The National Institute for Occupational Safety and Health, a divison of the Centers for Disease Control & Prevention, has issued its final report on the February 2007 death of fire cadet Racheal M. Wilson.

Wilson died in a training blaze set at a rowhouse in Southwest Baltimore that was riddled with dozens of safety lapses. Three fire officers were fired, though one won his job back, and several others were disciplined. The fire chief at the time resigned a few months later, citing personal reasons.

The Baltimore Fire Department and state authorities have already issued several critical reports on the fire and the city has made numerous reforms at its academy, to training standards and banned the practice of live-fire exercises at buildings in the city.

Problems cited in the reports included setting multiple fires when the national standard for training calls for only one, using a building that was so badly damaged that it helped the fire spread out of control, failing to instruct the trainees as to the nature of the exercise, giving them equipment that includes coats with holes, not having a backup firefighter with a charged hose line, and using supervisors who had no experience training recruits.

The city's report concluded, according to a Baltimore Sun article, that "Wilson had been sent into a burning building with an inexperienced instructor who didn't have a radio, wearing old protective pants with holes that frayed in the heat. She was ordered to climb above fires before putting them out, ultimately becoming trapped at a third-floor window when the flames below raged out of control."

The new federal report draws many of the same conclusions, but does recommend that the Fire Department "create a training atmosphere that is free from intimidation and conducive to learning."

The report doesn't expand on this, but the Baltimore Fire Department responded by announcing a new fitness program and said it has no plans to resume live-fire exercises.