Inquiry Lays Out Chain of Failures in High-Rise Fire

NY Times 8/21/2008

Eric M. Hazard/Associated Press

A fire at the former Deutsche Bank building claimed the lives of two firefighters in August 2007.

When a fire broke out last Aug. 18 at the tower, it took roughly 80 minutes to get water on the flames, in part because workers there waited some 13 minutes to call 911 and then gave firefighters inaccurate information about whether emergency equipment at the site was working.

And communication lapses further disrupted the firefighting response. Walkie-talkies failed, and critical calls for help went unheard. Men were lost in the confusion. One firefighter’s radio problems forced him to crawl to the building’s edge to report that two imperiled colleagues — Robert Beddia, 53, and Joseph Graffagnino, 33 — were trapped by stairwells that had been sealed off. Both men were killed.

Those are among the dozens of findings by a team of investigators who were enlisted by the New York Fire Department to conduct a formal inquiry into the deadly fire, according to people who have been briefed on the departmental investigation or have seen its findings. Those people said the report issued by investigators — which has not been publicly released — finds fault or concern with many aspects of the building’s demolition and the response to the fire.

The report, presented on Wednesday to fire union officials in a tightly controlled meeting at Fort Totten in Queens, will be turned over to the office of the Manhattan district attorney, Robert M. Morgenthau. His office has undertaken a broad criminal inquiry into the fire at the high-rise building, which was being simultaneously decontaminated and dismantled, floor by floor, after being damaged on Sept. 11, 2001, and contaminated by toxic substances.

Mr. Morgenthau’s office, which has been presenting evidence to a grand jury for months, is considering criminally charging the city as part of its inquiry into the fire that left the two firefighters dead, according to people who have been briefed on the inquiry.

After the death of a firefighter, the Fire Department always empanels a team to study any problems that might have contributed to the death.

This team found the Deutsche Bank fire to have been an operational nightmare, according to those who have seen or heard its findings. The building, originally 41 stories but torn down to its 26th floor when the fire took hold, was wrapped in heavy mesh to trap construction debris. Thick plastic drapes were hung from the walls to contain asbestos and other contaminants. Stairwells were sealed with plywood and plastic. The fire burned those materials, spewing impenetrable black smoke that choked the teams of firefighters as they twisted through a maze of narrow construction barricades.

The investigators do not fix on any specific problem as solely responsible for the deaths of the two firefighters.

Rather, they suggest that a series of building code violations — and perhaps firefighting problems, as well — led to the tragedy. Construction workers’ removal of a section of the building’s standpipe left firefighters without water on the upper floors, and local fire companies failed to conduct regular inspections of the building — although it is unclear whether inspectors would have noticed the broken standpipe in a maze of pipes in the building’s basement, or if they simply would have checked to see the standpipe in place in the stairwells.

It has been known from the day of the fire that the struggle to get water on the flames was great. But few understood just how long that struggle lasted — now pinpointed by investigators at more than an hour, an eternity in the dangerous, fast-moving conditions of a high-rise fire.

In encountering the many hazards at the building, investigators found, firefighters improvised in their response and broke rules. They pushed their emergency air packs beyond the 45-minute limit in providing oxygen; they removed their face pieces in an effort to save air; they ignored warnings of being in danger; one firefighter rode atop a construction elevator.

Firefighter Beddia was overcome by smoke. After his colleagues pulled him from a spot near Stairway B on the 14th floor, his air pack was found to still hold 800 pounds per square inch of compressed air — or about five to eight minutes’ worth of air, considering that a full tank has 4,500 pounds per square inch.

Investigators have surmised that Firefighter Beddia must have removed his face piece and pushed the manual shut-off switch of his air pack before he became unconscious.

Investigators could not say why Firefighter Beddia removed his face piece.

In describing some of the risky tactics employed by firefighters at the scene, the investigators were careful to qualify their criticism, saying that the culture of the department was rich with a kind of “can-do” attitude, according to people who are aware of the findings.

Francis X. Gribbon, the Fire Department’s chief spokesman, said the department had been scheduling time this week to brief the families of Firefighters Graffagnino and Beddia, as well as the firefighters involved in the fire, about the inquiry’s findings. He said the department would not comment publicly on the findings until the families had been briefed.

Stephen J. Cassidy, the president of the Uniformed Firefighters Association, a union that represents roughly 8,900 rank-and-file firefighters, read the department’s report at Fort Totten and criticized many parts of it, saying it largely spared senior department officials. He said the report failed to investigate why senior officials had not developed a plan for fighting a fire at such a complicated demolition site.

“This report is filled with contradictions and omissions of management’s failures,” Mr. Cassidy said. “For instance, the findings say firefighters failed to don their face pieces upon entering the building, as is required in a contaminated building. But the contradiction is they never reference the fact that the incident commander, nor any other chief involved, notified them that they were operating in a contaminated building or required them to do so.”

Others who have read the report, however, said investigators concluded that firefighters had been informed that they should wear their face masks because asbestos abatement was in progress.

“This is not about blaming anyone,” Mr. Gribbon said. “This report is an operational critique for firefighters and fire officers, written by specially trained safety officers with the goal of obtaining what we call ‘lessons learned,’ to learn the lessons of this fire; to not have a repeat of this tragedy; to find the truth. That is the purpose of this report."

In zeroing in on critical lapses by the city’s Fire and Buildings Departments, the investigators called for the two agencies to work more closely, especially on sharing information about the construction, demolition and abatement of city buildings.

Many of the lapses cited by investigators were addressed in a plan for regulating building sites that Mayor Michael R. Bloomberg put forward several weeks ago.

One issue his administration did not directly address was the decision by the Department of Buildings not to require the building’s owner, the Lower Manhattan Development Corporation, to obtain a demolition permit. The agency instead allowed the contractors to take out a series of alteration permits to disassemble the building one or two floors at a time.

Both types of permits require a series of safety measures that were not present at the time of the fatal fire: working standpipe and sprinkler systems, enclosed stairs and an unobstructed means of exit. The investigation has raised questions about whether a formal demolition permit should have been sought, in part because it might have required inspections of the building to have been done by agency inspectors, instead of by the licensed professionals who, under an alteration permit, conduct such work for a landlord.

A spokesman for the Buildings Department, Tony Sclafani, said he could not comment because the agency had yet to receive the Fire Department report.

City officials involved in the Bloomberg administration’s efforts to improve oversight of demolition work concluded that the permits issued for the floor-by-floor dismantling of the building were adequate.

The Fire Department investigators also expressed concern about the fact that several of the fire commanders at the Deutsche Bank blaze were operating in new jobs, acting temporarily in higher ranks. The first commander that day was a battalion chief acting as a deputy chief, for example, and a captain acted as a battalion chief. Those kinds of temporary assignments can be troublesome when they force commanders into roles to which they are unaccustomed or for which they are not fully trained, the investigators said.

“Several safety reports in the past have all stressed this — the elimination of acting out of title — for safety reasons, because you are taking, even an experienced fire officer, and putting him in a new job,” said Deputy Chief Richard J. Alles, an official of the Uniformed Fire Officers Association, representing 2,450 officers, who has not seen the report. “He has to think differently. It is a lot to ask somebody to be able to do that at the spur of the moment.”

Many of the communication problems cited by investigators have been longstanding vulnerabilities for the Fire Department.

The primary radio channel used by the firefighters was overwhelmed, according to those briefed on the findings. Three maydays, or emergency calls for help, were transmitted during one 2.5-minute period, and 14 maydays and 19 urgent calls were transmitted altogether. Some of the maydays were not heard by commanders in the rush, indicating that the department’s most vital communication equipment is not well matched to such a large crisis. Radio discipline was not always maintained. Transmissions were “stepped on,” or interrupted by other transmissions.

In the chaos, firefighters transmitted emergency messages before previous ones were properly handled, ignoring guidelines that state that maydays are supposed to prompt communications only between a commander and a firefighter in trouble.

The problem of multiple firefighters’ reporting maydays and urgent transmissions had been identified as a problem in the analysis of an earlier fire: one in August 2006 in the Bronx that also claimed the lives of two firefighters, Lt. Howard J. Carpluk Jr., 43, and Firefighter Michael C. Reilly, 25.

In the Deutsche Bank fire, a critical mayday message was transmitted by an Engine Company 24 firefighter who reported that two colleagues, Firefighters Graffagnino and Beddia, were out of air.

But the information transmitted was never received by any firefighters on the scene, investigators concluded.

The firefighter was not equipped with a radio device that had a remote emergency alert button on the microphone — worn on the shoulder and outside the bunker gear — that boosts the radio power to 5 watts from 2 watts. And there was confusion about who had transmitted the mayday, so no action was taken to address it.

Eventually, the Engine Company 24 firefighter made his way to the building’s perimeter, where, exhausted and vomiting, he informed his colleagues in person that there were still two men inside.

In their report, investigators cited the case of a Rescue Company 2 firefighter at the Deutsche Bank fire who successfully used the remote emergency alert button and was guided to safety.

The Fire Department has been trying since 2002 to retrofit its radios with the feature, according to union officials. Fire Department officials said that as of a month ago, every radio carried by every firefighter has the special button on its remote microphone.

Among other communication problems, the investigators found, firefighters split up and were unaccounted for at times, a procedure for taking roll call was ineffective, and commanders were unable to use radios to locate disabled firefighters.

William K. Rashbaum and John Sullivan contributed reporting.