You can read the entire report here.
The following are the contributing factors according the report:
- Lack of a vacant / hazardous building marking program within the city
- Vacant / hazardous building information not part of automatic dispatch system
- Dilapidated condition of the structure
- Dispatch occurred during shift change resulting in fragmented crews
- Weather conditions including snow accumulation on roof and frozen water hydrants
- Not all fire fighters equipped with radios.
- Identify and mark buildings that present hazards to fire fighters and the public
- Use risk management principles at all structure fires and especially abandoned or vacant unsecured structures
- Train fire fighters to communicate interior conditions to the Incident Commander as soon as possible and to provide regular updates
- Provide battalion chiefs with a staff assistant or chief's aide to help manage information and communication
- Provide all fire fighters with radios and train them on their proper use
- Develop, train on, and enforce the use of standard operating procedures that specifically address operations in abandoned and vacant structures