This is the first 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.

Van Buren Street runs three blocks through New Brighton, a few hundred yards from Staten Island's northern shoreline. It is a narrow, leafy street of mixed fortune, with well-tended gardens and rambling wood-framed houses sprinkled among bruised A-frames and yards of weedy neglect. The yellow two-story house at 39 Van Buren Street is the smallest and neatest on its block. A spotless patio and hip-high iron fence separate the sidewalk from a compact front garden of ferns and shrubs under a bay window. A slim cement path runs around the back to a tiny fenced-in backyard. Cheery and quiet, it does not look like the kind of building that would kill a New York City firefighter. It does not seem like the kind of place someone would die to save. But it is.

This month, New York City and the world will mark the grim anniversary of an event in which the New York City Fire Department, the largest fire service in the U.S., played a heroic and tragic role. The FDNY's 343 deaths on Sept. 11 represent the largest loss of life by any public safety agency in American history. And while just under 3,000 innocents were murdered on 9/11, including many other first responders, nothing captured the moral imprint of the day quite like the image of hundreds of firefighters making their way up the stairs while everyone else fled. Some firefighters stopped to make a last confession before they began their ascent. Some stayed with injured civilians even when death was certain. That day's scenes will never leave us.

Nor should its lessons. Sept. 11 was many things—a political earthquake, an intelligence debacle—but at its core, it was a fire. And so it had lessons to teach about how New York City might fight fires like that in the future.

Time, however, did not stop on 9/11. The city soon went back to living and working and burning. The FDNY has battled a quarter of a million structural fires since the twin towers fell. And it has lost 11 men doing so. One, Thomas Brick, got lost and died in a furniture warehouse. Another, Richard Sclafani, met his end in a cellar. John Martinson died in an apartment fire. The others fell off roofs or leapt from windows, or died in floor collapses or high-rise disasters.

Few will remember the anniversaries of these deaths. But in a way, they are just as important as the deaths on Sept. 11, not just to the families who lost husbands or sons but also to the firefighters who, as you read this, are probably pulling up in front of a building somewhere in New York City.
Ten years after Sept. 11 is a good time to revisit what that day's very costly lessons were and whether the New York City Fire Department has learned them. But the prospect of another Sept. 11 is as unlikely as it is terrifying. Fires in basements and factories and two-story homes, however, will happen all the time. So it's important to also learn the lessons that people like Brick, Sclafani and Martinson paid for with their lives.

Since 2006, City Limits has been using the Freedom of Information Law to gather official FDNY reports on line-of-duty deaths from 1991 to the present. These documents and others, along with interviews with current and former FDNY personnel, fire experts and kin of the deceased, point to a set of factors that contributed to those deaths, and the many reports on Sept. 11 detail the lessons that disaster had to teach. FDNY reports and interviews with experts indicate whether the lessons from these many fatalities have led to meaningful change in New York City. Our investigation found:

  • New York City firefighters are better equipped and trained than they were on Sept. 11, and the fire department has made enormous efforts to improve planning and procedures—although some questions linger about whether New York's emergency management strategy is fully prepared for another major cataclysmic emergency.

  • A familiar set of circumstances is found in most other line-of-duty FDNY deaths since 1991. The department has made improvements in several areas where its death investigations showed weaknesses. Some of these innovations took years to deliver, perhaps because of technological obstacles.

  • Other factors that have contributed to firefighter deaths persist. Some may be insoluble. Meanwhile, fiscal pressures threaten to introduce new dangers by reducing manpower on engine and perhaps ladder companies.

  • New York City has long employed an aggressive approach to fighting fires. This often saves civilian lives and property but also exposes firefighters to greater risks.

    A context for danger

    In addition to the 11 New York City firefighters who died fighting fires since September 11, three firefighters died of acute medical problems and two FDNY emergency medical services workers also died on the job.

    Firefighting is, however, far from the most dangerous job in America. Of all 4,551 people who died while working nationwide in 2009, only 41 were professional firefighters. In New York City alone, 81 construction workers died from 2006 through 2010, compared with nine FDNY members.


    Map of firefighter fatalities, 1991-2011

    But firefighting is one of the few jobs in which people die trying to save other people. And while firefighter deaths are fairly rare, they are more common than one might expect, given the sharp decline in fires over the past four decades. The rate of fires per 1,000 people in the U.S. decreased from 14.9 in 1977 to 4.4 in 2009. The number of firefighter deaths (including volunteers) fell from 157 to 90 per year in that time—an impressive change, for sure, but not in line with the fall in fires.

    In the entire U.K. in 2008—the last year for which statistics are available—not a single fire-fighter died. The year before, six did. More than 236 American firefighters died over that span of time.

    Across the country, efforts are under way to reduce firefighter deaths. The Department of Homeland Security is funding a program called the Firefighter Near Miss Reporting System, in which firefighters share near-deadly experiences in the hope of allowing others to avoid close calls. Meanwhile, the National Fallen Firefighter Foundation is mounting an effort called Everybody Goes Home that intends to change policies and practices that contribute to death at fire scenes.

    The FDNY has played a role in that national effort to make firefighting smarter and safer. This March the department hosted fire commanders from around the country for a symposium on firefighting tactics at its training academy on Randall's Island, which firefighters call the Rock.

    Comparing New York City firefighting to that of other American cities is difficult. No city is as vertical as New York, nor as large, nor as appealing a target for terrorists. But a crude look at statistics suggests that New York does not stand out for firefighter safety. Since 1990, Los Angeles has lost 17 firefighters in operations, Chicago 11, Houston seven. Not counting Sept. 11 or deaths from acute medical causes like heart attacks, New York City lost 32 firefighters in that period.

    One of them was Lt. Robert J. Ryan, Jr. He is the man who died at 39 Van Buren Street.

    Why did he die?

    Sometime around midnight on the Saturday before Thanksgiving 2008, electrical wiring over-heated and started a smoldering fire in the space between the second-floor ceiling and the attic floor at 39 Van Buren Street. A neighbor noticed and roused the residents, according to the report prepared by the FDNY Safety and Inspection Services Command, which investigates firefighter deaths and major injuries.

    Within 3 minutes, 17 seconds of being dispatched, Engine 155 traveled the seven-tenths of a mile between its firehouse on Brighton Avenue and the house on fire. Ryan, Engine 155's of-ficer or "boss," radioed in a "10-75," meaning that there was a "working fire" at the address. He headed into the building with two of his men who carried the hose.

    Fire could be seen lapping out and up the exterior of the house, but as Ryan climbed the stairs to the second floor and then the attic, he saw no flames. Members of a ladder company, using a special thermal-imaging camera, saw that heat was concentrated in one corner of the attic, so they ripped open a hole in the wall to expose fire and smoke. The attic quickly got very hot and smoky. Ryan spoke through his breathing mask into the radio, telling Engine 155's pump operator, "Give us water."

    Another ladder company arrived and started to rip open the walls and ceiling on the second floor. Ryan called the battalion chief, who was standing outside, running the operation. "We're trying to open up the walls," he said. "Fire's got up in the walls."

    A second engine company came into the house and began assisting Ryan's team with its hose, which was spraying into the attic. Sometime in the next minute, something knocked Ryan's helmet off. "I lost my helmet," one of the ladder company members in the attic heard him say.

    "The smoke and heat conditions increased dramatically in the attic," the FDNY report reads. There was so much smoke it would have been hard to find a helmet on the ground. "Lieutenant Ryan continued to operate without the thermal protection provided by a donned fire helmet," the report reads. "He made the decision to back the hoseline out of the attic." Indeed, now apparently not wearing his breathing mask, Ryan called into the radio, "Back out. Back out."

    The two men under Ryan's command edged their way back to the attic stairs to get out. Firefighters began banging into one another on and near the stairs. "We've got a lot of guys on the second floor, if you could start pulling them down," one ladder company officer radioed the chief.

    Ryan and two ladder company firefighters were still in the attic. "I'm burning up," Ryan told one companion. "Where are the stairs?" A ladder firefighter spoke into his radio. "Urgent, urgent, urgent—we have to back out of this room." Crawling, he guided Ryan to the stairs. Ryan passed out. The ladder firefighter called out for help. Ryan's gear got caught on a banister; it took three men to free him and carry him down to the landing. He had no pulse. A rescue team brought a stretcher up to where Ryan lay.

    As Ryan was being tended to on the second-floor landing, an emergency medical services ambulance pulled up to the scene. Its occupants began backing their rig down the street, away from the fire. As a group of firefighters bore Ryan down to the street, where some began CPR, a fire dispatcher called for EMS to send help faster. A minute and a half later, the dispatcher repeated that call. The EMS personnel in the ambulance down the street put on their gear and rolled their stretcher toward the house. A neighbor told them that a firefighter was in distress.

    Finally, five minutes after Ryan had been removed from the house, EMS personnel located him and began assisting with his treatment. Twelve minutes later, Ryan was in the back of an ambulance heading toward the hospital. The fire at 39 Van Buren Street was declared under control at 1:31 a.m. At around the same time, Robert Ryan was pronounced dead at Richmond University Medical Center.

    Several firefighters did their jobs very well the night Ryan perished, according to the official FDNY report. His engine chauffeur found a way to hook up to a hydrant despite an illegally parked car. Firefighters outside the building gave reliable reports on fire conditions. The men who brought Ryan out of the attic moved swiftly.

    Still, the FDNY's report raised disturbing questions. Ryan was wearing a standard Scott air tank with a 45-minute rating. He was in the attic for no more than seven minutes. Yet when he was removed, there was no air left in his tank. It is not clear why this problem, which was foreshadowed in several other fire fatalities, occurred. The crowding on the stairs may have complicated the evacuation of the attic. And all told, it took 23 minutes to get Ryan from the attic to a hospital two miles away.

    Strongly suggesting that the ambulance crew's delay was crucial, the official FDNY report into Ryan's death called for a new policy under which emergency medical services join the FDNY in an after-action investigation when a firefighter dies. But the report focused on Ryan's decision to stay in the attic without his helmet on and eventually with his breathing mask off. "The [self-contained breathing apparatus] facepiece must be continuously donned when in an IDLH [immediately dangerous to life or health atmosphere]. … No member should enter or operate in an IDLH without a helmet properly secured by a chin strap."

    It's entirely possible that Ryan contributed to his own death. But from the ambulance delays to the crowded stairs to the decision to have firefighters work in the attic, it's reasonable to wonder if other factors contributed to his death. This is a natural question whenever a person dies in service to his city, whether it's one man in an attic, two men in a doomed skyscraper or 343 people in two of the tallest buildings in the world.

    Click here to read chapter 2, "Out of 9/11 Tragedy Came Change for FDNY." Click here to read the sidebar "Diversity and the Department: The FDNY Recruitment Battle."