The San Francisco firefighter who fell to his death on Wednesday was knocked over by a water blast from a supply valve he “inadvertently” opened during a training drill, according to the department’s preliminary report obtained by the NBC Bay Area Investigative Unit.
The report stresses that department-wide measures designed to control the spread of Covid-19 likely played a role in Jason Cortez’s death on Wednesday. The accident happened at 10:07 a.m. at a training tower facility at 19th and Folsom street, while just four firefighters took part in a “pump drill” exercise designed to train a rookie – half the normal complement of personnel.
SFFD and national training standards normally call for more than one engine company to be involved in such exercises, but “due to COVID restrictions, Engine 3 conducted this drill alone,” according to the report findings.
That short-staffing may have led to confusion, the report suggests. As evidenced when Cortez inexplicably left other firefighters dousing the simulated fire on the third floor of the department’s training tower to return to fire escape below. It was at that point, the probe found, that he opened a valve on a two-sided connector attached to a wall mounted “standpipe” nozzle. The nozzle is part of the standpipe system built into high-rises that uses internal pipes to help firefighters get pressured water to flow to upper floors.
While one side of the connector on that standpipe nozzle was used to feed the hose, the other was shut off. It was that side, the report said, that Cortez had “inadvertently” opened, possibly intending to drain the system.
“The stream of water coming from the (valve) struck him in the chest, knocking him backwards into the fire escape railing, causing him to fall backwards off the fire escape,” according to the report.
The report indicated that the stream of water flowed out at as much as 100 pounds per square inch pressure.
The report stops short of saying that Cortez thought the drill was over, however.
“It is not known why he was standing on the fire escape at this time as the drill was not completed,” the report found.
But veteran firefighters say the evidence laid out in the report does substantiate why Cortez may have thought the drill was indeed over. They note that Cortez went out onto the fire escape landing just as the drill was entering a new phase. The idea was to cut the water pressure as a sign that water supplies were running low and needed to be replenished. But, they say, its possible that Cortez took the fluctuation as a sign water was being shut off and the drill was in fact over.
In fact, the report notes, that it was just as the water supply was fluctuating that the lieutenant in charge of the drill looked up and saw Cortez on the fire escape landing, and then witnessed him open the valve and get knocked over the railing.
The report cited several contributing factors for the accident, notably the department’s suspension of multiple company drills as a precaution to limit contact between firefighters in response to Covid-19 concerns.
The drill would normally be conducted with at least two engine companies and a total of eight firefighters, instead of four, the report stressed.
But because of that Covid-19 skeleton crew, the report concluded, each “firefighter was required to carry out tasks individually which are normally done as part of a team.”
The report also advised that “extreme caution must be exercised when conducting drills individually that normally require multiple companies” and that firefighters should review manual sections related to filling and draining building standpipe systems and safety reviews of other recent firefighter deaths.