A $31.5M Verdict: Why Command Skills and Mayday Training Are Not Optional

Introduction

In November 2025, a jury awarded the widow and children of a Sterling, Illinois Fire Lieutenant Garrett Ramos $31.5 million in a wrongful death case stemming from a 2021 residential fire. The outcome is sobering but it should also be a wakeup call for every fire and rescue agency.

This verdict reflects not only the tragic loss of a fire officer but also systemic failures in size-up, risk management, accountability, response to maydays, and operational discipline.

Systematic failures like this are not isolated or unpredictable. They highlight what many of us in the fire service already know:

Command skills are perishable, and mayday management cannot be improvised on the fireground. Training at the task, tactical, and strategic levels must be deliberate, frequent, and realistic.

A Brief Summary of the Incident

At 23:04 on December 3, 2021, the Sterling (IL) fire department provided automatic aid to the City of Rock Falls for a residential fire. Response time from dispatch to arrival of the first fire department unit was 10 minutes. City of Rock Falls Fire Chief Cris Bouwens arrived first to find a small, one-story house with a working fire in the garage with flames through the roof and extension into the home. Occupants reported that everyone was out of the house. Chief Bouwens assumed command at 23:14 and assigned Engine 48 to stretch two attack lines and on the arrival of Engine 6, initiated an exterior attack on the garage (NIOSH, 2025).

At 23:18, four minutes after command was established, Sterling Fire Department Deputy Chief Ken Wolf arrived and was assigned as the “Accountability Officer”. The crews of Engine 48, Engine 6, and Water Tender 1 transitioned to the interior through Side Alpha for fire control (NIOSH, 2025).

At 23:21, seven minutes after Chief Bouwens assumed command, the Sterling Fire Chief arrived and was assigned as “Operations Section Chief/Division Alpha”. Approximately five minutes after taking command, Chief Bouwens performed 360-degree reconnaissance from Side Delta to Charlie (counterclockwise) but failed to identify the presence and involvement or lack of involvement of the lookout basement. The house had two lookout windows on Side Charlie (NIOSH, 2025).

23:28, fourteen minutes after Chief Bouwens assumed command, The Sterling Fire Department Deputy Chief arrived and was assigned as Division Charlie Supervisor (NIOSH, 2025). Fireground operating time was now 15 minutes (total time since dispatch was 25 minutes).

Engine 48, Engine 6, and Water Tender 1 exited the building with their low air alarms sounding (NIOSH, 2025).

The crews from companies that had been operating inside the building split into mixed crews with personnel from different companies working together. Crews rotated in and out of the building for an extended time. At 23:59, Chief Bouwens reported the fire under control (NIOSH, 2025). Fireground operating time was now 50 minutes (total time since dispatch was 60 minutes).

At 00:01 a radio report was transmitted reporting a partial floor collapse. While exiting the building, Lieutenant Ramos fell through the floor of the family room in the center of the house on Side Alpha, ending up in the basement. At approximately 00:04 Lieutenant Garrett Ramos transmitted a Mayday. Command transmitted emergency traffic and asked for the member who called the Mayday to repeat the message. There was no response. The family room, where Lieutenant Ramos fell through the floor was heavily involved in fire (NIOSH, 2025). Fireground operating time was now 55 minutes (total time since dispatch was 60 minutes).

Two minutes after Lieutenant Ramos’s Mayday, a personnel accountability report was requested. A different firefighter (not Lieutenant Ramos) was thought to be missing and was quickly located on Side Charlie and approximately 10-12 minutes later a message was transmitted stating “we have PAR”.

Firefighting operations continued until 00:29 when firefighters in rehab could not locate Lieutenant Ramos. A search operation was initiated with multiple crews attempting to find Lieutenant Ramos. During this search, The IC, Chief Bouwens, was advised that the house had a full basement. A crew attempted to access the basement but was unsuccessful due to debris from the collapse of floor 1. Crews then cut a hole in the floor of a bedroom to gain access to the basement away from the collapse area. Shortly after crews entered the basement, they heard a personal alert safety system (PASS) sounding and located Lieutenant Ramos at approximately 00:59 with his facepiece and regulator intact and his helmet on (NIOSH, 2025). Elapsed time since Lieutenant Ramos had transmitted the Mayday 58 minutes.

Two initial attempts to remove Lieutenant Ramos from the basement were unsuccessful. However, on a third attempt, Lieutenant Ramos was removed from the basement and transferred to emergency medical services (EMS) at 01:02 (NIOSH, 2025). The total elapsed time from Lieutenant Ramos’s Mayday until he was transferred to EMS was 61 minutes.

NIOSH Top 5 Causes of Traumatic LODD on the Fireground

Growing out of an informal analysis performed by Chief Ron Sarnicki in 2013, the NIOSH 5 is an informal list of the five most common contributing factors that lead to traumatic firefighter fatalities on the fireground. These factors have been repeatedly identified across fatal fireground events and near misses for more than a decade, yet they maintain persistent contributors to preventable line of duty injuries and fatalities.

  1. Improper risk assessment.
  2. Lack of incident command.
  3. Lack of accountability.
  4. Inadequate communications.
  5. Lack of, or failure to, follow standard operating procedures (SOPs).

The same factors contributed to the death of Lieutenant Ramos, 12 years after these factors were initially identified. “Those who cannot remember the past are condemned to repeat it” (Santayana, 1905, p. 284).

Detailed Contributing Factors

Different, but overlapping sets of contributing factors were identified by the Illinois Occupational Safety and Health Administration (IL OSHA) and the National Institute for Occupational Safety and Health (NIOSH).

Size-Up & Risk Assessment

  • Inadequate scene size-up and risk assessment (NIOSH, 2025)
  • Failure to withdraw interior firefighters in a timely manner (Fire Law, 2025)
  • Basement not identified during size-up (IL OSHA, 2022)
  • Failure to verify the presence of a basement (Fire Law, 2025)
  • Basement fire (NIOSH, 2025)

Accountability & Crew Integrity

  • Lack of personnel accountability (NIOSH, 2025)
  • Lack of crew integrity (NIOSH, 2025)
  • Interior firefighter teams did not always stay together (IL OSHA, 2022)

Communications/Mayday Management

  • Mayday call was received, but the caller was not identified or located (IL OSHA, 2022)
  • Failure to timely initiate the PAR in response to Mayday calls (Fire Law, 2025)
  • Failure to properly administer the PAR in response to the Mayday (Fire Law, 2025)

Command Structure & Organization

Failure to timely appoint a Safety Officer.

Training & Professional Development

  • Lack of professional development (NIOSH, 2025)
  • Failure to adequately train for Mayday and PAR response (Fire Law, 2025)

Other Factors

  • Lithium-ion battery fire (NIOSH, 2025)
  • Unpermitted occupancy renovations (NIOSH 2025)

While not identified as a contributing factor, the fire and rescue agencies involved in this incident did not have current, up to date standard operating guidelines and did not consistently train on their existing guidelines (Fire Law, 2025).

When these operational and systemic factors align, consequences can extend beyond the fireground into regulatory and legal arenas.

The Legal System Is Now Holding Departments Accountable

In December of 2022, Lieutenant Ramos’s widow, Brittney Ramos, filed a wrongful-death suit against the City of Rock Falls, former Fire Chief Chris Bouwens, and then-Deputy Chief (now Chief) Ken Wolf, who had served respectively as the Incident Commander and Accountability Officer during this incident.

The complaint alleged that the chief officers “willfully and wantonly” disregarded the safety of firefighters by failing to follow proper procedures, including size-up, risk assessment, identification of the presence of a basement, command, accountability, response to the Mayday. The legal system increasingly views failures in command performance not as unavoidable mistakes, but as preventable outcomes linked to insufficient or inconsistent training.

While laws differ from state to state, this verdict is a wakeup call for fire and rescue services throughout the United States.

Reflect on the Following Questions

These are the questions that every department should be asking, before an incident forces the issue.

  • What does your initial training for incident commanders look like for company and chief officers?
  • Does your training program address all the functions that an incident commander needs to perform during fireground operations?
  • Does your training program provide the opportunity for participants to develop competence through simulation?
  • Are participants assessed on their performance prior to becoming an incident commander?
  • Does your training program provide ongoing professional development to maintain incident commander’s critical skills?
  • Do you have standard operating guidelines (SOGs) that address the function of command and risk management and train on those SOGs on a regular basis?
  • Does your agency have integrated training on the task, tactical, and strategic levels focusing on accountability and mayday management?

If the answers to these questions are “we don’t” or “no”, it is time to get after it and do the work.

Required for All Fire Officers!

Read Curt Varone’s analysis of this case and watch the panel discussion between Curt, Brad Pinsky, Chief Gary Ludwid (expert witness for the plaintiff), and Michael Gallager (attorney for the plaintiff). Read the NIOSH Death in the Line of Duty and IL OSHA reports and complete the UL FSRI online course on basement fires.

Regardless of rank or experience, every officer should engage with the primary source material and analyses from this incident.

Ask yourself if an incident like this could happen in your organization. Failure to train is a leadership issue that can have far reaching impact on your organization, on you personally, and results in significant liability.

What Can You Do Today?

The purpose of an incident command system is simple: accomplish the work and survive the work. Think about it: How did you learn to be an incident commander? If the answer is primarily by watching others, then your training system relies on chance rather than competence.

Practical Steps to Address these Issues

Examine your current systems of work with a critical eye. What works and what could use improvement?

IC Training and Certification: If you don’t have a system for training and qualifying or certifying incident commanders, I would encourage you to take a hard look at Blue Card. This is not the entire answer, but it is an excellent starting point with an excellent curriculum and concepts grounded in decades of solid command concepts. While some think that this program is expensive, it costs considerably less than 31.5 million dollars.

Having implemented Blue Card in several small fire protection districts with limited staffing and having worked with others that have implemented this system in large agencies, I can say definitively that this system is adaptable to varied staffing levels and operational contexts. But regardless of if you use Blue Card or you don’t, you need to have system to train and qualify incident commanders to national standards such as National Fire Protection Association (NFPA) 1561 Standard on Emergency Services Incident Management System (2020a)and Command Safety and NFPA 1700 Guide for Structural Fire Fighting (2020b).

Incident Management and Mayday Simulation: Regardless of whether you use Blue Card or not, use of simulations as a part of incident commander training, assessment, and continuous professional development is an excellent tool (if combined with solid front end training on command, strategy, and tactics). This too has a cost in terms of the expense of simulation software, and the time to become proficient in its use, and to develop good simulations. In addition to basic command simulations, realistic mayday simulation provides an opportunity to test your system and see what works and what does not. When a Mayday occurs, the IC (and everyone else on the fireground) will be under maximum cognitive load, making simple, well-practiced command and communications skills essential.

Hot Washes and After Action Reviews: Use hot washes and after action reviews on incidents where things went well as well as those where things did not go as intended. Be honest and act on what you discover.

Free Resources for Improving Command Competence

Another free way to begin work on command skills is using tactical decision games. Command Competence offers free, weekly 10-Minute Training tactical decision games that are an excellent asset for developing company and chief officer skills in size-up, decision making, communications, and command.

These materials are free to any fire department and are designed for rapid, practical command training for company and chief officers.

📧 Subscribe for a weekly email with links to the current 10-Minute Training

In addition, Command Competence maintains free Mayday resources including training bulletins and a collection of tactical decision games involving maydays.

👉 Visit 10-Minute Training: The Mayday Collection

The failures identified in this, and many other line of duty deaths that have occurred on the fireground align directly with the competencies targeted in the 10-Minute Training Mayday Collection.

Conclusion

Tragedies like Lieutenant Ramos’s line of duty death remind us that fireground success is built on preparation, discipline and practice. Command skills fade without ongoing practice. Mayday management fails without task, tactical, and strategic level training. As the late Chief Alan Brunacini often said, “when something goes wrong, you need to be doing everything right”. Building competence and operational resilience requires training and ongoing professional development. The cost of not training is measured in lives, and increasingly, in legal consequences. It’s never too late to build a culture of competence, and never too early to start.

References

Santayana, G. (2017). The life of reason. New York: Charles Scribner’s Sons.

Fire Law. (2025). Deep dive: $31.5 million verdict in Illinois LODD case. Retrieved November 28, 2025, from https://bit.ly/3JYeqRu.

Varone, C. (2025). Widow of Illinois firefighter awarded $31.5 million in wrongful-death trial. Retrieve November 28, 2025, from https://bit.ly/3KqvFL8.

National Fire Protection Association (NFPA). (2020a) NFPA 1561 Standard on emergency services incident management system and command safety. Quincy, MA: Author.

National Fire Protection Association (NFPA). (2020b). NFPA 1700 guide for structural fire fighting. Quincy, MA: Author.

National Institute for Occupational Safety and Health. (2025). Line of duty death report F2022-09. Retrieved November 28, 2025, from https://bit.ly/43URXve.

Illinois Occupational Safety and Health Administration (IL OSHA). The Ridge Incident: firefighter dies in house fire after first floor collapse and loss of accountability. Retrieved November 28, 2025, from https://bit.ly/488k7.

Underwriters Laboratories Fire Safety Research Institute (UL FSRI). (2020). Understanding and fighting basement fires [On-Line Course]. Retrieved November 28, 2025, from https://bit.ly/3XXIrny.

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