It comes down to a lack of continuing training for firefighters and a complicated radio system they used on calls like the one on Dalhgren Street in Madisonville 15 months ago.
A 350-page report, released Thursday, lays out how a fire combined with human error resulted in firefighter Daryl Gordon's death. The call for help on March 26, 2015 - "Mayday! Mayday! Mayday! We have a firefighter down!" - is still fresh in the minds of every Cincinnati firefighter.
Fire Apparatus Officer Gordon fell down an elevator shaft as he searched for victims in a fire at the King Towers apartments. Assistant Chief Tom Lakamp can't forget that morning.
Due to reduced staffing levels, Gordon was with a rescue squad that day, not on a truck in his usual job."FAO Gordon was assigned to the rescue company just for that day. He was not a permanently assigned rescue technician," Lakamp said.
Lakamp and Chief Richard Braun admitted Thursday for the first time that human error contributed to Gordon's death.
The report from the fire department's investigation says Gordon likely didn't hear a warning from his partners about the elevator shaft he fell into. That's because half of the firefighters were on different radio channels that morning.