Independent investigators have faulted Coatesville fire officials in the response to a blaze last fall that injured seven firefighters, according to The Daily Local News.
The 26-page report listed mismanagement, poor communication and broken leadership by Fire Chief Kevin Johnson and other commanders as significant factors during the Sept. 10, 2010 apartment fire.
More than 100 firefighters responded to the blaze at the Millview Apartments in the 1800 block of Saginaw Drive that caused approximately $1.5 million in damage to the 28-unit building.
A ceiling collapsed during the blaze, injuring seven firefighters, including Deputy Chief Robert Pacana.
Pacana -- who is also a paid firefighter in Washington, D.C. -- suffered severe burns and a serious leg injury and not been able to return to work.
The report states that the breakdown in communication led firefighters to "stay in an area of danger for far too long."
It also alleges that at least two Mayday calls went unanswered.
The city hired two retired Philadelphia deputy fire chiefs to conduct an independent investigation after Johnson called for one.
The fire chief received the report on March 29, but the city still has not released it to the public, according to the newspaper.
In April, the Daily Local News made a formal request for a copy of the report, but the city requested an additional 30 days to determine if the report should be released. The newspaper was later able obtained the report through another source.
The investigators outlined 24 recommendations on how to improve emergency responses based on how the incident was handled.
While an Incident Action Plan is required for all incidents, one did not exist for the fire at the Millview Apartments.
Investigators said that moving forward, the department should have a plan in place for all incidents.
"Though the incident commander may have had a mental plan at this incident; it was never made known to anyone," the report states.
The report goes on to state that without a plan, the firefighters working inside the burning building did not receiving appropriate guidance from their leaders.
The investigators also found issues with determining who was in command of the incident and said training is needed to clarify roles and responsibilities.