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

During his 20 years in the New York City Fire Department, Vincent Fowler had thought more than most firefighters about death. A veteran of four different fire companies during his time on the job, Fowler developed a step-by-step protocol for firehouses to follow when one of their members is killed at a fire. "One of the first things he told the men surviving was to call their wives," Ramona Fowler recalls. However, Fowler did not speak of the possibility that he might die. Nor did his wife dwell on the dangers of his job. "After you get through a certain amount of time, you figure that it's not going to be him," she says of the father of three.

Though he'd reached the point where he could have left the job and started drawing a pension, Fowler had decided not to even consider retirement until his three daughters finished college. He needed the salary, and he liked the work. Fowler had attained the rank of captain and was studying for the battalion chief's test when, on June 3, 1999, he responded to a house fire at 150-28 127th Street in South Ozone Park, Queens. He went into a cellar, ran out of air and collapsed. Soon after, Ramona Fowler received a phone call, but not from her husband. The next day, Capt. Fowler's death notification procedures were executed for his own demise.

Fowler was one of 43 New York City firefighters to die in the line of duty in the decade before and the decade after the Sept. 11 disaster. Ten died of heart attacks or other acute medical problems. Ten perished in collapses and four from falls and 18 died of burns or smoke inhalation. One was killed in combat as an Army reservist in Iraq, but his passing was considered a line-of-duty death.

Each death involved a unique person and unique circumstances. But according to investigations by the FDNY and the National Institute for Occupational Safety and Health, common contributing factors link many of the deaths. City Limits obtained FDNY investigation reports on 25 of the 1991-2011 deaths and NIOSH findings on 21 of the deaths during that span, including eight fatalities not covered by the documents that FDNY provided in response to our freedom of information requests.)

The FDNY has moved to address some of these factors. Other problems have proved more difficult to solve. And some, of course, might be inseparable from the risky work of fighting fires and saving fire victims.

Sometimes it was wrong information

Jan. 23, 2005, was a brutally cold day—so icy that Jeanette Meyran opted to walk to the grocery store near her Long Island home rather than risk driving there. Her husband, Lt. Curtis Meyran, had gone to work at a firehouse in the Bronx. He had been promoted to lieutenant two years earlier and was covering shifts at different firehouses to fill in for officers who were on leave or vacation until a permanent spot was found for him.

Walking back with her groceries in hand, Jeanette got a call from her son at home. There was an FDNY captain at the house. She dropped her groceries and moved as fast as she could across the frozen ground. All the captain told her on the drive to St. Barnabas Hospital was that her husband was hurt.

She remembers being hustled into a hospital room, where she saw a small man. "I know this man," she recalls saying to herself. "Who is this man?" The man came over to her, put his arm around her and said, "I'm so sorry." She still did not recognize him. "What are you sorry about?" she asked. Anxious glances were exchanged around the room; the men there suddenly realized that she hadn't been told the full story. The small man turned to her again: "He didn't make it." Soon, Jeanette Meyran realized that the small man was the mayor of the city of New York and that her husband was dead. He and five other firefighters had been driven by fire out of a fourth-story window on 178th Street in the Bronx. Meyran and Firefighter John Bellew, a member of Ladder 27 under Meyran's command, were killed in the fall. The other four were critically injured.

Bellew and Meyran were only the FDNY's first casualties on what would come to be known as Black Sunday; a few hours later, Firefighter Richard Sclafani would be pulled unresponsive out of a cellar in Brooklyn, where he'd been overcome by smoke.

The deaths at 178th Street were blamed largely on an illegal subdivision of apartments that created a deadly maze for firefighters. A jury in 2009 acquitted the tenants, and last year a judge threw out on technical grounds a lower court's conviction of the building owner. The Bronx district attorney is appealing the latter decision.

But several other factors played a role in the deaths on 178th Street. The FDNY investigation, for instance, found that "there were many failures" of communications procedures. "In many instances, members aware of important, even life-threatening information, did not transmit the information properly, did not get an acknowledgement, or simply never transmitted the information to anyone." For instance, firefighters inside the building didn't tell the incident commander that the fire was getting worse, and the commander didn't pursue information about searches going on inside. And "when officers on the floor above realized that there were members trapped, they failed to notify the incident commander."

The findings do not surprise Al Turi, a retired 34-year veteran of the FDNY who served as chief of safety in late 2001 into 2002. "Communications always played some kind of role in almost every firefighter fatality that I looked at," Turi says. "Sometimes it could have been handie-talkie or radio problems. Sometimes it could have been information that wasn't received by the chief at the command post. Sometimes it was information that was not received by the individual units or members. Sometimes it was wrong information."

After the 2008 death of Lt. John Martinson on Bedford Avenue in Brooklyn, investigators found that "handie-talkie communications at the scene did not give a clear and concise picture of fire conditions or the actions taken by units." The same was said of the third Black Sunday death, that of Sclafani. Often, the radio confusion is a result of the number of voices trying to crowd onto a single channel. At the Deutsche Bank fire, investigators found, commanders waited too long to establish a "command channel" that would have allowed chiefs to separate their strategic discussions from the jumbled, step-by-step talk on the channel used by rank-and-file firefighters.