This is the second of five chapters of an investigation supported generously by the Fund for Investigative Journalism and the George Polk grants for investigative reporting administered by Long Island University.

As amazing as it seems now, there was resistance to investigating Sept. 11. Twenty-two House Republicans voted against authorizing a study by the National Institute of Standards and Technology (NIST). President George W. Bush resisted the creation of the National Commission on Terrorist Attacks Upon the United States, a.k.a. the 9/11 commission. Mayor Michael Bloomberg took no questions from the 9/11 commission when it came to New York to investigate the city's response, and for a time he blocked the release of official records to the NIST investigators and the 9/11 commission, because the city was fighting an ultimately successful New York Times lawsuit to make the records public.

Meanwhile, neither the FDNY's Safety Battalion nor the National Institute for Occupational Safety and Health (NIOSH), which routinely probe firefighter deaths, investigated the World Trade Center fatalities. "At the time, I just think because of the magnitude of the event, nothing was done," says Tim Merinar, who leads NIOSH's firefighter fatality investigations. "I don't really think any organization did a true fatality investigation of the incident." (In fairness, the scale of the losses would have made such investigations, which detail the precise circumstances of each death, difficult to complete.)

Despite these obstacles, three reports—the NIST study, the 9/11 commission investigation and an FDNY-authorized report by the consultant McKinsey & Co.—managed to, very delicately, spell out Sept. 11's painful lessons for the city and its fire department.

Death in a disaster usually has multiple causes. You could talk about the Titanic and focus on the iceberg, not the lifeboats. You could discuss Hurricane Katrina and omit any mention of the levees. You could blame the Hindenburg only on static electricity. But none of these would give a full accounting of why people ended up injured or dead.

Sept. 11 would never have happened if terrorists hadn't decided to kill Americans. But it might have taken a lower toll on the fire department if problems with communications and personnel had been averted.

What was the mission?

Fighting fires in high-rise buildings is very different from battling blazes in shorter structures. Firefighters can't leave a tool in their truck and run down to get it or easily step outside for a new tank of air. Most important, they usually have to use a water system built into the high-rise building to put out the blaze. Even when that water is available, some high-rise fires are simply too large to put out. To extinguish even a flaming half-floor of the WTC would have required, by NIST's calculations, 1,250 gallons of water a minute, a deluge that might take 10 engine companies to provide.

Rescuing people in high-rise buildings is complicated too. The time it takes a person wearing at least 50 pounds of gear to climb dozens of flights of stairs could be longer than the time a civilian can survive trapped amid toxic smoke.

All these challenges were exacerbated on Sept. 11. Not only were multiple, huge floor areas in flame, the fires were also whipped by wind pouring in through the buildings' shattered sides. The standpipes in both buildings were believed to have been severed by the aircrafts' impact, meaning no water could reach the upper floors. The elevators were—with a single exception in each tower—rendered immobile, robbing firefighters of a method for reaching the fire faster.

So FDNY commanders decided early on at the World Trade Center that they would mount a rescue operation, not a firefighting one. "At best it would take hours to establish meaningful firefighting operations on the upper floors of the buildings," the NIST report found. "It was likely that many of the occupants trapped at or above the impact zone would die before help could get to them."

Despite this decision, the NIST report and individual firefighters' oral histories reveal that some fire companies were ordered to head to the impact zone and set up a post for what NIST dubbed "rescue and firefighting operations." That report found that "as the senior command level strategies were communicated to the lower levels, the concepts appeared to take hold at a slower pace at the next level down. … Some firefighters at the company level were disturbed by the operations order that signaled a change toward assisting with the evacuation. They wanted to go up and put the fire out." In the FDNY's oral histories, a number of firefighters recalled being told to prepare to extinguish the blaze, or being given vague orders to simply head upstairs.

Doing so was extremely difficult. One unit took an hour to reach the 31st floor. Many fire-fighters went 10 or 12 floors, rested, climbed five or six more, took another "blow," then scaled three or four additional flights. Several firefighters reported chest pains. Large groups of exhausted FDNY men were seen resting in a north-tower elevator lobby just before the building came down.

Despite the confusion and physical strain, firefighters doubtless saved lives by helping people evacuate. But late-arriving fire companies found few civilians left in the building

Keeping track of a tragedy

According to NIST, the fire department's personnel-tracking system "generally worked well for the first 30 minutes" but then became overwhelmed with the large number of units and personnel arriving at the scene. Sixty-one percent of the city's engine companies, 43 percent of ladder units and nearly half of all chiefs were dispatched to the World Trade Center, but all the incident commanders had to track them on was a suitcase-size "command board" that used a whiteboard and magnets to keep sense of who was being sent where.

There's a misconception that dozens of FDNY units deployed to the WTC on their own. In fact, only four did. But according to the 9-11 Commission, more fire units were dispatched to the scene than commanders asked for. Some fire trucks and engines "rode heavy," with fire-fighters who were going off duty leaping aboard to join the shift that had just come in. Several firefighters arrived on the scene as individuals, asking to help. McKinsey found that "as these units approached the area, many failed to report to the staging areas and instead proceeded directly to the tower lobbies or other parts of the incident area. As a result, senior chiefs could not accurately track the whereabouts of all units."

When the second plane hit, a second fifth alarm—the highest in the department's normal operational battle plan—was sounded. But, as had been pointed out after the 1993 bombing but never corrected, there was no procedure in place for an alarm greater than fifth. And it meant that units that were totally unfamiliar with the WTC were showing up at the scene, sometimes in the wrong place. Some firefighters who'd been assigned to the south tower showed up at the north tower instead, leading the south tower's fire commander to call for more men. "Because some units did not stage and chiefs were unsure of their location, additional units, that might not have been required at that time, were deployed to the incident," McKinsey continued. "If units had staged according to protocol, other units that were dis-patched to the World Trade Center might have been kept instead in the citywide pool."

And, one might speculate, more firefighters would have survived.

Communications problems

No part of the emergency response garnered more attention than the radios that FDNY personnel were using—they were, after all, the same devices that had performed so poorly at the 1993 Trade Center incident. A belated effort to replace them had been scuttled earlier in 2001 when a poorly tested replacement radio failed at one fire. NIST found that a third to a half of all emergency responders' radio transmissions at the WTC incident were "unreadable or incomplete." But the exact impact of radio problems is not a simple thing to gauge.

All handheld radios are susceptible to problems in high-rise buildings because their low wattage generates signals that are often too weak to travel multiple floors. After 1993 the FDNY had installed a repeater—a device that amplifies and retransmits radio messages—for both towers on the roof of 5 WTC. On 9/11, firefighters in the south tower apparently used their repeater. Firefighters in the north tower didn't, because chiefs there erroneously thought that repeater was broken. But it might not have mattered. When the south tower fell, the repeater was wiped out. If firefighters in the north tower had been relying on the repeater, their communications might have gone dark once the other tower fell.

More important than the brand of radio or the use of the repeater might have been the sheer number of firefighters trying to talk on one channel, which was simply overloaded. In addition, despite recommendations after the 1993 bombing and subsequent firefighter fatalities that such a device be developed, chiefs didn't have a special tone alert to help in ordering the evacuation of the north tower after the south tower collapsed. (Despite this, the 9/11 commission concluded that at least 24 of the at most 32 fire units known to be working in the north tower heard the evacuation order.)

And while having the ability to communicate is important, having good information to share is vital. The reports on 9/11 indicate that some fire commanders inside the towers had little idea what was going on outside, while fire leaders outside the buildings had no inkling of what NYPD helicopters were reporting to police commanders. This situation worsened exponentially when the first building came down, wiping out much of the FDNY command post, which had been set up within the collapse zone of the buildings. "This loss of human life and the capital assets makes it imperative that emergency operations protocols for tall buildings be critically reassessed," NIST concluded.

A decade of repair

In earlier days, New York firefighters resisted the move from a volunteer department to a paid one, then from hand-drawn fire apparatuses to horse-drawn engines and finally from horses to trucks. When blacks and women sought to join the department, there was a new generation of resistance. More recently, McKinsey noted in its report, the FDNY had considered several changes that would have made a difference on 9/11—new radios, a fire operations center, retraining and even sanctioning units that failed to deploy correctly—but the department hadn't followed through.

Paradoxically, even while stubbornly resisting some changes, the FDNY has throughout its history spearheaded others, like pushing for safer tenement construction and, after the Triangle Shirtwaist factory fire, demanding stricter fire regulations for businesses. Nicholas Scoppetta, who led the fire department from 2002 through 2009, believes this second side of the FDNY is what it has shown since Sept. 11.

"It's an entirely different department," he says of the FDNY since 9/11. "The equipment is improved. The tactics are improved." Scoppetta is proud that under his leadership, the FDNY achieved "the fastest response time in history: 4:01. That's astonishing. Almost before you put down the phone, the trucks were arriving," as well as "the lowest number of civilian fatalities in any eight-year period of the department."

Beyond the 343 people (boasting a combined 4,400 years of experience) who were killed on 9/11, the FDNY soon lost hundreds more who were forced out by injury or illness or who decided—perhaps encouraged by their families—to retire. The department decided to make up for lost experience with new training. It expanded the academy for new firefighters from 13 weeks to 23 weeks, instituted a Fire Officers Management Institute and created new training programs for battalion and deputy chiefs—the top two civil service ranks in the department. Every member of the department received training in the national incident command system, or ICS, an emergency leadership matrix geared to handling events like Sept. 11; officers have received intermediate and, in some cases, advanced training in ICS. On Randall's Island, the department built a new, $4.2 million high-rise simulator and, thanks to a grant from the Leary Firefighter Foundation, created two special training rooms to show new firefighters the subtle, lifesaving warning signs that a room is about to "flash over"—a terrifying phenomenon in which a room becomes so superheated that its contents simultaneously burst into flames, creating a fireball that can kill in seconds

"The training is unbelievable," says Jim Ellson, a retired fire captain who was once the executive officer at FDNY's special operations command and now consults on emergency preparedness. "There's no comparison. They're light-years ahead. It's constant training."

FDNY's Fire Department Operations Center, complete with live video feeds from police helicopters and computerized deployment systems, was launched in 2006. After replacing in short order the 91 pieces of apparatus that were destroyed in the collapses, the FDNY added to its number of hazardous-material tactical, or haztac, ambulances (which specialize in handling emergencies involving toxins), elite-trained ladder companies, and fireboats. The FDNY also re-evaluated its procedures for roof rescues, which would not have been feasible on Sept. 11 but might—as a last resort—come into play in a future disaster.

The FDNY modernized and automated its recall system, which brings in off-duty firefighters to help in major emergencies, while also establishing formal mutual-aid arrangements in which towns outside the five boroughs can supplement FDNY resources in the city, or vice versa. A newly invigorated planning unit was set up to develop strategies for different WMD attacks. Sixty-five key targets in the city were assessed for risk and vulnerability. It took more than five years, but in 2007 the FDNY released a comprehensive terrorism and disaster planning strategy to avoid another Sept. 11.

Capt. Alexander Hagan, the head of the Uniformed Fire Officers Association, says it was a "herculean effort to rebuild the fire department." It was not an easy period. "It was a daunting task, and it really was—it was dangerous," he recalls.

The expansion of the fire academy to 23 weeks did not last long; budget pressure soon forced the city to scale it back to 18 weeks. But that was still five weeks longer than before. "They increased the level and intensity of training," Hagan says. "They brought training to a place it had never been before in a fire department that trained a lot."

In 2007, Scoppetta wrote in the preface to the FDNY's strategic plan: "The past two years are proof that strategic management has a tremendously positive impact on both our operational and organizational development. … The Department has made great strides in the past two years to enhance its preparedness and effectiveness." Scoppetta added, "There is much more to do."

Critics still have their doubts about whether police and fire commanders are really better positioned to cooperate during a major emergency. NYPD and FDNY commanders now have radios on which they can talk to one another. The question is whether they will use the special cross-agency channels when the time comes. And the Bloomberg administration outraged fire department leaders when it created the Citywide Incident Management System, which, in-stead of laying out a clear hierarchy, split hairs on the question of who would command during a hazardous-materials incident. Peter Hayden, FDNY's second post-9/11 chief of department, was driven from office after publicly protesting the move to put cops in charge of hazmat incidents whenever terrorism is suspected—a policy that set New York apart from other cities and the national incident management model that post-September 11 reviews had insisted New York adopt.

Doubts of a different kind emerged after a fire broke out in the summer of 2007 at a building across the street from where the towers had fallen.

A harsh test

Twenty-three minutes after the first fire companies pulled up to the burning, half-deconstructed Deutsche Bank building on Aug. 18, 2007, Assistant Chief Thomas Galvin arrived to take command. First he had to find the command post. He contacted the incident commander, a battalion chief who was acting "out of title" as a higher-ranking division chief (and whose name we don't know):

GALVIN: "Hey Steve, where are you setting this up ‘cause there's just a little bit of confusion on how you want us to get in. Where do you want us to come in at?"

COMMANDER: "If we could get a company to force that, ah, plywood right behind Ladder 10's apparatus. We can get access to where we want to set up the, ah, operations, ah, the command post."

GALVIN: "Steve, we have no idea what you are talking about. We're a little confused right now."

Galvin eventually found the post. But within a few minutes, there were more signs of trouble. A firefighter on one of the upper floors of the building radioed, "Be advised that we have no water in the lines up here yet. So keep a good distance back. It's gonna be a little while before we get good water."

In fact, it would be 67 minutes from the time the first companies arrived at the building and the moment water finally began flowing into firefighters' hoses. By day's end there'd be at least 10 separate Mayday calls and several more "urgent-urgent-urgent" transmissions as the fire roared from the 17th floor up to the 23rd and top floor and down to 16, 15, 14—the floors where firefighters were staging—blanketing the air with thick smoke, separating men from their units and blinding them as their oxygen supplies diminished. At one point in the chaos, a company officer asked into his radio, "Do you have any of my men?"

Most of the firefighters made it out, some by leaping out onto scaffolding that jacketed the building. But Firefighters Robert Beddia and Joseph Graffagnino died of smoke inhalation. One hundred other firefighters were injured.

The issue of who was to blame for the Deutsche Bank disaster is well-trodden territory. This summer's failed prosecution of three construction supervisors pinned the deaths on the decision to cut a pipe, the standpipe, that should have provided water to firefighters on the upper floors. But according to then-Manhattan District Attorney Robert Morganthau, the Bloomberg administration avoided being indicted in the deaths only because of its status as a government entity, which gives it sovereign immunity. Reports by Morganthau's office and the Department of Investigation found that FDNY officers had failed in their responsibility to inspect the building and plan how to fight a fire there. On at least five occasions, subordinate fire chiefs tried to get their superiors to pay attention to the unique risks of the Deutsche Bank building, but little action was taken. Morganthau's report, for instance, says that "in February 2005, a memo was written by a Hazmat Battalion Chief and forwarded to the then-Chief of Operations containing recommendations for an emergency firefighting operation plan for the building. However, the Chief of Operations neither approved nor endorsed the recommendations; nor did he distribute them to the first-due units, the [nearby] 10/10 Firehouse, or the Battalion, Division, Special Operations Command or the Manhattan Borough Command." The DA's report does not name current FDNY commissioner Salvatore Cassano, but he was the chief of operations in February of 2005.

The DA confirmed that firefighters at the local house didn't even have the right protective equipment to conduct the inspections they were supposed to do every 15 days.

In an exceedingly rare move during the 2009 campaign season, the FDNY publicly reprimanded seven officers (Cassano not among them) for failing in their duty to inspect the building. But six of those seven officers appear to have remained on the FDNY payroll at least into 2010.

Scoppetta also came in for some blame, with the New York Post campaigning for his resignation. The former commissioner attributes the tabloid criticism he faced to a misunderstanding of his role, in which he did not have control of day-to-day operations. "It'd be very unusual for a commissioner to be involved" in supervising the inspections of a particular building, he tells City Limits.

Beyond the inspections

What has gotten less ink than the standpipe and the inspections is the fact that the FDNY response to the Deutsche Bank building on the day of the fire suffered from some of the same problems that exacerbated the toll on Sept. 11.

There's no denying that the Deutsche Bank building, which was being simultaneously decontaminated and dismantled, was dangerous. It had a severed standpipe, heavy barricades be-tween floors that served to trap firefighters and even banks of industrial fans that could not be shut off, adding noise and mechanized wind to an already treacherous operation.



Click here to download an excerpt of the FDNY radio chatter from the Deutsche Bank incident.

But these obstacles weren't the only problems on Aug. 18, 2007. The FDNY's official investigation indicates that because commanders waited until too late to set up a separate command channel, the tactical radio channel was overwhelmed. Some of the many Maydays given weren't heard or acknowledged by other firefighters—apparently, Beddia and Graffagnino both gave Maydays, but they did not come up on the audio recording of the event. Commanders never said which of the three engine companies that had been dispatched to the upper floors was supposed to be in charge of getting water on the blaze. Windows were broken to vent the fire in a manner contrary to procedure. Firefighters either couldn't or didn't leave the area of danger when their air canisters ran low.

The FDNY's report recommends, among dozens of suggestions, that the department develop policies on alternative ways to get water to a high-rise fire when the standpipe is unusable.

But a separate investigation by NIOSH goes even further in hinting that FDNY firefighting strategy was either not followed at the Deutsche Bank disaster or is in need of revision given what occurred there. It calls for the FDNY to "review and follow existing standard operating procedures on high-rise fire fighting to ensure that fire fighters are not operating in hazardous areas without the protection of a charged hoseline" and to "develop and enforce risk management plans, policies, and standard operating guidelines for risk management during complex high-rise operations."

In other words, the Deutsche Bank response may have suffered not just from water prob-lems, but also from troubling tactical choices. Galvin, the high-ranking chief who eventually took charge of the operation, himself seemed concerned about the way the fire response was being run, barking into the radio at one point, "Do we have a roll call finished up there? I do not give a shit about the building. I give a shit about the guys," and later, "Let's get everybody below this fucking fire for a change."

One would need a lot of chutzpah to question the decisions made in the heat of the moment by men with decades of firefighting experience. But some wonder why FDNY commanders kept shuttling men into a burning building where there were no civilians to save and no water to put the blaze out. Christopher Naum, the head of training at the Command Institute in Washington, D.C., has written that "fire suppression operations in buildings during construction, alterations, deconstruction, demolition and renovations present significant risks and consequences that require a methodical and conservative approach towards incident stabilization and mitigation."

He adds: "You cannot implement conventional tactical operations in these structures. Doing so jeopardizes all operating personnel and creates unbalanced risk management profiles that are typically not favorable to the safety and well-being of firefighters."

Vincent Dunn, however, does not believe there were command errors at the Deutsche Bank building. "The strategy for high-rise fire is to send a ‘blitz' attack during the initial stage to quell a fire," says the veteran fire chief. "The Deutsche Bank building fire was a one in a mil-lion—standpipe shut off and stairs blocked. Like 9/11, this was not a strategy problem. It was a building problem."

The trials of tracking

As the situation as the Deutsche Bank fire grew tense, commanders ordered roll calls to see which members weren't accounted for. Not only did this prove hard to accomplish on the overcrowded radio channel, but the roster of companies initially read off by chiefs also didn't even include the unit, Engine 24, that the dead men were in, and there was constantly confusion about which floor different units were on, who was in the building and who was down below.

This—more than anything else about the Deutsche Bank fire—echoed 9/11 and the over-whelmed command board at the World Trade Center. As the NIST report on the WTC pointed out, tracking firefighters is "an issue that has been studied by the emergency responder community for many years." It added, "Unfortunately, failures of accountability on the fire ground have often been associated with the injury or death of firefighters." Indeed, problems with keeping fire companies together and tracking personnel at a fire scene have—according to investigations by FDNY or NIOSH—factored into at least seven other FDNY deaths since 1991.

The McKinsey report, which the FDNY commissioned, called for the department to develop better technology for tracking firefighters. By mid-2002, Motorola was rolling out a fire ground accountability tool. The Tulsa, Okla., fire department was beta testing that system by 2003. Departments as small as the Ponderosa Volunteer Fire Department in Houston have implemented such a system.

The FDNY, however, facing unique needs as the largest and most vertically oriented department in the country, wanted to develop its own system through a partnership with outside techies. Its 2004 strategic plan said that by the end of that year, "electronic wireless command post boards, using personal computers that can graphically display the locations of unit deployments, will improve on-scene incident management." When that deadline passed, the department said it would deploy such a system in 2007. It's only now that the FDNY is deploying its electronic fire ground accountability system, or EFAS, which keeps track of who is issuing a mayday. The electronic command post is close to being unveiled.

NIOSH investigator Tim Merinar says tracking firefighters "is an issue all across the fire service all across the country." He adds, "Because of limitations with the technology, there's still not a real good solution to that problem."

Perhaps the FDNY's caution in embracing such a system will help it avoid those technological pitfalls. But the human factor still concerns Steve Mormino, a retired FDNY lieutenant who runs the Firefighter Near Miss Reporting System. "I think that [EFAS] is a positive development, but it's not a 100 percent cure-all. It might give you a bit more information, especially when things go crazy, like when you have a collapse," he says. "Like anything else, you have to be real careful. Too much information can be just as dangerous as not enough information."

In the wake of the Deutsche Bank disaster, the FDNY increased the amount of time each week that a fire company does inspections. And it developed new policies for what to do when fire officers run out of air and must leave, and are faced with either leaving their company leaderless or taking everyone under their command out with them; now, they take everyone out.

A day no one died

For every fire in which something goes terribly wrong, as it did at Deutsche Bank, there are hundreds where most things go mostly right. These success stories are often retold in the FDNY's internal magazine, With New York Firefighters, or WNYF, which since 1940 has allowed fire commanders to share with other FDNY personnel their lessons learned.

One recent issue detailed the response to a fire in Woodhaven, Queens, in early 2009 in which wind gusting to 55 mph pumped fire through a common cockloft (or void) that ran through 20 wood-framed buildings—one of which, inconveniently, held more than 2,000 rounds of ammunition that began exploding when the flames hit.

Following prescribed incident command system procedure, the chief in charge set up separate radio channels to keep communications flowing and delegated the control of certain aspects of fighting the fire to other chiefs: One oversaw the fight on one flank of the fire; another chief took the other side; others were responsible for doing roll calls to make sure all firefighters were accounted for and ensuring that water was getting to the water cannons washing down the fire from outside. Three hours after the initial alarm, the fire was under control, several homes had been saved, and no one was dead.

Fires like that, where things go well, do not take away from the pain of errors made at the Deutsche Bank incident or the World Trade Center. They suggest, instead, that the FDNY can learn from its tragedies. Even if it takes a decade.

Click here to read chapter 3, "This Building Killed 1 Firefighter but May Save Dozens." Click here to read the sidebar "The New 911: Emergency Calling Changes."