by a piece of furniture that had been moved by other firefighters to cover the hole.
Sanford died four days later from complications of a near drowning, the report said.
State investigators did not say if Sanford fell through the hole or if he went down into the basement and was hit by falling furniture.
According to state investigators, who interviewed the three surviving Inwood firefighters who went inside the burning house, the team broke up shortly afterward.
They were entering from the rear when one of the firefighters had an air pack malfunction and returned to the fire truck.
The other three searched part of the first floor and saw a "pitched and partially collapsing floor," the report said. The team's acting commanding officer ordered everyone to the rear of the house. One of the firefighters stayed to help another department's hose team.
Moments later, the acting commander went to the middle of the first floor where he met his colleague, who had returned with an air pack. At that point, they didn't know where Sanford was, investigators said.
Attorney Christopher McGrath, who represents Sanford's widow, Jacqueline Scott-Sanford, said the firefighter would never have worked without a partner because he was "Mr. By the Books."
His widow has filed a wrongful-death lawsuit against the Woodmere home's owners and the painters. "The question that is always going to remain is how did this happen?" said McGrath, of Garden City. "What we hope happens is that all the fire companies learn a lesson from this, train harder and make sure everyone is accountable, that no one is left alone inside a fire."
The National Institute for Occupational Safety and Health, part of the U.S. Centers for Disease Control and Prevention, intends to release a more in-depth report on the fire response by December.