A faulty elevator door fire that investigators said was the primary factor in the death of a Cincinnati firefighter last year has been an issue for years, the building's residents said.A 30-year veteran firefighter, Gordon died on March 26, 2015 while searching for victims after a fire on Dalghren Street in Madisonville. Fire apparatus operator Gordon fell to his death in an elevator shaft at the King Towers Apartments while responding with Heavy Rescue Unit 14.Watch the latest report | Full news conferenceThe fifth-floor door to the elevator opened even when the elevator car was not present, the fire department's report states. A latch built to keep the door closed until the elevator arrived on the floor was faulty.바카라 게임 웹사이트�The real problem here that resulted in the accident with Daryl was the failure of the elevator door,바카라 게임 웹사이트� District Fire Chief Greg Potter said.Though the elevator passed inspection four months before Gordon's death, residents told fire investigators that the door had malfunctioned for several years.A fire specialist from Cincinnati's Fire Prevention Bureau visited the elevator the day before Gordon's death, after a fire lieutenant noted problems with the elevator's alarm system.After the March 2015 fire, the Fire Prevention Bureau noted 60 violations in the apartment building.Though Cincinnati Firefighter, Daryl Gordon, died after falling through a faulty elevator door at a March 2015 fire scene, several other factors contributed to his death, as well, a report released Thursday states.The City of Cincinnati's 353-page report detailing Gordon's death lists factors related to training, operations and communication."Whenever a department has a loss of a firefighter, we like to take that to honor them by doing an exhaustive report on what happened. We look at everything on that day, what everyone was doing," said Cincinnati Fire Chief Richard Braun.바카라게임 is reviewing what바카라 게임 웹사이트�s being called the 바카라 게임 웹사이트�Line of Duty Death Report.바카라 게임 웹사이트� Here are some of the report바카라 게임 웹사이트�s key findings.View the report - Note: Report is 350+ pages; may take some time to loadThe elevator's broken door latch was the primary factor in Gordon's death, the Line of Duty Death Report states, but Braun said the department has learned several lessons from the death and lists 44 areas of improvement for the department.The report recommends that the department improve its training, operations and communication. Several specific suggestions are listed in the report, including increasing training staff and upgrading the training facility, creating a division chief rank and improving radio communication skills.Firefighter Union President Matt Alter was critical of the department's staffing levels, and Braun said that low staffing, referred to as "brownouts," that ended in 2014 contributed to limited training.While he hopes staffing levels will improve, Alter said he valued the effort that went into the Line of Duty Death Report and said learning lessons from Gordon바카라 게임 웹사이트�s death is critical.바카라 게임 웹사이트�Making sure that we do everything we can to implement all these recommendations is the least we can do to honor his family,바카라 게임 웹사이트� Alter said. 바카라 게임 웹사이트�The way that we can really honor Daryl's legacy is to make sure that we do everything we can to make sure it doesn't happen again.바카라 게임 웹사이트�The report also recommends that the department step up its fire prevention education efforts.Cincinnati investigators had already concluded the fire's cause was accidental, ignited by food left unattended on a stove.Three other firefighters had injuries, and three residents were treated at hospitals, the report stated. A total 21 residents were rescued.The report indicates firefighters initially expected a fairly minor "food-on-the-stove" fire inside a unit in the apartment building on Dahlgren Street.The occupant awoke to the smell of smoke and called 911.The occupant then left the apartment, but the report says the apartment door "remained opened due to a faulty self-closing mechanism, allowing smoke and fire to spread throughout the building."When Gordon arrived at the scene of the fire with Rescue Unit 14, 30 minutes after the original 911 call, the fire was out, but residents were still trapped on the higher floors due to the smoke.Gordon was ordered to assist with the primary search of the apartment building's 5th floor. As Gordon put on his breathing mask, the report says, he became separated from his crew.The three other members of his team found an elevator shaft on the 5th floor with a broken latch on its door, and wrote a warning on the door: "Do Not Enter Open Shaft." They told a supervisor about the faulty elevator door, but the report says the information was not broadcast over the radio.At some point later, Gordon opened the door and fell into the shaft. His colleagues did not realize he was missing for more than 10 minutes, the report adds.Gordon had fallen from the fifth floor to the elevator's roof, which was stopped on the second floor, and gotten wedged between the elevator and a wall, the report said.바카라 게임 웹사이트�We thought he was on top of the elevator,바카라 게임 웹사이트� Assistant Fire Chief Thomas Lakamp said, 바카라 게임 웹사이트�We went to the top of the elevator and realized he was wedged in between the elevator car and the back wall of the elevator shaft, in a space of about 12 inches.바카라 게임 웹사이트�His colleagues tried heroically to save him, tearing the wall down behind the elevator shaft to free his body. After 14 frantic minutes, Gordon was rushed to UC Medical Center, where he was pronounced dead.The report was 바카라 게임 웹사이트�dedicated to Fire Apparatus Operator Daryl Gordon, his wife Angela, his daughters Angelique and Chelsea, his extended family and his brother and sister firefighters within the Cincinnati Fire Department. Daryl will never be forgotten, and, to honor his sacrifice, the Cincinnati Fire Department will share our lessons learned from this tragic day."The report says, "Every firefighter should feel a sense of pride in believing that Daryl's sacrifice will help prevent others from experiencing this same type of tragic loss - not only in Cincinnati, but nationwide."Gordon joined the Cincinnati Fire Department June 30, 1985. He was also a 10-year employee of UC Health Air Care and Mobile Care unit.Large crowds of Cincinnati officials, residents and firefighters from around the country turned out for services honoring the 54-year-old Gordon.