Firefighter Joyce Craig made five "Mayday" distress transmissions as she became trapped in the dining room of a burning West Oak Lane home on Dec. 9, 2014.
"Engine 73 can't breathe, I can't breathe," Craig, 37, said in her final transmission.
Nine minutes later, Craig – the first female Philadelphia firefighter to die in the line of duty – was found by her comrades with her left hand still near the nozzle of her fire hose, according to a report released Monday by the National Institute for Occupational Safety and Health. She was pronounced dead a short time later at a hospital.
The NIOSH report cites several factors in Craig's death, including broken and outdated breathing equipment, becoming separated from her crew members, unrestricted air flow in the house, and a backup team that took 21 minutes to arrive.
The report also criticizes the controversial "brownout" policy that temporarily took engines or ladders out of service and a firefighter rotation policy, both of which were in effect at the time of Craig's death but since have been discontinued.
The policies "may impact effective firefighting teams and removes firefighting expertise from neighborhoods and the family culture," the report says. "An important aspect of being a fireighter is being able to work as a member of a team."
Among the report's 10 recommendations: Firefighters should be trained in the best firefighting tactics; crews should stick together when fighting fires; all firefighters should be trained in Mayday techniques; and the department should consider upgrading its breathing apparatus.
In a statement Monday, Fire Commissioner Adam Thiel said the Philadelphia Fire Marshal's Office had reached many of the same conclusions about training, communication, and equipment. He said breathing equipment already had been updated and more firefighter positions added this year, with more expected in 2018.
"Joyce Craig's death was devastating to her family and to the Department," Thiel wrote. "We hope the lessons learned from these reports will prevent such tragedies in the future."
Craig, a mother of two, had been with the department for 11 years. In January 2015, she was posthumously promoted to lieutenant.
The fire that claimed Craig's life began around 2:49 a.m. in a middle-of-the-row house on the 1600 block of Middleton Street. The fire originated in a recreation room of the basement, but the cause remains "undetermined," according to the report.
During the blaze, which took firefighters 38 minutes to bring under control, an elderly woman was rescued from the second floor.
According to the report, firefighters should always enter a burning building in teams of at least two, "and no fire fighter is allowed to be alone at any time while entering, operating in, or exiting a building."
But Craig became separated from her team in the smoke and heat, and her two team members left the house without her, believing she already had escaped, the report says.
NIOSH found that although Craig's 2013 face piece for her self-contained breathing apparatus worked properly, her 2002-edition buddy breather hose "suffered a catastrophic thermal degradation resulting in a very large and quick air loss."
The cause of death, according to the Medical Examiner's Office, was suffocation: She had no signs of smoke inhalation and her burns were not fatal, the NIOSH report says.
Although Craig was able to call for help, "the response seemed delayed," according to the report. Firefighters were not able to "establish verbal communication" with Craig, which could have helped them find her, the report says. And although her radio worked, Craig's older-model personal alert safety system did not sound, the report says.
The lawyers representing her estate, Robert J. Mongeluzzi, David L. Kwass and David J. Langsam, issued a statement saying the report aids their case in a pending suit against the companies that manufactured her safety gear.
"This report appears to advance our arguments regarding the liability of the equipment manufacturer and affiliated defendants," they said, adding that it is silent on how those responsible should be held accountable.
"Those questions will ultimately be answered at trial by a jury," the statement said.
Craig was stationed at Engine 64 in Crescentville, but was working overtime that day with Engine 73 in West Oak Lane. Another factor that led to a delay in getting to her, the report says, was that when another female firefighter exited the burning building, she was mistaken for Craig, "since normally Engine 73 only has one female in their company." The emergency was briefly suspended before the mistake was realized and the search continued, according to the report.
The Rapid Intervention Team (RIT) — a ladder assigned for "rapid deployment to complete any emergency search or rescue" — that was supposed to respond to the fire was on a medical call, the report says, and another ladder company took 21 minutes to arrive because it was not familiar with the streets.
Thiel is scheduled to discuss the report at a news conference Tuesday morning.