This is the fifth and final chapter in an investigation supported generously by the Fund for Investigative Journalism and the George Polk grants for investigative reporting administered by Long Island University.

In a publication offering recruitment advice to fire departments, the National Fire Protection Association lists 13 attributes that the job of firefighting requires. Most are physical—the ability to climb a lot of stairs, lug a lot of gear, move heavy hoses around, rescue large people and the like. But one goes to what's under the helmet.

A firefighter, says the NFPA, must be capable of "critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous environments (including hot, dark, tightly enclosed spaces), further aggravated by fatigue, flashing lights, sirens, and other distractions."

Even if a fire department had all the best equipment and all the right tactics for every possible situation, and all the person-power it could possibly need, firefighters could still die. Indeed, in many cases, fires don't kill firefighters and equipment doesn't save them. Decisions do.

'We're not daredevils'

Some of those decisions are made by individual firefighters.

There is a narrow middle ground between being unwilling and being too willing to risk one's life, and fire departments survive on personnel treading that border very carefully. Civilians cannot afford to have firefighters who are too careful; otherwise they'd never risk coming through smoke and fire to save you. But firefighters can be harmed by what the FDNY probe of Deutsche Bank called a can-do attitude.

"The 'can do' attitude," the report reads, "has enabled the FDNY to protect life and property at a superior level of excellence since the Fire Department's inception." But, the report continues, the attitude can also lead firefighters to take unnecessary risks.

Retired FDNY lieutenant Steve Mormino recalls a chief who once told him that the problem with firefighters wasn't getting them into a burning building; it was getting them out. "We pride ourselves on that," Mormino says. "We know that we're a last line of defense for someone. We're constantly trained on that. To know that someone's survival depends on you is one of our biggest motivating factors. I don't know how to curtail that." Plus, there's a part of it that is not conscious. Sometimes at a fire, he says, "you get tunnel vision. You're just not aware of everything that's going on around you."

The fire department says it is trying to change firefighters' approach to risks by making videos of safety tips available to firefighters, scheduling presentations and discussions about safety at firehouses, and encouraging FDNY members to participate in the Near Miss program and Pass It On project, in which firefighters share safety information and stories of close calls.

There are signs the culture is changing. The stigma around issuing Maydays has largely disappeared, firefighters say. More people are using their breathing equipment more often. "We're not daredevils," says the second fire lieutenant we spoke to. "We don't want to die."

"FDNY guys go in."

In December 1999, the fire department in Worcester, Mass., responded to a blaze in an abandoned industrial building called the Cold Storage Warehouse. There were reports of squatters living inside, so firefighters mounted a search as the flames grew. Six men from three different fire units became lost inside. Their radio transmissions are still chilling. "Get people up on this floor now or we are going to die! We have no air, and we cannot breathe," one man called. Other firefighters fought through heat and flames to try to signal the way out, but the fire drove them back. Finally, the chief in charge, Mike McNamee, ordered the building evacuated. He physically barred the door to prevent other firefighters from obeying their fundamental instincts and running in. He cut his losses.

While firefighters make choices that risk or save their own lives, fire officers make decisions that affect the safety of dozens of people. Those decisions naturally come under the microscope when a firefighter dies.

"Some decisions, you can establish a commission, pose a question," says Al Hagan, the FDNY captain who leads the union that represents chiefs and other officers. "After six months or a year, you come up with a decision. Fire ground commanders are not afforded that luxury. We make those decisions in a blink. It all happens at a subconscious level, and it happens very quickly. You search your mental Rolodex for the closest match [of earlier fires] and you say, 'What was done? How did it turn out?' "

The officer in charge at a fire makes a risk-versus-reward assessment to determine how much danger he should expose his firefighters to. It's a complex, multivariate calculation: Are there civilians in danger? Can they be saved or, like those victims trapped above the floors of impact on Sept. 11, are they doomed? Does the likelihood of saving them outweigh the risk that rescuers would take in the attempt? How close do we get to the fire before its threat to us exceeds the advantages of fighting the blaze at close range?

One of the key decisions an incident commander makes, says NIOSH's Tim Merinar, is "how aggressively you want to fight an individual fire."

The FDNY prides itself on weighting its risk-reward calculus toward aggressive, interior firefighting. "You have to put it in the context of the culture of the FDNY. They are very aggressive," says former fire commissioner Nicholas Scoppetta. "There are fire departments in the world that sort of fight fires from the outside. But if there is any indication that there are people inside the building, FDNY guys go in." And there is more than machismo behind that approach. In a dense, urban environment, playing it safe and fighting a fire from the outside means exposing nearby buildings to fire risk, accepting that families will be made homeless and setting neighborhoods up for the social impact that burnt-out buildings can have. It's not an easy choice.

Since Sept. 11, the FDNY has increased training for safety investigators and developed an annual risk management plan that assesses the possibility of death or injury and recommends changes. Injury reports have been computerized to allow lessons to be extracted. The department is also participating in what FDNY documents describe as a "national, multi-year academic research project to develop a world-class safety management system."

But NIOSH investigators have suggested after several recent fatal fires that the FDNY's risk-reward decisions could use a rethink. In the wake of Thomas Brick's 2003 death at a furniture warehouse, NIOSH found that fire commanders should "conduct a risk-versus-gain analysis prior to committing fire fighters to an interior operation, and continue to assess risk-versus-gain throughout the operation." The death of Richard Sclafani in 2005 was in part blamed on an incomplete initial "size-up" by an officer. A lesson from the 2006 store collapse that killed Howard Carpluk and Michael Reilly was, in NIOSH's view, that officers must "consider the live load of water on the structure and go defensive when water load potentially compromises the structural integrity."

There are mistakes at every fire, says Hagan. At fires like Sept. 11 and Deutsche Bank, "were there glaring errors that led to deaths? No," he contends. "We make more rescues than we have deaths. In an urban area, if we step back and go, 'Well, someone could get hurt here … ' Someone could get hurt here? Then get rid of the fire department. I am very proud that our overarching strategy is one of interior, aggressive attack."

Frank Gribbon, the FDNY spokesman, says the department's approach is constantly evolving. When he joined the department 22 years ago, not every firefighter had a radio, the helmets were made of leather and the protective jacket was canvas. All that has changed. But the FDNY's general approach to fires has not.

"I think we've become smarter with that strategy over the years, sometimes having learned tough lessons at some fires where we've had deaths, but there is no shift on the horizon in terms of not being an aggressive firefighting force," Gribbon says. "This is what we do, we do it very well, and we're doing it better than we ever have before."

FDNY commanders, Gribbon adds, are taught to risk a lot to save a lot and risk a little to save a little. A life that can be saved is worth a lot of risk to firefighters. "When there's risk to property, then we're going to risk little," he says.

At least six of the 11 FDNY members who have died since Sept. 11 perished in an effort to save buildings in which there were no people. That is something we know in hindsight.

"It's a dangerous business," Scoppetta reminds us. "It calls for immediate response to changing conditions. You can second-guess, I suppose, anybody's actions in a situation like that."

Finding the courage

The National Fallen Firefighters Foundation's Everyone Goes Home program says in its literature: "Firefighters must have the courage to face a multitude of risks in order to save lives and protect their communities. A different type of courage is required to stay safe in potentially dangerous situations, avoiding needless risks and tragic consequences."

The FDNY has the first kind of courage in spades. On the second, there has been progress. There was a time in the 1960s when the FDNY didn't even issue gloves to its members. When Mormino started at the FDNY in 1987, the department had just moved to prohibit firefighters from riding on the back step of their truck or engine. Firefighters die much less often in New York than they used to—thanks to the decreasing number of fires and evolving safety attitudes. "We're learning a little about a better way to do things," says Mormino.

Elsewhere across the U.S., the firefighter death rate appears to be falling. But there's still a way to go, for the FDNY and other U.S. fire departments. Over the past decade, the country of England (one of four countries in the UK, with a population of 51 million) lost 23 firefighters, compared with 1,091 in America. From 2000 through 2010, London lost two firefighters in operations. New York City buried 11.

"We do not want them to change their attitudes toward aggressive firefighting tactics," Jerry Tracey, the retired chief who is pushing the FDNY to adopt new methods for dealing with wind-driven fires, says of the department's officer class. "What we want to be able to do is to educate them as best we can to make educated decisions based on an understanding of risk."

Tracey is one of many who argue that despite the decrease in fires, the fire ground is more dangerous now than ever. Interviewed at a Queens diner, he lifts up his plastic-encased laptop computer. "This is gasoline in a solid state," he says. We point around the room at the other plastic items. We note the tightly sealed windows, seen in many buildings, which allow flammable gases to build up to the point where they flash over into a killer fireball. "So the challenge is much greater today."

Like most threats, that of fire is born unequally, by firefighters and victims. Fires are still one of the leading causes of accidental death in America, but some people are far more likely than others to die in fires: the old more than the young, men more than women, the poor more than the rich. Black people are twice as likely as whites to die in fires. Black children are three times more likely than white kids to be killed in a blaze. The safety of firefighters matters to potential fire victims because, in a sense, when your life is at risk, you are only as safe as your rescuer.

At the fire on Watts Street in 1994, flames exploded from the fire apartment on the floor below, billowing up onto the landing where Capt. John Drennan and Firefighters Christopher Siedenburg and James Young were standing. The three were subjected to severe heat for five to seven minutes. Young died at the scene. Siedenburg died the next day. Drennan survived for 40 days, then succumbed. His widow, Vina, dedicated her life to saving others who fight fires. In 2004 she addressed fire departments across the country in an online commentary:

We are called by something deep inside to want to make a difference. We must re-think this dangerous job of firefighting. We must find ways to circumvent the old ways and old bureaucracies that see a death as an inevitable part of this job. We here can find the courage to say, 'Enough.'

Haven't we suffered enough to question charging into the mouth of hell? Are our heads so afraid of change that it has stunted our hearts? Let's challenge the fire service to have zero tolerance for a line-of-duty death. It's time to question. No firefighter should die doing this job in America.

Click here to return to chapter 1, "Costly Lessons: What We've Learned From Firefighter Deaths."