BALTIMORE — On Friday, Niles Ford resigned from his longtime position as Baltimore City Fire Chief.
He steps down in light of a new 314 page report that investigated the line of duty deaths of three firefighters in January.
Paul Butrim, Kelsey Sadler and Kenneth Lacayo lost their lives after becoming trapped in a burning vacant home that collapsed.
Following the incident, Ford assembled a Board of Inquiry to take a deep dive into what went wrong.
Their findings were revealed Friday and turned out to be highly critical of the department's response that day, prompting Ford's immediate resignation.
In the report, the panel makes frequent mention of confusion and disorganization on scene as crews determined how to best battle the blaze.
"In several instances, important reports and requests associated with the rescue were followed by units calling en route, radio traffic concerning water supply, and suppression activities in the exposure dwellings," the panel wrote in their report. "The issue of increased and unnecessary radio traffic was prevalent throughout most of this incident."
In a one hour time span, the report found 185 subscriber rejects, meaning that 185 times someone tried to transmit a message but were rejected due to other radio traffic.
Sadler and Lacayo, along with firefighter John McMaster were aboard Engine 14, who arrived first on scene.
The report concluded that the engine's crew members failed to announce they had arrived, and assumed "first due engine responsibilities."
McMaster and Lacayo were later found to have left their portable radios in the truck, and therefore couldn't be reached.
Less than 10 minutes in, the incident commander told investigators he'd made the decision to order an evacuation.
But over the next 29 seconds, before he could even key up on the radio, the catastrophic collapse occurred, creating confusion of how many firefighters were trapped.
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The report suggests the incident commander might have been overwhelmed, in part because responsibilities weren't being properly relegated to others.
McMaster was the first member rescued and in the quickest amount of time at 14 minutes. He survived but was badly injured. It took 90 minutes to pull Lacayo from the rubble, and 130 minutes to get to Sadler.
A firefighter then noticed his lieutenant was unaccounted for, which is what prompted a search for Butrim.
His body wasn't recovered until more than 10 hours later.
Another highlight of the report is the ongoing problem the city faces with vacant buildings.
MORE: Same vacant home that collapsed killing three Baltimore firefighters also caught fire in 2015
The panel cites the U.S. Census Bureau which estimates half of all buildings in Baltimore City are vacant.
In the Mount Clare area alone, where the fatal fire took place, there are 547 vacant buildings, according to the report.
They accuse the City of undercounting vacant buildings and fires associated with them.
"The City of Baltimore’s definition of vacant buildings, as well as inconsistent data collection methods, leads to underreporting or misclassification of fires that are marked as trash or left undetermined," the report reads.
In closing the panel made several recommendations, including some that were supposed to be implemented in the past.
"There was no program or policy in effect that addressed notification to members of dwellings which were vacant and unsafe," the report said. "The pilot program for Unsafe Vacant Buildings, established in 2010 by Departmental Order 102-10, was not continuously supported and never fully implemented throughout the Department. The absence of critical building information to responding units and the lack of a visual que on the building was detrimental to the outcome of this fire."
Back in October the City relaunched a similar program that entailed posting red reflective signs on the front and back of vacant buildings that have been deemed unsafe.
"My administration will immediately establish an accountability program to ensure that these recommendations are properly implemented and that we have a department that is not only committed to protecting and saving the lives of our residents, but is equally committed to carrying out this work in a manner that also safeguards the lives of those men and women who selflessly serve others on a daily basis," said Mayor Brandon Scott upon release of the report.
Ford was hired by former Mayor Stephanie Rawlings Blake in 2014, after a stint as City Manager in Chamblee, Georgia. Prior to that, he served nearly four years as Fire Chief in Lincoln, Nebraska.
While the City searches for Ford's permanent replacement, Assistant Chiefs Charles Svehla, Chris Caisse, and Dante Stewart will rotate in an acting capacity.
SEE ALSO: ATF completes investigation into January 24 fire that killed 3 Baltimore City firefighters
As for the criminal aspect of the investigation, the ATF recently referred their findings to the Baltimore City State's Attorney's Office.
Little information has been revealed on any potential suspects. So far, investigators have only released a 40 second video clip that shows a person near the scene of the fire the night before. In February a $100,000 reward was offered for information leading to that person's identity. Since then, there has been no update on whether or not that individual was ever identified, or if he's still even considered a suspect or person of interest.
