A series of mistakes and misjudgments by fire personnel contributed to the injuries suffered by seven Prince George’s County firefighters when a fireball blew through a burning house last year, according to a 301-page report issued Monday by the county’s Fire and Emergency Medical Services Department.

After an exhaustive 15-month safety investigation, the report identifies a litany of factors that contributed to the severity and number of injuries in the February 2012 fire — including how fire personnel assessed the blaze’s dangers, critical strategic and tactical decisions once firefighters entered the condemned house, and problems with protective gear.

The comprehensive review, ordered last year by Fire Chief Marc S. Bashoor in the wake of the serious breach of firefighter safety, also identifies deficiencies in training, accountability, and command and control “at all levels,” and it includes 46 recommendations “so future incidents do not have similar or worse outcomes.”

“Training is a big part of it,” Bashoor said at a Monday afternoon press conference. “So is people following the rules and procedures.”

Seven volunteer firefighters were hurt in the blaze — two critically — when they were engulfed by a 300- to 400-degree jet of gas and smoke that shot up a flight of stairs and out of the house in what authorities described as a freak occurrence.

Bladensburg Volunteer Fire Department firefighter Kevin O'Toole is driven away in the department's ladder truck after he was released from the Medstar Washington Hospital Center on April 20, 2012, after being burned in a house fireon Feb. 24. (Mark Gail/The Washington Post)

Bashoor called it a “near-miss incident” and said the two most critically injured firefighters could have died.

Ethan Sorrell suffered respiratory burns through his esophagus and down to his lungs but is answering fire calls again. Kevin O’Toole suffered second- and third-degree burns over 50 percent of his body and underwent 10 operations at MedStar Washington Hospital Center, where doctors grafted skin on his hands, knees, calves, arms, stomach, sides and shoulder. He was released 56 days after the fire at 6407 57th Ave. in Riverdale Heights but has not returned to riding: He will have another surgery — his 13th — in two weeks.

According to the safety investigation, some of the men who suffered injuries last year were wearing personal protective equipment that did not match, was too old or was not approved, including gloves that were known to shrink when exposed to high heat.

Among the other findings:

●The first company officers to arrive at the house did not complete “an effective size-up” by taking a “360-degree survey walk around the building” or fully evaluate environmental conditions, which included “significant sustained winds and gusts” that contributed to the fireball.

●Despite sending word internally on the morning of the fire that high winds were expected, the information was not conveyed to all of the department’s decision makers.

●No action plan to attack the fire was communicated.

●Firefighters were “dangerously positioned above and in the outflow path of the fire,” which began in the walk-out basement of the vacant home and shot up an interior stairwell and through the first floor after the front door was opened. Sorrell and O’Toole were trapped in the fireball without the protection of a water-hose line.

●When the routine fire turned into a life-threatening emergency, “a firefighter MAYDAY” was not transmitted effectively.

Produced by a 13-member group that included multiple department outsiders, including chiefs from other jurisdictions, the report takes pains to note that the investigative team “had months to examine the incident and develop recommendations. In contrast, the first arriving crews on the scene had only seconds to make critical incident decisions and take action.”

The report does not mention any fire personnel by name, identifying them by their company numbers and assignments.

“We’re not focusing on individual actions,” said Battalion Chief Sayshan Conver-White, an operational safety officer who co-chaired the safety investigation team. “It’s about identifying organizational aspects that can be improved.”

The recommendations include new training programs and procedures — some of which have already been implemented, Bashoor said.

“We are not going to be dwelling on our regrets or what coulda, woulda, shoulda happened,” he said.

Within days, the fire was ruled an arson. There have been no arrests; the front page of the new report notes a $5,000 reward for information about the incident. At the press conference, Bladensburg Volunteer Fire Department Chief Randy Kuenzli added $10,000 to the reward.

Sorrell, then 21, and O’Toole, then 22, were riding with Truck 809 from Bladensburg on the night of the fire. On Monday, both men were at the press conference, where officials played a chilling helmet-cam video from the incident mixed with dispatch recordings and radio chatter from the fire scene. The audio includes Sorrell screaming for help as O’Toole is trapped inside the house.

“There’s a lot of good that’s going to come from a bad incident,” Sorrell said. “They’re going to make it better and safer for us.”