FIRE DEPARTMENT CITY OF NEW YORK

SAFETY AND INSPECTION SERVICES COMMAND

INVESTIGATIVE REPORT
MANHATTAN BOX 7-7 0047
130 LIBERTY STREET
AUGUST 18, 2007
CASE NUMBER SB 75/07
FATAL INJURY
FIREFIGHTER JOSEPH GRAFFAGNINO
, LADDER COMPANY 5
FIREFIGHTER ROBERT BEDDIA
ENGINE COMPANY 24
VOLUME I
THE INVESTIGATION
II. INTRODUCTION
On August 18, 2007, a fire occurred at 130 Liberty Street. This fire claimed the
lives of Firefighter Joseph Graffagnino, Ladder Company 5, (detailed to Engine
Company 24) and Firefighter Robert Beddia, Engine Company 24. The building conditions
that confronted FDNY members that day were extremely dangerous for firefighting
operations. These included out of service fire protection systems and blocked means of
egress.
On September 11, 2001, the building was damaged as a result of the collapse of the
World Trade Center and was never reopened for business purposes. The Lower Manhattan
Development Corporation (LMDC) assumed ownership of 130 Liberty Street on
August 31, 2004. Asbestos abatement and deconstruction were to take place concurrently at
different locations within the building. Bovis Lend Lease was hired by LMDC to oversee
this project. No demolition permit for 130 Liberty Street was filed or issued. A series of
alteration permits were filed and issued by the New York City Department of Buildings.
Fire Department operations in high-rise buildings present particular challenges and
are dependent on building design and building systems, such as access and egress, fire
detection and fire suppression systems, and communications systems. Sections of the New
York City Building Code address these inherent problems. Certain code requirements are
intended to protect the occupants of the building; other sections of the code specifically
provide systems to enable firefighting operations. At 130 Liberty Street typical firefighting
challenges were compounded by the lack of serviceable building systems and blocked exits.
The following building conditions contributed significantly to the deaths of Firefighter
Joseph Graffagnino and Firefighter Robert Beddia: .


The sprinkler system required by code was out of service.
The standpipe system required by code was out of service.
The means of egress (A and B stairways) required by code
sealed wooden platforms that prevented members from
below the fire.
were blocked by
dropping down
The stairway enclosures required by code had been either
removed at several locations.
compromised or
2 of 176
Sprinkler System Out of Service
When originally constructed, 130 Liberty Street had all the fire protection systems
and construction features required by the NYC Building Code. This included an automatic
wet sprinkler system throughout the building. The sprinkler system was damaged on
September 11, 2001 and was out of service on August 18, 2007. The fire load was
significantly increased in this building when combustible wood structures, approximately
26' x 26', were built on several floors for the decontamination of personnel working on the
floors where asbestos abatement was taking place.
At the time of the fire there was no working sprinkler system. The fire intensified
and extended to the floors above and below the original fire floor. According to the NYC
Building Code the sprinkler system should have been maintained as a non-automatic system
in a building undergoing demolition unless a variance had been requested and approved by
the New York City Fire Department. The Investigative Team was unable to determine if a
variance had been requested. A variance had not been granted.
Standpipe System Out of Service
When originally constructed, 130 Liberty Street had a standpipe system as required
by the NYC Building Code. This included a riser in both the A and B stairways. Sections
of the standpipe system had been removed prior to the date of the fire. Another section of
the standpipe system broke apart when supplied with water. This prevented the Fire
Department from successfully delivering water to the upper floors via any of the building
siamese connections on August 18, 2007.
The standpipe system required two fire pumps one automatic pump and one
manual pump. These pumps were designed to insure that adequate water pressure was
available for firefighting streams in the event of fire occurring on an upper floor. The fire
pumps were not maintained and were not operational on August 18, 2007.
The NYC Building Code requires a structure with an existing standpipe system to be
maintained as a dry system in a building undergoing demolition. A building undergoing
alterations is also required to maintain an existing standpipe system. The standpipe system
at 130 Liberty Street was not maintained and was not operational on August 18,2007.
3 of 176
Required Exits Blocked
The two building stairways were required by the NYC Building Code to be
maintained free of obstructions and to provide access and egress between floors. Access
and egress within the stairways were blocked by sealed wooden platforms on most even
numbered floors. As a result members on the 14th floor were prevented from exiting to the
safety of the 13
th
floor via the A and B stairways. It was very difficult and time consuming
to break through the hatches in these sealed wooden platforms.
Required Stairway Enclosures Removed
The NYC Building Code requires stairway enclosures to remain intact. It requires
these egress stairs to be fully enclosed with fire rated construction and equipped with fire
rated self-closing doors. On many of the floors within the fire area, the fire rated
construction surrounding the required means of egress (the A and B stairways) had been
either partially or completely removed. This allowed smoke and heat to enter the stairways
preventing Firefighters from using these stairways as areas of refuge.
4 of 176
VI. FDNY OPERATIONS
The following account of operations, in general, follows sequentially. However,
many actions are in fact occurring simultaneously and at different areas of the fire scene. It
is recommended that the reader refer to the Chronological FDNY Operations (Chapter 10)
and diagrams to aid in understanding the sequence and location of events.
On Saturday, August 18, 2007, at 1536 hours the Communications Office of the
New York City Fire Department in the Borough of Manhattan received a telephone alarm
reporting a scaffold fire at 88 Greenwich Street. Box 0047 was transmitted at 1537 hours.
Engine Company 10, Engine Company 4, Ladder Company 10, Ladder Company 15, and
Battalion 1 were assigned and responded. Engine Company 10 and Ladder Company 10
also received a verbal alarm in quarters. At 1538 hours the dispatcher filled out the alarm
due to a second source. Engine Company 6, Engine Company 7, Squad Company 18, and
Rescue Company 1 were assfgned and responded. At 1539 hours Hazardous Materials Unit
1 (Haz Mat 1) and Hazardous Material Battalion 1 (Haz Mat Battalion) were assigned and
responded.
The temperature was 73 Fahrenheit with relative humidity of 40%. The wind
direction was variable with a wind speed of 3 mph gusting to 16 mph.
The fire building, 130 Liberty Street (formally owned by the Deutsche Bank) was a
26 story high-rise office building undergoing asbestos abatement and demolition. The
original structure, completed in 1974, was a 38 story, steel frame, center core, curtain-wall
building with two levels below grade. The building dimensions were 182' x 182' and
occupied one city block. (LIBERTY STREET WILL BE REFERRED TO AS THE FRONT OF THE
BUILDING THROUGHOUT THE REPORT.)
(Diagram 10)
#1 - Liberty Street
#2 - Greenwich Street
#3 - Albany Street
.... ...J'" #4 - Washington Street
32 of 176

v. THE BUILDING
130 LIBERTY STREET

DESCRIPTION OF BUILDING

The original structure, completed in 1974, was a 38 story, high-rise office building.
It was a steel frame, center core, curtain-wall building with two levels below grade. The
first level below grade was designated Sub-Level A. There was a truck loading ramp at
street level on the Washington Street (exposure #4) side, which provided access to Sub

Level A. The second and lowest level was designated Sub-Level B. The building's exterior

skin was a glass and aluminum curtain-wall, mechanically attached to the building's
structure. The building dimensions were 182' x 182' and occupied one city block. On
August 18
th
, 2007, the fire building was undergoing asbestos abatement and demolition. It
was demolished down to the 26 floor.
On September 11, 2001, the building was damaged when falling debris from the

World Trade Center (WTC) cut a gash in the north f a ~ a d e of the building's exterior from the
6th to the 22nd floor. The debris also broke approximately 1,500 windows. A combination
of soot, dust, dirt, debris, human remains and contaminants settled in and on the bUilding.
Since September 11, 2001, the building has been closed for business purposes.

On August 31, 2004, the Lower Manhattan Development Corporation (LMDC) took

ownership of the building located at 130 Liberty Street. The demolition of this building
began in early 2007. The permits issued by the New York City Department of Buildings
were for alterations, not for the demolition of the building.
The exposures were as follows: (Diagram 1)
Exposure # 1 Liberty Street

Exposure #2 - Greenwich Street
Exposure #3 Albany Street
Exposure #4 - Washington Street

13 of 176

I

130 Uberty Street
.\







_ t\)ld
ran
\
_Siamese
es
Diagram 1
O.e 'lileW of Flr
e
\lull
dlng
and E"pos"r
rbead
DESCRIPTION OF TERMINOLOGY USED IN THIS REPORT
The Investigation Team used the following terminology 10 the body of the report:
(Diagram 2)
Access Corridor - This refers to the areas between the clean and contaminated zones of
the building. These areas were constructed of plywood walls covered with polyethylene
plastic. Polyethylene plastic and Tyvek sheets were used as curtains to restrict air flow
from the contaminated floor area. These hanging sheets created mazelike conditions for
operating members. (Diagram 2)
Core Area - The area of the building in which the original elevators, stairways and
building support systems were grouped together. The core area was located in the
center of this building.
Elevator(s) - All original building elevators were grounded with all counterweights and
cables removed. Two, dual car, exterior personnel/material construction hoists
(elevators) were installed to assist with the movement of construction workers and
material in and out of the building. One set of elevators was located on the Liberty
Street (north) side and the other set on the Albany Street (south) side. Due to the
location of the fire, the Albany Street elevators could not be used. All fire operations
were conducted using the Liberty Street elevators. Throughout this report, all references
to elevator(s) unless otherwise noted refers to these hoists (Photo 1).
Elevator Lobby - This refers to the area on each floor just outside the exterior
personnel/material construction hoists (elevators) located on both the north
(Diagram 2) and south (Diagram 4) sides of the building.
Exhaust Fans -This refers to the portable equipment which created a negative air
pressure within the asbestos abatement areas. (Diagram 2)
Polyethylene Plastic Sheets - A product that was used to line the decontamination
areas. The material was 6 mil thick. These plastic sheets were also used as curtains in
access corridors to provide protection between clean and contaminated zones.
(Diagram 2)
Scaffold - Scaffolding was erected to the roof level around the entire building (Photo 2).
As upper floors were removed, the scaffold was dismantled level to the highest floor.
15 of 176
The scaffold was erected approximately 4' from the curtain wall of the building. Some
of the floors had work platforms installed at certain locations within the scaffold. A
limited number of ramps on various floors allowed access from the inside of the
building out onto the scaffold. Stairs were incorporated within the scaffold assembly
that provided access between floor levels. A black mesh netting was attached to the
outside of the scaffold. This mesh provided an additional level of protection to
surrounding areas from falling debris.
Tyvek - This is a registered trademark of the DuPont Corporation. It is a flash spun
high density polyethylene fiber. The material is very strong; it is difficult to tear but can
be cut with scissors or any other sharp object. Tyvek was used in this building as an air
and water intrusion barrier. These plastic sheets were also used as curtains in access
corridors to provide protection between clean and contaminated zones.
Dotted Unes Indicate
Hanging Plastic Sheets


..-----IIID-r----....... ,_,
Diagram 2
Q - Decking Area, Elevator Lobby and Access Corridor on 14th and 15
th
Floors
All interior walls constructed of plywood

3'0'
Plywood Walls
Q - Decking Area
Approx. 26' x 52'
Co\:lidor
, '
.
.
,
'

Elevator Lobby
DraINing not
to scale
16 of 176
FLOOR DESIGNATIONS
The floors were renumbered for the demolition project. These designations were
prominently marked with spray paint at each level on the exterior and interior of the
building. This numbering system differed from the original floor designation. This report
will refer to the floor numbering system used by the construction company
(Photos 3 and 4).
Diagram 3 shows the original floor numbering and the floor numbering at the time of the
fire.
Original Floor Designations (Old) Construction Floor Designations(New)
28
ln
26
m
27
ln
2S
m
26'" 24'"
2Sl
n
23.0
24'" 22
no
23.0
21
5
22
n
" 20'"
21
sl
19
11l
20
ln
18
m
19'" 17'"
18
m
16
m
17'" 1S'"
16
m
14'"
1S
m
13
m
14'" 12'"
12
m
11
m
11
lr
10
m
10
m
gm
gIn 8m
8[11
7
m
7
m
6
1n
6'" Open
SIn Sm
4'"
4tn
3
ra
3
ru
2
na
2
na
Mezzanine Mezzanine
Ground Floor Ground Floor
Sub-Level A Sub-Level A
Sub-Level B Sub-Level B
Diagram 3
Floor Designations
18 of 176
..
Photo 3
Photo 4
Floor Designation Painted
Floor Designation Painted
On Each Elevator Lobby Wall
On Exterior of the Building
DESCRIPTION OF CONDITIONS FOUND
1. Q - DECKING AREA
The Q decking area was constructed as a temporary repair for damages sustained to
the north side of the building on September 11, 2001. This temporary floor was constructed
of exposed metal Q - decking materiaL This area was located adjacent to and east of the
elevator lobby. This area was enclosed with plywood and lined with plastic from the floor
to the ceiling on three sides. The Q - decking area was accessible from the elevator lobby
via a doorway within the west plywood wall. The north side of the Q - decking area had no
wall or windows and was open to the exterior. On the 13
th
, 14th and 15
th
floors the flexible
hose attached to the exhaust fans vented directly to the Q decking area through the east
plywood wall (Diagram 2).
2. ELEVATOR LOBBY AND ACCESS CORRIDOR ON THE LmERTY STREET (NORTH) SIDE
Two doorways were in the elevator lobby. One, containing a single plywood door, led to
the Q - decking area. The other, containing a pair of plywood doors, led to the access
corridor. An access corridor was constructed of plywood walls covered with polyethylene
plastic. Polyethylene plastic and Tyvek sheets were used as curtains to restrict air flow from
the contaminated floor area (Diagram 2). These hanging sheets created a mazelike
condition.
19 of 176
#
3. DECONTAMINATION AREAS
Decontamination areas were located adjacent to the elevator lobby areas on several
floors within the building. The majority of the decontamination areas were located on the
south side of the building. The dimensions of the south decontamination areas were
approximately 26' x 26' (Diagram 4). These decontamination areas were temporary wooden
structures, lined with plastic, on both the interior and exterior surfaces. Plastic and Tyvek
sheets were used as curtains to restrict air flow from the asbestos contaminated floor area.
These hanging sheets created a maze like condition. The south decontamination areas
contained a wide corridor for construction material delivery, showers for the
decontamination of workers and a sitting room. It should be noted that on the 16
th
and 17th
floors decontamination areas were located on both the north and south side of the building.
Scaffold Stairs
..........
,-------,--Elevators
Sitting Room
17' x 9' Irr.
Drawing not 10 seal"
Circuit Panel
Dotted lines Indicates
Hanging Plastic Sheets
4 Decon Showers
30' x 32"
Enter Here ~
48" opening
Diagram 4
Sonth Decontamination Area
All interior walls constrncted of plywood
20 of 176
4. STAIRWAYS
There were two return type stairways designated the A and B stairways in the core
area of the building. The A stairway was located at the south end of the core and the
B stairway was located at the north end of the core. These stairways extended from
Sub-Level B to the top floor. There were ten steps leading to a half landing and another ten
steps led to the next floor. The width of the stairway in both the A and B stairways from the
14th to the 15
th
floors was approximately 54". The half landing between the 14th and 15
th
floors was approximately 114" wide and 57" deep. The landings on the 14th and 15
th
floors
were approximately 114" wide and 124" deep. The steps in the A stairway were removed
between Sub-Level A and the Sub-Level B. The width of the B stairway was reduced from
approximately 54" to approximately 25" by the construction of plywood walls from the
4th to the 6
th
floor (Photo 5).
Photo 5
Plywood Walls Reducing Width in B Stairway
21 of 176
S. STAIRWAY AND HATCHES
Wooden platforms were constructed m the stairways to prevent asbestos
contamination to other floors during the abatement process. These wooden platforms
obstructed access and egress between certain floors. The wooden platforms were
constructed as follows:
Metal I beams (approximately 4" x 4") were placed horizontally over the floor
openmg.
Shoring planks (approximately 2" x 8") were oriented with their long dimension
placed horizontally (on the flat) across the metal I beams creating a solid wooden
platform covering the entire stairway opening.
Openings (approximately 24" x 84") were framed out in the platform.
Shoring planks and plywood were then used to construct hatch covers for the
openings. These hatch covers were hinged on one side and opened upward.
The wooden platforms and hatches in both the A and B stairways on the 14th and
16
th
floors were covered top and bottom in polyethylene plastic and completely
sealed shut. The hatches were not visible from above or below. An expandable
foam sealant was used to fill gaps to prevent air infiltration. As members moved up
the stairs the height in the stairway was further reduced by the platform overhead.
Each step they moved upward required them to crouch down further. There was
minimal space which forced members to lie on their backs on the stairway as they
operated to create an opening in the platform. Assemblies on other floors were
similarly constructed (Photos 6 and 7).
Photo 6
Underside of a Sealed Wooden Platform
Note: Platforms Covered by Polyethylene Plastic
22 of 176
Photo 7
Top of the Sealed Wooden Platform
of the B stairway on the 20
th
floor.
Stairway A
There were wooden platfonns with hatches blocking access on floors 4, 5, 6, 10, 12,
14, 16, 18, 20, 22 and 24. Hatches on floors 5, 14 and 16 were completely sealed shut
(Diagram 5).
Stairway B
There were wooden platfonns with hatches blocking access on floors 6, 10, 12, 14,
16, 18, 20, 22 and 24. Hatches on floors 14, 16, and 20 were completely sealed shut
(Diagram 5).
A Stairway
Plywood
Enclosure
From 4th to 6
th
Access Stair
From 16-18
Diagram 5
The Shaded Areas Denote Wooden Hatches Completely Sealed With Polyethylene
Plastic On the Day of the Fire. Other Wooden Platforms May Have Been Similarly
Sealed On the Day of the Fire.
23 of 176
..
6. SPRINKLERS
The sprinkler system was damaged on September 11, 2001 and was out of service on
August 18, 2007.
7. STANDPIPES
The building was originally constructed with two 6" standpipe risers, one riser located in
each stairway. These standpipe risers extended from Sub-Level B to the top floor. At the
time of the fire the following conditions were found:
There were three serviceable standpipe siamese connections. One was located on
Greenwich Street, the second on Albany Street and a third located on Washington
Street. A fourth siamese on Liberty Street had been removed prior to the fire. The
standpipe system was supplied by city mains feeding both a manual fire pump
(750 GPM) and an automatic fire pump (500 GPM). Both fire pumps were out of
service the day of the fire. The standpipe supply line had sections of pipe missing in
Sub-Level A (Photos 8 and 9). This prevented the system from being successfully
supplied via any siamese connection (Diagram 6) because any water being supplied
flowed out the missing pipe sections into Sub-Level A.
The standpipe riser in the A stairway was intact.
An outside screw and yoke (OS&y)l valve was located in Sub-Level A in the A
stairway at the ceiling level. This valve was in the open position as required by the
NYC Building Code. This negated the possibility of successfully supplying the
system through any of the standpipe riser outlets in the A stairway unless the OS&Y
valve was located and closed.
Note: Fire Department procedures are to connect a supply line to the first floor
outlet of the standpipe riser when there is a break in the piping below grade.
The standpipe riser in the B stairway was disabled. The hose outlets used for firefighting
purposes had been removed and capped as part of the demolition and asbestos abatement.
This eliminated the possibility of members connecting their hoselines to this riser. There
was a 42-inch section of the riser pipe removed at the mezzanine level with additional
sections removed on the 16tl! and 21 st floors. The construction workers modified this riser
on certain floors to provide water for routine daily use (photos 10 and 11).
I Outside Screw and Yoke (OS & Y) Valve - A gate valve used to control water flow to a sprinkler or
standpipe system. This valve has a screw stem that extends out of the valve handle. This stem provides a
visual indication whether the valve is open or closed.
24 of 176
r
Albany Street Siamese Street Main
ShutOff
42' section of pipe removed
-....----"'--+-+- '1----+- \.-----1
,
A Line
Standpipe
Riser
Standpipe Riser J
OS & Y Valves _ \
..
500GPM
Automatic /j ..
Fir. Pump
750 GPM
Manual
B Line Fire Pump
FaHed Elbow
Conn.ecbons
Missing
I
Section of
Piping
-4-------....
Uberty Street Siamese
(Previously Dismantled)
i
Washington Street
Siamese
Greenwich Street
Siamese (
;
Drawing not to scale
Diagram 6
Sub-Level A Standpipe Piping Schematic
25 of 176
Photo 8
Photo 9
Disconnected section of pipe for standpipe
Separated section of pipe for standpipe
system located on Sub Level A
system located on Sub Level A
Photo 10 Photo 11
Removed section of Standpipe Riser, Riser in B Stairway With Construction
in B stairway Mezzanine Level Workers Water Hoses
26 of 176
..
8. EXHAUST FANS (NEGATIVE PRESSURE SYSTEM)
Due to the ongoing asbestos abatement, portable exhaust fans were located on
numerous floors including the 13
th
to the Ii
h
floors. The purpose of these exhaust fans was
to prevent contaminated air from flowing out of the building. Exhaust air was filtered and
discharged to the exterior.
The 130 Liberty Street Implementation Plan, issued by the John Galt Corporation,
cited the following regarding the exhaust fans:
The average volume of air space per floor was 480,000 cubic feet.
A minimum air exchange of 4 air changes per hour was required per floor.
Each exhaust fan was rated at 2,000 cubic feet per minute (cfm).
Each exhaust fan was fitted with a high efficiency particulate air (HEPA) filter.
Each exhaust fan, attached with a 12" diameter flexible hose, was vented to the
exterior of the building (Photos 12 and 13).
Photo 12 Photo 13
Hose Exhausting to Q - Decking Area Exhaust Fans with HEPA Filters
Note: Twenty-five 2,000 cfm exhaust fans were positioned and operating on the exposure
#1 side of the building on each of the 13
th
, 14
t
\ and 15
th
floors. These fans exhausted out
onto the Q - decking area.
27 of 176
DESCRIPTION OF THE 17TH, 16TH, 15TH AND 14TH FLOORS
17TH AND 16TH FLOORS
The asbestos abatement on the l7th and 16
th
floors was near completion. All interior
sheet rock walls as well as the original building elevator hoistway doors and walls located in
the core area had been removed. Both stairway enclosures had also been completely
eliminated. The removal of these fire rated walls negated the required protection for the
means of egress, the A and B stairs. This created an open and unenclosed floor area.
The elevator lobby, decontamination areas, access corridors and exhaust aIr
enclosures were temporary wooden structures constructed on these floors. There were
decontamination areas located on both the north and south side of the building. Plywood
walls enclosed the Q - decking area on three sides. There was an access stair located toward
the southeast comer connecting the 16
th
, l7th and 18
th
floors (Diagram 7).
Albany Street
Exposure 113
DecontaminatiOn
Area
Dotted Lines Indicate
Hanging Plaslic Sheets
Exhaust
Fans as
Up
Access Stairs
Plywood COIIered
,..--------,---,----,-Elevator Shalls
Dotted Lines Indicate
Hanging Plastic Sheels Exhaust
'g"".""I
Drawing not \

e e" e
e e 6l El
81 B2 83
DacontaminatiO<1 Area COtrldor
/
Q Decking Area
Liberty Street
Exposure #1
1:
i:
" !! ::I o
;;'''
.=&.
..c: ..
.. w

7
17th and 16
t
Floor Layout
28 of 176
15TH FLOOR
This floor was in the early stage of asbestos abatement and demolition. Stairway
enclosures and the original building elevator hoistway doors and walls in the core area were
still intact on this floor. Interior office walls were in the process of being removed. Ceiling
tiles and track, electrical conduit and wiring, plumbing pipes and construction material
littered the floor. The elevator lobby, access corridor and decontamination area were
temporary wooden structures constructed on this floor. Plywood walls enclosed the
approximately 26' x 52' Q - decking area on three sides (Diagram 8) .

Albany Street
Exposu",,'3
Decontamination
Area
Dotl&d Lines Indicate
Hanging Plastic Sheets
(25) Exhaust Fans
Dotted Lines Indicate
Hanging Plastic Sheets \

Access Corridor \
..
D,awingnot
to ${;8/6 Q - Decking Area
Liberty Street
Exposu","1
Diagram 8
15
th
Floor Layout
29 of 176
14TH FLOOR
This floor was in the early stage of asbestos abatement and demolition. On this floor
all original elevator hoistway doors in the core area had been removed and the shafts sealed
with solid planking and plywood at the floor leveL The lower half of the hoistway walls
had been removed. The stairway enclosures had been removed up to approximately a
4' height. Partial removal of these fire rated walls negated the required protection for the
means of egress, the A and B stairs. The openings in the stairway enclosures were sealed
with plastic sheeting. Interior office walls were in the process of being removed. A metal
turnstile was present on the 14th floor at each end of the original building elevator lobby
which partially obstructed access to and egress from this area. There was an opening next
to each turnstile (Photos 14 and 15).
The elevator lobby, access corridor and decontamination area were temporary
wooden structures constructed on this floor. Plywood walls enclosed the approximately
26' x 52' Q - decking area on three sides (Diagram 9).
Photo 14
North Turnstile Near B Stairway
F a c i n ~ South
30 of 176
Photo 15
South Turnstile Near A Stairway
Facing North

Albany Street
EXPOSUN'3
Decontamination
Area
Dotted lines Indicate
Hanging Plastic Sheets
Soult! Turnstile
__________.-J
Dotted Line. Indicate
North Turnstile
(25) Exhaust Fans

Drawing nol
fo scale
Diagram 9
14th Floor Layout
31 of 176
Liberty Street
Exposu", #,
Q DecKing Area
Hanging Plasjic Sheets"\
Access Corridor \ \
/ ......
VI. FDNY OPERATIONS
The following account of operations, in general, follows sequentially. However,
many actions are in fact occurring simultaneously and at different areas of the fire scene. It
is recommended that the reader refer to the Chronological FDNY Operations (Chapter 10)
and diagrams to aid in understanding the sequence and location of events.
On Saturday, August 18, 2007, at 1536 hours the Communications Office of the
New York City Fire Department in the Borough of Manhattan received a telephone alarm
reporting a scaffold fire at 88 Greenwich Street. Box 0047 was transmitted at 1537 hours.
Engine Company 10, Engine Company 4, Ladder Company 10, Ladder Company 15, and
Battalion 1 were assigned and responded. Engine Company 10 and Ladder Company 10
also received a verbal alarm in quarters. At 1538 hours the dispatcher filled out the alarm
due to a second source. Engine Company 6, Engine Company 7, Squad Company 18, and
Rescue Company 1 were assigned and responded. At 1539 hours Hazardous Materials Unit
1 (Haz Mat 1) and Hazardous Material Battalion 1 (Haz Mat Battalion) were assigned and
responded.
The temperature was 73 Fahrenheit with relative humidity of 40%. The wind
direction was variable with a wind speed of 3 mph gusting to 16 mph.
The fire building, 130 Liberty Street (formally owned by the Deutsche Bank) was a
26 story high-rise office building undergoing asbestos abatement and demolition. The
original structure, completed in 1974, was a 38 story, steel frame, center core, curtain-wall
building with two levels below grade. The building dimensions were 182' x 182' and
occupied one city block. (LIBERTY STREET WILL BE REFERRED TO AS THE FRONT OF THE
BUILDING THROUGHOUT THE REPORT.)
The exposures were as follows: (Diagram 10)
Exposure #1 - Liberty Street
Exposure #2 - Greenwich Street
Exposure #3 - Albany Street
Exposure #4 - Washington Street
32 of l76

COt'lftWC\\o1'l
'nailers
130 UbertY Street
_\1),d
rant
@
Fan. --........,.'"
,..----r--EI&vators

Plywood Covered
Diagram 11
Fire Origin - 17th Floor Decontamination Area
INITIAL OPERATIONS FROM 1540 HOURS TO 1559 HOURS
At 1540 hours the Ladder Company 10 Officer transmitted a 10-84 and a 10-75 for
heavy smoke on approximately the 20
th
floor of the Deutsche Bank. The Ladder Company
10 Officer corrected the address of the fire building to l30 Liberty Street. Ladder Company
1, Battalion 2 and Division 1 were assigned on the transmission of the 10-75. The
Manhattan Dispatcher notified Ladder Company 1 that they were designated as the
Firefighter Assist and Search Team (FAST Unit).
At 1541 hours the Ladder Company 10 Officer observed fire venting out the
exposure #3 side of the building and transmitted a 2
nd
Alarm. He reported heavy fire
coming "through the skin."
34 of l76
Albany Street
Exposure #3
Fire Origin
Decontamination
Area
_UP
Access Stairs
/1\
ExhaustFans
I \
,...crt
...
I e
B1 82 B3
Hanging Plastic
".---------,-,.-----r- Elevator Shalls
Liberty Street
Exposure.1
Decontamination
Area
Q Decking Area
Elevators--'-----"
The following units were assigned to respond on the transmission of the 2
nd
Alarm:
Engine Companies 55, 24, 15, 33, 9 with Satellite 1
Ladder Companies 8, 6
Battalions 4 (Safety Officer), 32 (Resource Unit Leader) and Rescue
Battalion 1
Field Communications Unit 1
Tactical Support Unit 1
Squad Company 1 with Technical Response 1 (Haz Mat Tech Unit)
RAC Unit 1
At approximately 1541 hours Engine Company 10 was positioned at a hydrant on
Washington Street just north of Albany Street (Diagram 12). There was a standpipe
siamese on the Washington Street (exposure #4) side of the building near Albany Street. A
construction worker informed the Engine Company 10 Officer that this siamese would not
supply the standpipe. He said there was another siamese on Albany Street (exposure #3)
about 100 feet east of Washington Street that would supply the standpipe system. This
construction worker then led Engine Company 10 to the elevators on the Liberty Street side
of the building.
While Engine Company 10 made their way to the elevator the Officer ordered his
Chauffeur to supply the siamese on Albany Street. The Engine Company 10 Chauffeur
began to stretch a 3Y2" supply line to this siamese. This stretch took approximately
15 minutes because the 3W' supply line had to be stretched a long distance and around
construction trailers that hindered access to the siamese. The Engine Company 10
Chauffeur initially had no assistance when he began the stretch.
At approximately 1542 hours the Ladder Company 10 Officer transmitted an
URGENT message via the Department radio. He reported that the scaffold was on fire. He
also reported that the fire was on multiple floors and that units should use caution. Division
1 requested the Dispatcher to transmit the Critical Information Dispatch System (CIDS)
information for the corrected address of 130 Liberty Street. The Dispatcher transmitted the
following CIDS information to responding units via Department radio:
"MAJOR ALTERATION - 38 STORY 210 x 320 - UNOCCUPIED-HOLES IN FLOOR AND EXTERIOR
WALLS ON FLOORS 1 THROUGH 30 SPRINKLER SYSTEM OUT OF SERVICE AND THE STANDPIPE
IS DRY ENTRANCE VIA LOADING DOCK WASHINGTON STREET ASBESTOS AND HAZARDOUS
MATERIALS ON ALL FLOORS."
35 of 176
"
Eng.
ine
COfl'p3!\'j 219
Engine
coos\!UG1iOO
1"ra\\er5
En9\oe
Con'lpaO'f "\5
130 Uberty Street
..._ commafld \:lost
... .... . .
1:;09\n
6
Cott\pl!llYi ,
0

Olf\'\pa(1)' 55
_rI'iora
nt
@ _Siamese
Diagra11112
ratuS
Location of "ngln. Co....pany J\ppa
At 1543 hours Engine Company 7 arrived on the scene and assumed the role of the
2
nd
due Engine Company. They reported to the front of the building with their roll-ups and
standpipe bag. The Engine Company 7 Chauffeur hooked up to a hydrant on the west side
of Greenwich Street (exposure #2) near Cedar Street. He supplied the siamese located on
the exposure #2 side of the building without delay.
At 1544 hours Engine Company 10 entered an elevator
2
with the construction
worker. The construction worker operated this elevator throughout most of the incident.
The elevator operator informed the Engine Company 10 Officer that the standpipe system
worked, but it was dry. The Engine Company 10 Officer notified the Ladder Company 10
Officer that the fire was reported to be on the 17th floor. When Engine Company 10 arrived
on the 15
th
floor the elevator operator guided them from the elevator to the core area
3
where
the A and B stairways were located (Diagram 13).
The conditions on the 15
th
floor were clear at this time. Engine Company 10 entered
the B stairway. The Engine Company 10 Officer noticed that there was no outlet on the
standpipe riser. He attempted to go up to the 16
th
floor but the stairway was blocked by a
wooden platform, sealed in plastic (Photo 16). He then dropped down to the 14th floor.
There was also no outlet on the standpipe riser on the 14th floor. He returned to the 15
th
floor. While their Officer was checking for an outlet on the floor below, two members of
Engine Company 10 used their knives to cut the plastic that covered the underside of the
sealed wooden platform. They were unable able to gain access to the 16
th
floor due to the
sealed wooden platform.
Engine Company 4 and Ladder Company 15 arrived on the scene and proceeded to
the front of the building.
At 1545 hours Ladder Company 1 (FAST Unit) arrived on the scene and proceeded
to the front of the building.
At 1546 hours Battalion 1 arrived on the scene.
2 There was a dual car exterior personnel! material construction hoist (elevators) located on the Liberty Street (north) side
of the building. They were the only elevators that the Fire Department used during this incident. All references to the
elevator(s), unless otherwise noted, shall refer to the dual car exterior personnel! material construction hoist(s) on the
Liberty Street side of the building.
3 The area of the building in which the original elevators, stairways and building support systems were grouped together.
The core area was located in the center of this building.
370f176
---
Albany Street
exposure IJ3
DeC(')ntaminaua(1
Area
Dotted Lines Indicate
Hanging Plastic Shoets -\
;
Exhausl Fans
Ac<:es. Corri<:lOf
I
Drawing not
Q Deci<ing Area
10 scale
liberty Street
exposureIJ1
Diagram 13
The Dashed Line Indicates Engine Company 1O's Path
to the Core Area on the 15
th
Floor
Photo 16
An Example of a Sealed Wooden Platform
38 of 176
At 1547 hours Battalion 1 transmitted a 10-76. The following units were assigned
on the transmission of the 10-76:
Engine Company 3 with High-Rise Unit 1
Battalion 31
Division 11
Mask Service Unit I
The Battalion 1 vehicle was parked on the corner of Liberty Street and Greenwich
Street. Because of the difficulty in gaining access to the construction site, it took
approximately seven minutes from the time of his arrival for Battalion 1 to reach the base of
the elevators on Liberty Street. The Battalion 1 Firefighter was also delayed getting to the
front of the fire building to staff the Command Post.
The Ladder Company 10 Officer made a handie-talkie transmission informing
everyone to use their SCBA because there was asbestos abatement in progress in this
building.
Rescue Company 1 and Squad Company 18 arrived on the scene and reported to the
front of the building. The Squad Company 18 Chauffeur assisted the Engine Company 10
Chauffeur with stretching the supply line to the siamese on the exposure #3 side of the building.
Engine Company 6 arrived on the scene and reported to the front of the building
with their roll-ups and standpipe bag. The Engine Company 6 Chauffeur also assisted the
Engine Company 10 Chauffeur stretching the supply line to the siamese on the exposure #3
side of the building.
At 1548 hours the Engine Company 10 Officer contacted the Ladder Company 10
Officer via handie-talkie and advised him that he needed a couple of saws to get through the
sealed wooden platforms. The Ladder Company 10 Officer acknowledged and ordered the
Ladder Company 10 Chauffeur via handie-talkie to bring two saws with him. Members of
Ladder Companies 10 and 15 and Engine Company 7 took the other elevator from street
level to the 15
th
floor. This elevator was operated by another construction worker.
Ladder Company 8 arrived on the scene and was ordered by Battalion 1 to bring
15
th
saws to the floor and assist Ladder Company 10. In order to gain access to the
construction site Ladder Company 8 forced a construction gate on Greenwich Street near
Liberty Street. This provided an access point for later arriving units.
39 of 176
Engine Company 10 left the B stairway on the 15
th
floor and entered the A stairway.
There was a serviceable outlet on the standpipe riser in the A stairway. The Engine
Company 10 Control Firefighter opened the outlet valve and there was no water in the
standpipe riser. Engine Company 10 then connected their 2%" hoseline to the outlet and
waited for the standpipe to be supplied. At 1548 hours the Engine Company 10 Officer
transmitted via handie-talkie that he observed fire dropping down to the 15
th
floor near the
decontamination area. The Engine Company 10 Officer contacted the Engine Company 10
Chauffeur to determine if he was supplying water to the standpipe system. The Engine
Company 10 Chauffeur responded that he was having trouble gaining access to the siamese.
At 1548 hours the Manhattan Dispatcher transmitted Box 9031. At 1549 hours the
Manhattan Dispatcher transmitted Box 9032. (THESE BOXES ARE TRANSMITTED UPON
RECEIPT OF SIGNAL 10-76 IN MANHATTAN BELOW CHAMBERS STREET AS PER THE
COMMUNICATIONS MANUAL.) The following Brooklyn units were assigned to respond:
Engine Companies 205 and 279
Ladder Companies 110 and 101
Battalions 57 and 41
At approximately 1549 hours members of Ladder Companies 10 and 15 and Engine
Company 7 arrived on the 15
th
floor. They were guided to the core area by the second
elevator operator. Ladder Companies 10 and 15 started working in the A stairway to gain
access to the 16
th
floor. (THE SEALED WOODEN PLATFORM CAUSED ASIGNIFICANT DELAY IN
GAINING ACCESS TO THE 16TH FLOOR.) The elevator car remained on the 15
th
floor while the
members and the elevator operator went to the core area. The elevator remained on this
floor until 1556 hours when it was taken down to the ground floor by the elevator operator
accompanied by the Ladder Company 10 Outside Ventilation Firefighter.
At 1549 hours Engine Company 24 and Battalion 2 arrived on the scene. Engine
Company 24 positioned their apparatus at a hydrant on the comer of Albany Street and
West Street. Engine Company 24 reported to the front of the building with their roll-ups
and standpipe bag. Battalion 2 reported in to Battalion 1 at the base of the elevators on
Liberty Street. Rescue Company 2 was assigned to respond.
At approximately 1550 hours, the Engine Company 10 Control Firefighter moved
toward the exposure #2 side of the 15
th
floor. He realized that there was going to be a delay
before access was made to the floors above. He was looking for access above and for
40 of 176
..
another means of egress in case conditions changed. Using a fire extinguisher he broke a
window on the exposure #2 side of the building approximately 75' from the exposure #3
side. He exited onto the scaffold platform and made his way to the exposure #1 side of the
building where conditions were clear. He then moved to the exposure #3 side of the
building and observed fire on the floors above. He reentered the building and returned to
the core area outside the A stairway to inform his Officer of what he had observed.
At 1550 hours the Rescue Battalion and Engine Company 15 arrived on the scene.
They proceeded to the front of the building. The Rescue Battalion had difficulty gaining
access to the construction site.
At 1551 hours the Engine Company 7 Officer reported to Battalion 1 that the
stairway leading to the 16
th
floor was boarded up. He also stated that Engine Company 7
was teamed up with Engine Company 10. Battalion 1 acknowledged this transmission.
Engine Company 7 attached two lengths of 2V2" hose to the three lengths of 2V2" hose
stretched by Engine Company 10 on the 15
th
floor.
At approximately 1551 hours the Engine Company 7 Chauffeur supplied the
siamese on the exposure #2 side of the building. He supplied 200 psi and delivered
930 gpm to the standpipe system. This was the first supply line to provide water to the
standpipe system. This was 14 minutes after the alarm was transmitted. (IT WAS NOT
KNOWN AT THIS TIME THAT THE STANDPIPE SYSTEM WAS OUT OF SERVICE)
At 1551 hours the Haz Mat Battalion 1 arrived on the scene and reported to
Battalion 1. He gathered some information about the building from a construction worker
who he believed was the Site Safety Director. Battalion 32 arrived on the scene and
proceeded to the front of the building to operate as the Resource Unit Leader.
At 1552 hours Battalion 4 arrived on the scene and proceeded to the front of the
building to operate as the Safety Officer. Ladder Companies 5 and 20 were special called as
additional ladder companies.
At 1553 hours Division 1 contacted Battalion 1 via handie-talkie, announced his
arrival on the scene, and requested his location. Battalion 1 informed Division 1 that he was
in front of the building. Division 1 had difficulty gaining access to this location. Ladder
Company 6 arrived on the scene and proceeded to the front of the building.
At 1554 hours Squad Company 1 arrived on the scene with Technical Response
and proceeded to the front of the building.
41 of 176
At approximately 1554 hours Ladder Company 1 arrived on the 15
th
floor with their
required compliment of FAST tools and equipment. There was no smoke condition on the
floor at this time. They staged in the core area between the A and B stairways. The Ladder
Company 1 Can Firefighter entered the A stairway with a Partner saw and began cutting the
16
th
sealed wooden platform in an attempt to gain access to the floor. Even with the
assistance of other members, this operation took approximately eight minutes.
While the sealed wooden platforms in the A and B stairways were being worked on,
the Ladder Company 15 Officer, the Ladder Company 15 Roof and Forcible Entry
Firefighters, and the Engine Company 7 Officer took the elevator from the 15
th
floor to the
16
th
floor to check conditions. They exited the elevator on the 16
th
floor and moved to the
access corridor. They observed maze like conditions with hanging plastic sheets similar to
15
th
the conditions found on floor. They re-entered the elevator and returned to the
15
th
floor.
At 1555 hours the Ladder Company 10 Chauffeur, positioned at the base of the
elevators, notified the Ladder Company 10 Outside Ventilation Firefighter that the elevators
were needed at ground level. The Ladder Company 10 Outside Ventilation Firefighter,
assigned to staff the elevator, directed the elevator operator to bring the elevator back to
ground level.
The elevator made several trips to the 15
th
floor. Battalion 2, Rescue Company 1,
Ladder Company 8, the Ladder Company 10 Chauffeur and the Ladder Company 15
Chauffeur arrived on the 15
th
floor at approximately 1558 hours. At this time there was a
light smoke condition on the 15
th
floor.
At 1556 hours Battalions 45 and 7 were assigned and responded. The Engine
Company 10 Chauffeur assisted by the Engine Company 6 Chauffeur, the Engine Company
4 Chauffeur, and the Squad Company 18 Chauffeur supplied water to the siamese located
on the exposure #3 side of building. (THIS WAS THE SECOND SUPPLY LINE INTO THE
STANDPIPE SYSTEM.)
At approximately 1557 hours Battalion 4, while proceeding to the Command Post,
observed window glass and debris falling from above on the exposure #3 side of the
building. He relayed this information to Division 1. Battalion 4 heard a handie-talkie
transmission reporting that there was no water in the standpipe. He saw a construction
worker in the loading dock area on Washington Street who identified himself as the building
42 of 176
engmeer. The building engineer stated that there was water in the north (B) stairway
standpipe and that it was serviceable. The engineer also stated that he was going to start the
pump. (THE INVESTIGATION REVEALED THAT THE PUMP THE ENGINEER REFERRED TO WAS TO
SUPPLY WATER IN THE B STAIRWAY RISER FOR ROUTINE DAILY USE BY THE CONSTRUCTION
WORKERS. THE B STANDPIPE RISER COULD NOT BE UTILIZED FOR FIRE SUPRESSION PURPOSES.)
At 1557 hours Battalion 31 arrived on the scene and proceeded to the front of the
building. Engine 9 with Satellite 1 arrived on the scene and positioned Engine 9's apparatus
at a hydrant on Thames Street. Engine Company 202 was assigned to respond as the
CFR-D Engine. Engine Company 14 was assigned to respond as the Lobby Control Unit.
Battalion 8 was assigned and responded.
At approximately 1558 hours Battalion 2 proceeded to the core area on the
15
th
floor and assumed command of firefighting operations at this location. Rescue
Company 1 surveyed conditions on the 15
th
floor. The Ladder Company 10 Chauffeur
entered the B stairway and worked to open the sealed wooden platform which blocked
access to the 16
th
floor.
The following units arrived on the scene at 1558 hours:
Engine Companies 33 and 279
Ladder Companies 5 and 20
Division 11
Car 15
They all proceeded to the front of the building.
At approximately 1559 hours the Engine Company 10 Officer was informed by the
Engine Company 10 Chauffeur that he was supplying water to the standpipe system. There
15
th
was still however no water in the A stairway on the floor. (THE INVESTIGATION
REVEALED THAT THE STANDPIPE RISER IN THE A STAIRWAY WAS UNABLE TO BE SUPPLIED
WITH WATER FOR FIREFIGHTING PURPOSES VIA THE SIAMESE DUE TO MISSING SECTIONS OF
PIPING ON SUB-LEVEL A.)
43 of 176
..
OPERATIONS FROM 1600 TO 1613 HOURS
At approximately 1600 hours Division 1 arrived at the front of the building and
repositioned the Command Post (Diagram 12). The Battalion 1 Firefighter had not yet
arrived in front of the building. Field Communications Unit 1 arrived on the scene and
proceeded to the front of the building. They began setting up the Command Board.
Haz Mat 1 arrived on the scene. The Haz Mat 1 Officer reported to Division 1. The
Haz Mat 1 Officer spoke with a construction worker who identified himself as the site
supervisor and stated that he was in charge of the building. The site supervisor informed the
Haz Mat 1 Officer that there was no fireproofing on the top seven floors. He also informed
him that there were eight oxy-acetylene carts on the 221ld floor. The Haz Mat 1 Officer
relayed this information to the Rescue Battalion.
The Ladder Company 1 Officer and the Ladder Company 1 Chauffeur left the core
area and surveyed the 15
th
floor. After arriving at the exposure #2 side of the building, the
Ladder Company 1 Chauffeur and the Ladder Company 10 Roof Firefighter teamed up. At
approximately 1600 hours they exited the 15
th
floor onto the scaffold through the window
opening that the Engine Company 10 Control Firefighter had made earlier on the exposure
#2 side of building. They used the scaffold stairs to reach the 17
th
floor. They observed
smoke pushing from vents on the 17
th
floor on the exposure #1 side of the building. These
two members remained on the scaffold and never reentered the building because of the
15
th
drastic change in conditions which would occur on the floor. They eventually
descended the scaffold to the street.
At approximately 1601 hours, while units were working to open the sealed wooden
16
th
platforms blocking access to the floor in the A and B stairways, a heavy smoke
condition from the floor above developed in both stairways. Ladder Company 10 attached
their search rope to a door frame just outside the A stairway on the 15
th
floor. This was
done prior to the completion of any opening being made in the sealed wooden platform in
the A stairway leading to the 16
th
floor.
The Engine Company 9 Officer and Battalion 4 were at the Command Post. Engine
Company 9 used the Satellite 1 apparatus to start stretching a 5" supply line to the front of
the building. This stretch took approximately 20 to 25 minutes. They needed to reposition
several apparatus in order to complete the stretch.
44 of l76
While waiting for water the Engine Company 10 Control Firefighter observed that
the decontamination area on the 15
th
floor was on fire. He used a fire extinguisher in an
attempt to extinguish the fire on the exterior wall of the decontamination area. The fire
however, was still pushing from the base of the wall. He returned to the A stairway and
informed the Engine Company 10 Officer of his observations.
At 1601 hours the Manhattan Dispatcher informed Division 1 that a progress report
was due. No progress report was given. Division 1 advised incoming units via handie
talkie of the best way to gain access to the front of the building. Engine Company 3 with
High-Rise Unit 1 arrived on the scene. The Engine Company 3 Officer reported into the
Command Post.
At approximately 1602 hours members created an opening in the sealed wooden
platform in the A stairway leading to the 16
th
floor. This opening was approximately
24" X 84" (Photo 17). Members of Ladder Company 10 passed through this opening and
encountered a heavy smoke condition on the 16
th
floor. The Ladder Company 10 Officer
used his thermal imaging camera to scan the floor area. The thermal imaging camera
indicated little heat. The interior walls, including both stairway enclosures, were removed
and provided a nearly unobstructed scan of the entire floor.
Photo 17
24" X 84" Hatch Opening, 16
th
Floor A Stairway
45 of 176
..
At approximately 1602 hours Squad Company 18, Engine Company 4 and Engine
Company 6 arrived on the 15
th
floor via the elevator. The Squad Company 18 Officer
checked the B stairway. He ordered the Squad Company 18 Hook and Roof Firefighters to
assist with opening the sealed wooden platform in the B stairway which blocked access to
the 16
th
floor. The Squad Company 18 Officer checked for standpipe outlets in the B
stairway and observed that they were missing. He discussed with the Engine Company 4
Officer the need for an exterior hoseline stretch. Because the standpipe in the B stairway
could not be utilized, Engine Companies 4 and 6 surveyed the 15
th
floor looking for an
alternate standpipe location.
After the Ladder Company I Chauffeur and the Ladder Company 10 Roof
Firefighter exited the building from the 15
th
floor onto the scaffold, the Ladder Company 1
Officer continued toward the exposure #3 side of the building. He observed a light smoke
condition and no visible fire. The Ladder Company 1 Officer then returned to the core area
and rejoined his unit at approximately 1602 hours.
At approximately 1602 hours Division 11 and Car 15 each contacted Division 1 to
ascertain the location of the Command Post. The Engine Company 24 Chauffeur notified
Battalion 1 that there was fire in the construction site across Albany Street (exposure #3)
and requested a com pan y to extinguish the fire. The Engine Company 6 Chauffeur used an
apparatus mounted multiversal to extinguish this fire.
At approximately 1603 hours Rescue Company 1 entered the A stairway on the
15
th
floor and proceeded to the floors above. Several members of Rescue Company 1 began
a search of the 16
th
floor using a search rope. The Rescue Company 1 Officer and Forcible
Entry Firefighter along with the Ladder Company 10 Officer, Forcible Entry and Can
Firefighters (Inside Team), continued up the A stairway to the 17th floor. At the top of the
stairway the Rescue Company 1 Officer encountered heavy smoke and heard fire crackling.
He used his thermal imaging camera and it showed high heat. He reported this information
to Battalion 2 via handie-talkie at 1607 hours.
Squad Company 1 arrived on the 15
th
floor in the same elevator as Engine Company
24. Squad Company 1 surveyed the 15
th
floor. The Squad Company 1 Roof and Hook
Firefighters entered the decontamination area on the 15
th
floor and observed fire from floor
, to ceiling in the exposure #3/4 comer of the decontamination area. They left this area and
reported the fire condition to the Squad Company 1 Officer. The Squad Company 1 Officer
46 of 176
sent the Squad Company 1 Roof Firefighter to get a hose line to extinguish the fire in the
decontamination area. This Firefighter returned a short time later and said there was a
hoseline in the A stairway but there was no water in the hoseline.
Engine Company 24 proceeded to the core area on the 15
th
floor. They teamed up
with Engine Companies 4 and 6.
At approximately 1603 hours Division 11 and Rescue Company 2 arrived at the
Command Post. Rescue Company 2 was ordered to stand fast.
At 1604 hours the Ladder Company 10 Officer made the following transmission,
"Ladder 10; be advised we gained entry to the one - six floor. Search rope is being
deployed. The search is going slow due to the fact that we may have holes in the floor.
do not believe that the fire is on one - six K. It may be on the 11h. Say again, it might
not be on 17. I don't think I have fire on 16." Battalion 2 acknowledged this
transmission. (THE INVESTIGATION REVEALED THAT THE LADDER COMPANY 10 OFFICER
INTENDED TO COMMUNICATE THAT THE FIRE WAS ON THE 17TH FLOOR, NOT ON THE 16TH
FLOOR.)
At 1604 hours CFR-D Engine Company 202 and Tactical Support Unit 1 (staffed by
the T AC-l Firefighter) arrived on the scene and proceeded to the front of the building.
At approximately 1605 hours Ladder Company 15 returned to the A stairway on the
15
th
floor shortly after the sealed wooden platform was opened. They went up through the
hatch to the 16
th
floor in the A stairway and conducted a search using a search rope. They
15
th
remained on this floor for a short time and returned back down to the floor at
approximately 1608 hours.
At 1605 hours the Engine Company 7 Chauffeur informed Battalion 1 via handie
talkie that he was already hooked up to the standpipe and supplying it with 200 pounds of
pressure.
At approximately 1605 hours Battalion 41 arrived on the scene and proceeded to the
front of the building.
At approximately 1606 hours Car 15 arrived at the Command Post and assumed
command. The Command Board was being set up by Field Communications Unit 1 at the
Command Post. The Command Post was located on the Liberty Street side of the building.
47 of 176
..
I
Division 1 exchanged information with Car 15. They discussed the location of
operating units, water prohlems, and if all civilians had heen accounted for. Car 15 then
spoke with a civilian who identified himself as a Bovis4 representative. The representative
informed him that there were no problems with the standpipe system and that the pumps
were working. (THIS INFORMATION PROVIDED BY THE BOVIS REPRESENTATIVE WAS
INCORRECT AND CAUSED CONFUSION AT THE SCENE.)
Division 1 received a transmission from Squad Company 1 reporting that there was
fire on the 15
th
floor in a 20' x 40' room. Division 1 acknowledged this transmission and
cautioned them that there was a water prohlem and there might be a bad section valve.
Ladder Company 8 operated on the 15
th
floor and remained together as a unit. They
observed fire in the exposure #3 area of the 15
th
floor and informed Battalion 2. As conditions
worsened on the 15
th
floor, they dropped down to the 14th floor via the B stairway.
At 1606 hours the Engine Company 7 Chauffeur contacted his Officer to see if he was
getting water on the 15
th
floor. The Engine Company 7 Chauffeur was informed that there
was no water in the standpipe riser and that there might be a problem with an isolation valve.
At approximately 1607 hours the Rescue Battalion reported in to Car 15. He was
ordered to go upstairs and provide a report of conditions found. The Rescue Battalion took
an elevator to the 14th floor with the Rescue Battalion Firefighter, the TAC 1 Firefighter and
the Squad Company 1 Chauffeur. The Rescue Battalion ordered the T AC I Firefighter and
Squad Company 1 Chauffeur to team up and operate together.
Battalion 41 reported in to the Command Post and was ordered by Car 15 to see if
the standpipe was working. Battalion 41 took an elevator up to the 3
rd
floor with Ladder
Company 101 to begin the examination of the standpipe.
At 1607 hours the Engine Company 4 Officer made a transmission to Battalion
stating that they might need to drop a line down the exterior of the building.
Battalion 2, still positioned on the 15
th
floor, received the following transmission,
"This is Rescue 1. We got up two floors above where I saw you. I believe it's 17. Ah, we
could hear a good body offire crackling up here. Lotta heat, ah, the camera's showing
hot. I don't see any actual flaming, but I hear it. We're basically right at the stairway.
4 General Contractor hired by the Lower Manhattan Development Corp. to demolish 130 Liberty Street.
48 of 176
Ah, no line or nothing up here yet. There are lots of holes in the floor right by the
stairway, so tell the guys to be careful."
Battalion 2 acknowledged this message and instructed the Rescue Company 1
Officer to use caution because there was no water in the hoseline. He also informed Rescue
Company 1 there was fire on the 15
th
floor.
At 1608 hours Division 1 contacted Battalion 2 to ascertain if he had a unit
available to check the standpipe riser for any closed section valves or open outlets.
Battalion 2 responded that he would assign a unit. Battalion 2 assigned Ladder Company 15
to check the standpipe risers. Battalion 2 informed Division 1 that there was one room of
fire on the 15
th
floor and that there was heavy fire on the 17th floor. He also reported that
there was still no water to the upper floors. Division 1 ordered Battalion 1 into the building
to try and solve the water problem. Battalion 1 entered the building with a construction
worker via the loading dock entrance on the exposure #4 side of the building.
At approximately 1608 hours Division 11 was ordered by Car 15 to determine if all
building workers were accounted for. Division 11 conferred with a construction worker
who informed him that everyone should be out of the building, but he was not sure.
Division 11 relayed this information to Car 15.
At approximately 1609 hours members operating in the B stairway were able to cut
a small hole in the hatch of the sealed wooden platform leading to the 16
th
floor. They were
unable to gain access to 16
th
floor through this opening because it was too small.
The Ladder Company 15 Officer ordered his Forcible Entry and Outside Ventilation
Firefighters to check on the standpipe risers below the 15
th
floor. These two members went
down the A stairway to the 14th floor. There was a sealed wooden platform blocking their
th
descent to the 13 floor. They then entered the B stairway which also had a sealed wooden
13
th
platform that covered the stairs leading to the floor. (THESE SEALED WOODEN
PLATFORMS ON THE 14TH FLOOR PREVENTED MEMBERS FROM DESCENDING TO THE
13
TH
FLOOR. THEY ALSO PREVENTED MEMBERS ON THE 13
TH
FLOOR FROM ASCENDING TO THE
14TH FLOOR. THE SEALED WOODEN PLATFORM IN THE A STAIRWAY WAS FORCED OPEN FROM
BELOW AT 1717 HOURS. THE SEALED WOODEN PLATFORM IN THE B STAIRWAY WAS FORCED
OPEN AT APPROXIMATELY 1735 HOURS.)
The Ladder Company 15 Forcible Entry and Outside Ventilation Firefighters
returned to the 15
th
floor. They informed their Officer that they would attempt to use the
49 of 176
..
elevator to check the floors below. They proceeded to the elevator at approximately
1612 hours.
At 1609 hours Battalion 4 reported via handie-talkie that the building engmeer
stated that he had started the pump. Battalion 4 informed Car IS that the engineer said that
the standpipe was serviceable in the B stairway. (THE INVESTIGATION REVEALED THAT THE
STANDPIPE IN THE B STAIRWAY WAS NOT SERVICEABLE AND THAT THE PUMP THE BUILDING
ENGINEER REFERRED TO WAS NOT A FIRE PUMP.) Car IS contacted Battalion 2 to verify this
information. Car IS was informed by Battalion 2 and the Engine Company 4 Officer that
there was no water in the B stairway.
At approximately 1610 hours the following units were at the Command Post:
Engine Companies 279, 20S, 202, IS, 33, SS and 3
Ladder Companies 110, 20, 6, and S
Battalions 7,8,31, and S7
Rescue Company 2
At approximately 1610 hours the Squad Company 18 Officer surveyed the perimeter
of the lSth floor looking for a location to stretch an exterior hoseline. Engine Companies 4, 6,
and 24 dropped down to the 14th floor via the B stairway. The Officers of Engine Companies
4, 6 and 24 decided to lower a hoseline down the exterior of the fire building. They
proceeded to the elevator lobby to find a suitable location to lower the hoseline.
At approximately 1610 hours the Rescue Battalion arrived on the 14th floor with the
Rescue Battalion Firefighter, the T AC 1 Firefighter and the Squad Company 1 Chauffeur.
There were hanging plastic sheets from ceiling to floor in the access corridor near the
elevator lobby. The Rescue Battalion ordered the members with him to cut a wide opening
through the plastic. They made their way to the B stairway and found a long garden type
hose used by the construction workers. The Rescue Battalion had the Firefighters with him
stretch this hose back to the elevator so it could be used as a guide if needed.
At approximately 1611 hours Car IS told Battalion 4 to get water. Battalion 4
interpreted this order to mean that a hoseline should be stretched up the exterior of the
building. Battalion 4 ordered the Engine Company 9 Officer to use the Satellite manifold to
supply an exterior hoseline.
At 1611 hours Battalion 2 ordered Rescue Company 1 to drop down to the 14th floor
due to fire on the ISth floor and no water. Conditions on the ISth floor had changed from a
so of l76
haze to heavy smoke overhead. Rescue Company 1 and Ladder Company 10 started down
from the 17th and 16th floors via the A stairway. It was a slow process because it was
difficult getting through the narrow opening in the sealed wooden platform on the 16
th
floor.
The Squad Company 18 Roof and Outside Ventilation Firefighters, who had cut a small
hole in the hatch of the sealed wooden platform in the B stairway leading to the 16
th
floor,
began to drop down to the 14th floor.
At approximately 1612 hours the Ladder Company 10 Inside Team dropped down
in the A stairway to the 15
th
floor. The vibralerts of the Ladder Company 10 Can and
Forcible Entry Firefighters activated and they notified their Officer. There was a heavy
smoke and high heat condition on the 15
th
floor so they continued down to the 14th floor
where a heavy smoke condition also existed. They attempted to drop down to the 13
th
floor,
but were blocked by the sealed wooden platform on the 14th floor. The Ladder Company 10
Officer went out onto the 14th floor and moved toward exposure # 1. He was blocked by a
metal turnstile. Due to the heavy smoke condition on the 14th floor, the Ladder Company
10 Officer was unaware of the doorway opening immediately adjacent to the turnstile
(Photo 18).
Photo 18
Turnstile Outside the A Stairway on the 14th Floor
(Facing North Towards Exposure #1)
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"
The Ladder 10 Company Officer returned to the A stairway and led his members
toward the exposure #3 side of the building. They met the T AC 1 Firefighter and the Squad
Company 1 Chauffeur. The T AC-l Firefighter informed the Ladder Company 10 Officer
that there was heavy fire behind the wooden wall of the decontamination area. The
members of Ladder Company 10 traveled along the exposure #3 wall toward the exposure
#2/3 comer.
At 1612 hours the Squad 18 Officer was on the scaffold at the exposure #1/4 comer
on the 15
th
floor and asked if he should drop a rope down to pull a hoseline up the outside of
the building. Battalion 1 told him to stand by. Division 1 also heard the transmission and
believed that the standpipe problem would quickly be resolved. Members had been
15
th
assigned from the floor and from the ground level to check the condition of the
standpipe riser.
At approximately 1612 hours Engine Companies 4, 6, and 24 were at the elevator
lobby on the 14th floor and began to connect their roll-ups to prepare for an exterior hoseline
stretch.
Battalion 2 and Ladder Company 1 were now positioned at the elevator lobby on the
15
th
floor. At 1613 hours the Engine Company 7 Officer was in the core area on the 15
th
floor and made the following transmission, "We're on the 15
th
floor ... we're gonna have to
drop down a floor. The fire'S taking off. We have no water." Battalion 1 acknowledged
this transmission. As Engine Companies 10 and 7 disconnected their hoseline from the riser
in the A stairway, conditions continued to deteriorate. They proceeded toward the B
stairway.
At approximately 1613 hours, after stopping on the 3
rd
and i
h
floors to examine the
standpipe risers, Battalion 41 arrived on the 14th floor via the elevator.
The Engine Company 33 Chauffeur looked through an opening on the exposure #2
side of the building and observed water cascading into Sub Level A. He attempted to relay
this information to Command via handie-talkie with no success. He then informed a
Battalion Chief of this condition in a face to face conversation. Later, he informed another
Battalion Chief of this condition as the Chief passed him on the street.
Car 15 conferred with the Haz Mat Battalion and ordered him to establish a
decontamination area. Car 15 ordered the Resource Unit Leader to establish the Command
Channel.
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At approximately 1613 hours visibility dropped to near zero on the 15
th
floor. It
was described by numerous members as a curtain of black smoke falling rapidly. Heat
conditions also intensified significantly. A CO detector carried by Ladder Company 1
displayed the maximum reading of 999 parts per million. Construction debris and
deteriorating fire conditions impeded numerous members from exiting to a safe area. Some
members became disoriented and were separated from their units. At this time several
members' vibralerts activated as they attempted to exit. This was 36 minutes after the alarm
was transmitted
EMERGENCY TRANSMISSIONS BEGIN AT 1614 HOURS
During the next 63 minutes from 1614 hours to 1717 hours there were
14 MAYDAY transmissions and 19 URGENT transmissions recorded on the Primary
Tactical Channel.
As Engine Companies 10 and 7 were attempting to exit the 15
th
floor they were
unable to locate the B stairway. At 1614 hours the Engine Company 10 Control Firefighter
transmitted the following MAYDAY message, "10 Control. MAYDAY-MAYDAY
MAYDAY. Engine 10 Control.". The MAYDAY was immediately acknowledged by Car
15. The Engine 10 Control Firefighter stated, " ... assist us. It's banked down and starting
to get hot." Car 15 contacted Battalion 2 and ordered him to communicate with the Engine
Company I 0 Control Firefighter.
The Rescue Battalion and the Rescue Battalion Firefighter were in the B stairway on
the half landing between the 14th and 15
th
floors when they heard the MAYDAY from the
Engine Company 10 Control Firefighter. They proceeded to the 15
th
floor in response to
this MAYDAY.
The Engine Company 10 Officer had difficulty finding the B stairway, so he decided
to head back to the A stairway. He felt heat in front of him and behind him. At 1615 hours
he transmitted, "Engine 10 MAYDAY-MAYDAY-MAYDAY. We're on 15, outside the
elevators with a number of members trying to find the B stairwell to evacuate." (THE
ENGINE COMPANY 10 OFFICER WAS REFERRING TO THE ORIGINAL BUILDING ELEVATORS.)
Due to numerous transmissions occurring at this time there was confusion over the identity
of the member transmitting this MAYDAY message. Car 15 ordered Rescue Company 2
into the building to address these MAYDAY transmissions.
53 of l76
At approximately 1615 hours Division 11 was ordered into the building to
coordinate fire operations. He took the elevator with the Division 11 Firefighter to the
13
th
floor. He was unable to gain access to the 14th floor due to the sealed wooden
platforms in both stairways.
At 1615 hours the Haz Mat Battalion special called a Decontamination Task Force
which consisted of Engine Company 263, Ladder Company 117 and Battalion 49. The Haz
Mat Battalion contacted the EMS Haz Tac Ambulance on the scene to ensure that they were
aware of the potential for victims contaminated by asbestos.
At approximately 1616 hours the Engine Company 7 Officer located the B stairway
on the 15
th
floor. He guided the Engine Company 7 Control Firefighter to the B stairway.
There was a heavy smoke condition in this stairway. These two members safely dropped
down to the 14th floor. Their egress to the 13
th
floor was blocked by the sealed wooden
platform. (THE LOWER PORTION OF THE STAIRWAY ENCLOSURE WALL WAS ALREADY REMOVED
AS PART OF THE ASBESTOS ABATEMENT PROCESS AND WAS ONLY SEALED WITH SHEETS OF
PLASTIC.) Members of Ladder Company 8, operating outside the stairway, removed the
plastic sheets from the exposure # 1 side of the B stairway wall. This allowed the Engine
Company 7 Officer and the Engine Company 7 Control Firefighter to exit this stairway.
The Engine Company 10 Nozzle Firefighter became separated from his company in
the core area on the 15
th
floor. At 1617 hours he transmitted the following MAYDAY
message, "MAYDAY-MAYDAY-MAYDAY. Engine 10 MAYDAY. Engine 10 Nozzle
MAYDAY." Car 15 and Battalion 2 both acknowledged the MAYDAY given by the
Engine Company 1 0 Nozzle Firefighter.
These three separate MAYDAY transmissions were given within a 2 minute and
36 second time frame. The Tactical Channel quickly became overwhelmed. Transmissions
were being "stepped on" (interrupted by other transmissions). As a result, some messages
were not completely received or not heard at alL Car 15 attempted to gain control of the
handie-talkie network. Transmissions were made by members other than the Incident
Commander instructing the members who transmitted the MAYDAY messages to activate
their PASS Alarms.
Battalion 2 was located near the elevator on the 15
th
floor when he heard the first
MAYDAY. He ordered members of Squad Companies 1 and 18, who were also in this
area, to search for the member who transmitted the MAYDAY. Battalion 2 ordered Ladder
54 of 176
Company 1 (FAST Unit) to remain at that location and monitor the rescue effort. Utilizing
a search rope and thermal imaging cameras, members of Squad Companies 1 and 18 were
able to assist several members to the elevator lobby. The Squad Company 18 Officer and
the Squad Company 18 Can Firefighter continued their search.
Battalion 1 had entered the building earlier with a construction worker to try to
correct the water problem. Battalion 1 observed a missing section of the standpipe riser
between the ground floor and second floor (mezzanine level) in the B stairway. He moved
to the A stairway with the construction worker and proceeded to the 4th floor. Access was
blocked to the 5
th
floor by a sealed wooden platform. The construction worker informed
Battalion 1 that he could not go from floor to floor via the A stairway. He also informed
Battalion 1 that he was not sure if the standpipe outlet valves were closed or capped.
At approximately 1617 hours the Engine Company 10 Control Firefighter and
several other members including the Engine Company 7 Nozzle and Back-Up Firefighters
were trying to exit the 15
th
floor. They were near the exhaust fans by the plywood wall at
the Q - decking area (Diagram 13). They started to bang on the plywood wall. The Ladder
Company 15 Roof Firefighter and members of Ladder Company 1 (FAST), on the north
side of the plywood wall in the Q - decking area, heard the banging. They proceeded to
breach the plywood wall near the exhaust fans. The Ladder Company 15 Forcible Entry and
Outside Ventilation Firefighters were waiting in the elevator lobby for an elevator on the
15
th
floor when they also heard the banging. They entered the Q - decking area and helped
to breach the plywood wall. The Ladder Company 15 Forcible Entry and Outside
Ventilation Firefighters became involved in the rescue effort.
At 1618 hours the Engine Company 10 Control Firefighter made a handie-talkie
transmission stating, "Engine 10, Engine 10 Control. I gave the MAYDAY, and we're
being assisted out in the hallway, but we're still stuck." Members operating in the
Q -decking area completed the breach of the plywood wall. The trapped members exited
onto the Q - decking area. Battalion 2 made several attempts to contact the member who
transmitted the second MAYDAY (The Engine Company 10 Officer). Car 15 and Battalion
2 attempted to clarify the identity and location of this member. (ALL OF THE MAYDAY
TRANSMISSIONS UP TO THIS POINT HAD BEEN IMMEDIA TEL Y ADDRESSED.)
At approximately 1618 hours the members of Engine Company 9 positioned the
Satellite manifold in front of the fire building while the 5" supply line was still being
55 of 176
...
stretched. Rescue Company 2 arrived on the 14th floor to locate the members who had
transmitted MAYDAY messages.
OPERATIONS TO SUPPLY WATER TO TIIE STANDPIPE SYSTEM FROM INSIDE TIIE
BUILDING
Division 1 ordered Battalion 31 to supply a standpipe riser inside the building.
Engine Company 279 was ordered to find a riser on the 1st floor and supply it. At
approximately 1619 hours Engine Company 279 entered the building on the exposure #4
side with a construction worker and proceeded to the B stairway. (THERE WERE NO
SERVICEABLE STANDPIPE HOSE OUTLETS CAPABLE OF BEING USED FOR FIREFIGHTING
PURPOSES FOR THE ENTIRE RUN OF THE B STANDPIPE RISER.) On the second floor in the
B stairway Engine Company 279 found a I" brass fitting with non FDNY threads connected
directly to the standpipe riser. The fitting had a ball cock valve with a garden hose attached
(Photo 19). (THE INVESTIGATION REVEALED THAT THE B RISER WAS BEING USED BY THE
CONSTRUCTION WORKERS TO PROVIDE WATER FOR ROUTINE DAILY USE.) The Engine
Company 279 Officer opened the ball cock valve and water came out. The construction
worker stated that he could provide a fitting from a tool room on the 8
th
floor that would
enable the Fire Department to connect their hoseline. The Engine Company 279 Officer
ordered his Back-Up Firefighter to escort the worker to obtain the fitting.
Photo 19
I" Brass Fitting Attached to the Standpipe Riser in the B Stairway on 2
nd
Floor
56 of 176
The Engine Company 279 Officer with his remammg members returned to the
street. They stretched a 2Y2" hoseline from the Engine Company 15 apparatus to the
2
nd
floor standpipe riser in the B stairway. The construction worker and the Engine
Company 279 Back-Up Firefighter returned to the 2
nd
floor B stairway. They informed the
Engine Company 279 Officer that there was no fitting available which would allow them to
connect their hose line to the riser.
The Engine Company 279 Officer moved to the A stairway and observed another
standpipe riser with a standpipe outlet. He opened the valve and heard a rush of air.
Members of Engine Company 279 moved to the A stairway and connected their inline
pressure gauge and one length of 2V2" hose to the riser in the A stairway. The Engine
Company 279 members then connected the hoseline from the standpipe to the 2V2" hose line
that was stretched from Engine Company 15's apparatus. Battalion 31 observed Battalion 1
in the A stairway on the 2
nd
floor. Battalion 31 then returned to the Command Post.
The Engine Company 279 Officer, formerly an Engine Company Chauffeur,
returned to the Engine Company 15 apparatus. At approximately 1639 hours he ordered
the hoseline charged which supplied the outlet in the A stairway on the second floor. He
checked the pressure gauges on the pump panel and suspected a problem with the water
supply. He returned to the outlet on the 2
nd
floor to investigate. The valve was opened and
there seemed to be adequate pressure. He checked the 3
rd
floor outlet in the A stairway to
see if water was flowing. He opened the valve and there was no water flow. However, he
did hear a rush of air. He then closed the valve and moved to the first floor outlet (the floor
below the outlet supplying the standpipe). He opened the valve on the first floor in the A
stairway and water did flow out. He closed the valve and proceeded to Sub Level A. In
Sub Level A he observed water dumping to the floor because of a 42' missing section of
piping at ceiling level. He also observed water dumping from a different section of piping
at ceiling level near a separated 90 degree elbow in Sub Level A (Photos 20 and 21). He
attempted to correct this condition by locating a valve which would isolate the A riser. He
was unable to locate a valve.
57 of 176
Photo 20
Part of the 42 Foot Section of Missing Pipe in Sub-Level A.
Photo 21
Separated Section of Standpipe System at Sub-Level A
58 of 176
Engine Company 279 exited the building and returned to the Command Post. The
Engine Company 279 Officer informed the Command Post at approximately 1700 hours
that the standpipe was not serviceable. This was approximately 83 minutes after the alarm
was transmitted.
Battalion 1 had also reported earlier to the Command Post and advised Division 1
that the standpipe was not serviceable.
CONTINUING OPERATIONS ON THE UPPER FLOORS
At 1619 hours, the Ladder Company 10 Officer located on the exposure #3 side of
the 14th floor transmitted an URGENT message stating, "Ladder 10 to Battalion. Be
advised that we had to drop down to 14. We're blowing windows out on the, ah ... I'm not
sure which side I'm on, but we're blowing the windows out. We're out of air. I got the
Inside Team with me, south side ofthe building." This transmission was acknowledged by
Car 15.
The Engine Company 10 Officer returned to the A stairway and dropped down to the
14th floor. He exited the stairway on the 14th floor and encountered a high heat and heavy
smoke condition. Just north of the A stairway door his egress was blocked by the metal
turnstile so he returned to the A stairway. Due to the heavy smoke condition on the
14th floor, the Engine Company 10 Officer was unaware of the doorway opening
immediately adjacent to the turnstile (Photo 18).
Shortly before the first MAYDAY was transmitted at 1614 hours, members of
Rescue Company 1 began to descend the A stairway from the 17th and 16
th
floors to the
14th floor. These members were unable to descend to the 13
th
floor due to the sealed
wooden platform that covered the stairs at the 14th floor level. The Rescue Company 1
Hook Firefighter attempted to cut the sealed wooden platform with their demo saws. The
saw would not operate properly in the heavy smoke condition and was ineffective.
The Rescue Company 1 Officer entered the 14th floor to locate another means of
egress. Just north of the A stairway his path was blocked by the metal turnstile. Due to the
heavy smoke condition on the 14th floor, the Rescue Company 1 Officer was unaware of the
doorway opening immediately adjacent to the turnstile (Photo 18). The Rescue Company 1
5 This saw is a gas powered saw with an 8" blade carried by Rescue Company 1.
59 of 176
-------'
Dolloo Lines Indicate
Haegicg Plastic SheelSl
Access Conidor
-------y--........:--"T-.L
Q - OeCl<ing Area
Officer returned to the A stairway. He then made several additional attempts from the
A stairway to find a safe exit from the 14th floor.
The Rescue Company 1 Chauffeur was in the A stairway on the 14th floor at the
exposure #4 side of stairway enclosure. When the Rescue Company 1 Officer returned to
the A stairway, the Rescue Company 1 Chauffeur realized that the lower portion of the
stairway enclosure was only covered with sheets of plastic. (THE LOWER HALF OF THE
STAIRWAY ENCLOSURE WALL WAS ALREADY REMOVED AS PART OF THE ASBESTOS
ABATEMENT PROCESS AND WAS ONLY COVERED WITH SHEETS OF PLASTIC.) The Rescue
Company 1 Chauffeur removed the plastic and exited the stairway. He observed daylight
coming from the exposure #1 side of the building. All the members in the 14th floor
A stairway enclosure exited through this opening. They moved north toward the
Q decking area at approximately 1628 hours (Diagram ]4).
Albany$I......t
Exposu.... 13
Elevator lobby
DooontaminatiOl1
Area
L Dotted lines Indicate
Hanging PlasUc Sheets
South Turn s\il"
Norlh TumsUle --
;
(25) Exhaust Fans
Drowing nol
to sellie
Liberty $1 ...... 1
Exposure 111
Diagram 14
Dashed Line Indicates Members Path from the
A Stairway to the Q - Decking Area on the 14th Floor
60 of 176
1621:53 (Car 15) "10-4. I copy that Jack. Command to Battalion 2."
1621:57 (Battalion 2) "Battalion 2 to Command."
1621:59 (Car 15) "Listen, these are the companies we have to account for and I want you
to start doing now: Engine 10, Engine 4, Ladder 10 and Ladder 15. Let's get a roll call
up there. Let's find out who's missing, alright?"
At 1622 hours Battalion 2 acknowledged Car 15 and requested the elevator to be
staged on the 15
th
floor for possible egress. He also informed Car 15 that there was heavy
fire and no hoseline on the 15
th
floor. Car 15 acknowledged this transmission.
At approximately 1622 hours Rescue Company 2 deployed their search rope on the
14th floor. The Rescue Battalion operating in the B stairway ordered Rescue Company 2 to
conduct a team search for missing members on the 15
th
floor. They stretched the search
rope through the opening on the exposure #1 side of the B stairway and up to the 15
th
floor.
Rescue Company 2 searched on the exposure #1 side of the building. The Rescue Company
2 Can Firefighter remained near the B stairway, on the 15
th
floor, monitoring conditions and
members with a thermal imaging camera.
Members of Engine Companies 4, 6, and 24 stretched the uncharged hoseline from
the elevators and only had enough hose to reach the base of the B stairway on the 14th floor.
Additional lengths were required to advance the hoseline. Firefighter Robert Beddia, the
Engine Company 24 Nozzle Firefighter, assumed the Nozzle position on this hoseline.
At 1623 hours the Squad Company 18 Officer gave a MAYDAY transmission to
clear the air of handie-talkie traffic. He contacted the Engine Company 10 Officer to
ascertain his location. The Engine Company 10 Officer acknowledged this transmission.
He informed the Squad Company 18 Officer of his location in the A stairway on the
14th floor. The Engine Company 10 Officer then asked the Squad 18 Officer if he had any
of the Engine Company 10 members. The Squad Company 18 Officer informed him that
some of the Engine Company 10 members had come out. He advised the Engine Company
10 Officer to activate his PASS Alarm. The Engine Company 10 Officer stated that he did
not need any help and that he was with other members.
(DURING THE NEXT SEVERAL MINUTES NUMEROUS HANDIE-TALKIE TRANSMISSIONS
WERE MADE INCLUDING MAYDAY MESSAGES AND REPORTS OF MEMBERS MISSING. DUE TO
SIMULTANEOUS TRANSMISSIONS, SOME MESSAGES WERE NOT COMPLETELY RECEIVED OR NOT
HEARD AT ALL.)
62 of 176
..
At 1625 hours Battalion 41 made the following transmission to Car 15, "All the
staircases, all the landings are plywooded up, ah, really secure. It would take us a week
to get up there if we were to go and check each one. All the way up to the 15
th
floor you
cannot get into the staircase." Car 15 acknowledged this transmission.
The Engine Company 7 Officer, located on the 14th floor, transmitted a MAYDAY
message when he could not locate two members of Engine Company 7. This transmission
was not acknowledged. Fourteen seconds later the Engine Company 7 Officer transmitted
another MAYDAY message stating, " ... MAYDAY-MAYDAY. Engine 7 .... " The rest of
his transmission was cut off or not recorded. His third MAYDAY transmission at 1627
hours was acknowledged by the Ladder Company 1 Officer who accounted for Engine
Company 7' s two missing members.
The Ladder Company 15 Officer, located on the 14th floor, attempted to contact his
Forcible Entry and Roof Firefighters. He was unable to contact them and notified the
Command Post that he was missing his Forcible Entry and Roof Firefighters. He also gave
their last known location. Approximately a half minute later the Ladder Company 15 Roof
Firefighter got through on the handie-talkie and notified his Officer that the Ladder
Company 15 Forcible Entry and Roof Firefighters were accounted for and operating on the
north side of the 15
th
floor.
At 1626 hours Battalion 58, the Air Recon Chief, contacted the Command Post and
advised them that they were in the air above the scene and had a view of the building.
At 1627 hours Division 11 reported to Command on the Command Channel
(Channel 2), H we're on the 1fh floor. The stairways, both A and B, do not allow access
above the 1fh floor, and they don't therefore allow, you know egress, down from the 14h
floor. They are blocked off." The Resource Unit Leader acknowledged this transmission
for Command. Division 1 ordered Field Communications Unit 1 to account for all units.
This was 50 minutes after the alann was transmitted.
At 1628 hours Division 11 received the following transmission from the Resource
Unit Leader on the Command Channel, "Yeah, the construction guy says that what's
blocking you off is just a sheet ofplywood and some plastic. Simple forcible entry tools
should be able to take it down." (THE INVESTIGATION REVEALED THAT THIS INFORMATION
WAS INACCURATE. IT WAS EXTREMELY DIFflCUL T AND TIME CONSUMING TO GAIN ACCESS
THROUGH THE SEALED WOODEN PLATFORMS.)
63 of 176




Battalion 41 transmitted an URGENT message requesting extra SCBA cylinders on
the 14th floor. He requested three or four more lengths of hose to be added to the hoseline
stretched up the exterior of the building. He also requested additional Engine Companies on
the 14th floor to assist in pulling the hoseline up. Division I ordered Engine Company 3, the
High-Rise Unit, to bring extra SCBA cylinders up to the 14th floor.
At approximately 1628 hours the members of Rescue Company 1 and the Engine
Company 10 Officer exited the exposure #4 side of the A stairway through the opening in
the lower half of the stairway enclosure. They moved north toward the Q - decking area.
At 1629 hours the TAC 1 Firefighter transmitted an URGENT message that there
was fire in the rear on the 14th floor. He also stated that a couple of members from Engine
Company 10 were low on air and were making their way out onto the scaffold. (THE TAC 1
FIREFIGHTER WAS ACTUALLY REFERRING TO THE MEMBERS OF LADDER COMPANY 10 NOT
ENGINE COMPANY 10.) The Rescue Battalion contacted Car 15 on the Command Channel
and reported high heat and zero visibility on the 15
th
floor. He informed Car 15 that there
were still people missing. He also requested that an additional Rescue Company be special
called.
Car 15 contacted Battalion 2 and asked if a roll call had been completed and if he
knew who was missing. Battalion 2 responded, "So far, can not contact Ladder 15
Officer, Ladder 15 Can." The Ladder Company 15 Officer contacted Battalion 2 and
informed him that the Ladder Company 15 Can Firefighter was accounted for.
At 1630 hours Car 15 ordered all members to stay off the Tactical Channel unless
URGENT. He told Battalion 2 to get an accounting of Engine Companies 4 and 10 and
Ladder Companies 10 and 15.
The Rescue Battalion moved to the Q decking area on the 14th floor and met up
with the Engine Company 10 Officer. The Officer informed the Rescue Battalion that he
did not have any of the Engine Company 10 members with him. The Rescue Battalion
relayed this information to Command on the Command Channel.
At 1630 hours the supply line to the Satellite 1 manifold, which was positioned in
front of the fire building, was charged. This was 53 minutes after the alarm was
transmitted.
At 1631 hours an unidentified handie-talkie transmission was made requesting two
more lengths of hose on the 14th floor. Battalion 41 contacted Car 15 for a second time and
64 of 176
requested that three more lengths be added to the hoseline stretched up the exterior. The
Engine Companies at ground level added lengths of 2 W' hose to this hoseline. They
connected this hoseline to the Satellite 1 manifold.
At 1632 hours Car 15 contacted Division 11 on the Command Channel telling him
that he needed a roll call of the initial units.
At approximately 1633 hours the Officer and two members of Engine Company 3,
the Hi-Rise Unit, arrived on the 14th floor with the spare cylinder cart. They also brought
additional 45 minute SCBA cylinders. The remaining members of Engine Company 3
returned to their apparatus to obtain more cylinders.
The Rescue Battalion contacted Command on the Command Channel to confirm that
all Engine Company 10 members were down on the street The Engine Company 10
Officer notified Division 1 via handie-talkie that all of his members were accounted for.
Car 15 contacted Battalion 41 and informed him that extra lengths were added to the
exterior hoseline at ground level and could be pulled up. Battalion 41 acknowledged this
message.
At approximately 1634 hours Battalion 41 ordered the Engine Company 3 Officer to
find out what was going on with the hoseline. The Engine Company 3 Officer left the
elevator lobby and followed the uncharged hoseline towards the B stairway on the 14th
floor.
At 1634 hours the Engine Company 4 Officer transmitted a MAYDAY because he
couldn't locate the Engine Company 4 Control Firefighter. Battalion 2 acknowledged this
MAYDAY and accounted for this member.
At approximately 1635 hours Firefighter Robert Beddia handed the nozzle to the
Engine Company 24 Back-Up Firefighter just outside the B stairway on the 14th floor.
Firefighter Robert Beddia proceeded up to the 15
th
floor via the B stairway in a heavy
smoke condition. (THE ENGINE COMPANY 24 BACK-UP FIREFIGHTER STATED THAT
FIREFIGHTER JOSEPH GRAFFAGNINO MAY HAVE ACCOMPANIED FIREFIGHTER ROBERT BEDDIA
UP TO THE 15
TH
FLOOR.)
Car 15 asked Battalion 41 if he was ready for water. Battalion 41 replied, "No, not
yet. We're not ready yet, a couple of minutes away." Car 15 informed Battalion 41 to
contact Battalion 4 when he was ready for water.
65 of 176
The Ladder Company 8 Officer transmitted an URGENT message to the Command
Post. He requested FAST-PAKS, extra SCBA cylinders and fresh units. He was advised
that there were extra SCBA cylinders on the 14th floor.
Division 11 informed Battalion 2 that Car 15 wanted a roll call for Engine
Companies 4 and 10, Ladder Companies 10 and 15, Rescue and Squad.
At 1636 hours Battalion 41 attempted to contact Engine Company 24 via handie
talkie. There was no acknowledgement. Battalion 2 informed Car 15 that Squad Company
18 and Engine Company 10 were accounted for and that he was checking on other units.
The Engine Company 3 Officer observed Firefighter Robert Beddia in the
B stairway on the 15
th
floor. Firefighter Robert Beddia stated that they wanted to add
lengths to the front of the hoseline. The Engine Company 3 Officer returned to the elevator
lobby area and reported the need for additional hose to Battalion 41.
The Engine Company 4 Officer met with the Engine Company 24 Back-Up
Firefighter just outside the B stairway on the 14th floor who told him that he needed more
hose. The Engine Company 4 Officer went back to the elevator lobby area to get additional
hose.
The Engine Company 24 Officer and the Engine Company 7 Officer went up to the
15
th
floor via the B stairway to find additional hose. The Engine Company 7 Officer found
two lengths of hose and passed them to members located in the B stairway. Both Officers
returned to the 14th floor.
At 1637 hours Car 15 contacted Battalion 2 and asked if they could pull members
down to the 14th floor. He also asked what the current conditions were. Battalion 2
informed Car 15 that there was heavy smoke and fire where they were operating. He stated
that Squad Company 18 was about to go back in to find the last missing member. Car 15
then attempted to ascertain the identity of the missing member. (THE RAPIDLY CHANGING
15
TH
CONDITIONS ON THE 14TH AND FLOORS HAD LED TO NUMEROUS MEMBERS BEING
SEPARATED FROM THEIR OFFICERS. SEVERAL OFFICERS TRANSMITTED EMERGENCY
MESSAGES REPORTING A MISSING MEMBER. ACTUALLY, ALL OF THE MEMBERS WHO WERE
REPORTED TO HAVE BEEN MISSING HAD TEAMED UP WITH OTHER MEMBERS AND WERE IN SAFE
LOCATIONS. DUE TO THE SIZE OF THE BUILDING AND COMPLEXITY OF THE OPERATION, ALL
MEMBERS WERE NOT DEFINITIVELY ACCOUNTED FOR UNTIL MUCH LATER IN THE OPERATION.)
66 of 176
At approximately 1638 hours Squad Company 1, now located on the 14th floor, was
ordered by Battalion 41 to take over the hoseline on the 14th floor. Squad Company 1 left
the elevator lobby and followed the uncharged hoseline.
At 1638 hours Field Communications Unit 1 transmitted a progress report for Car
15 stating, "Fire on the one-five through the one-seven floors. Currently conducting a
Roll Callfor a missing member. A MAYDAY was transmitted. In the process of trying to
account for all members. Command Channel has been activated, K."
At 1639 hours Car 15 transmitted a MAYDAY message for everyone to stay off the
air. He was attempting to contact the Engine Company 10 Officer whom he believed was
missing. Twelve seconds after Car 15's transmission, the Ladder Company 10 Officer
transmitted an URGENT message. He stated, "We got fire extension on the 11k floor. It
just blew through the wall here. We're going over on the scaffold, K. Say again, we're
bailing out on the scaffolding. South side of the building, K." (THE WALL REFERRED TO
BY THE LADDER COMPANY 10 OFFICER WAS A PLYWOOD WALL WHICH ENCLOSED THE
DECONTAMINATION AREA.) Car 15 acknowledged and asked if he had all his members with
him. There was no response.
At 1640 hours the Rescue Battalion transmitted on the Command Channel that the
Engine Company 10 Officer was accounted for but that members of Engine Company 7
were missing. The Ladder Company 1 Officer contacted the Engine Company 7 Officer
and told him that he had the two members of Engine Company 7 with him.
At this time the members on the 14th and 15
th
floors had been operating for up to
50 minutes. In order to escape the smoke condition on the 15
th
floor members exited from
the Q - decking area to the scaffold. On the 14th floor, some members regrouped in the
Q decking area. Other members began to exit the 14th floor via the elevator or the
scaffold. Engine Company 4 and Engine Company 6 moved toward the elevator on the
14th floor. They intended to drop down to a lower floor to regroup. The Engine Company
24 Back-Up Firefighter maintained his position with the hoseline on the 14th floor outside
the B stairway.
At 1641 hours the Engine Company 4 Officer informed Battalion 2 that all his men
were accounted for. Division 11 confirmed to Car 15 that Engine Company 10 was
accounted for. Car 15 replied to Division 11, " ... Ifwe have Engine 4, Engine 10, Ladder
10, Ladder 15, Rescue, Squad and Battalion 2 confirmed where they are, let's get
67 of 176
everybody down below this fire, and we'll start all over again. I want to make sure we
have everybody accounted for. "
Rescue Company 2 completed their search on the 15
th
floor. The Rescue Company
2 Officer contacted his members and ordered them to drop down. The Rescue Company 2
Officer with two of his members exited onto the scaffold from the Q - decking area on the
15
th
floor. The Rescue Battalion dropped down to the 13
th
floor via the elevator to check
conditions.
The Engine Company 9 Officer told Battalion 41 that he could have water whenever
he wanted it. The Squad Company 1 Officer spoke to the Engine Company 24 Back-Up
Firefighter who was positioned at the nozzle on the 14th floor outside the B stairway. He
told the Squad Company 1 Officer that he needed more hose and water. The Squad
Company 1 Officer told him that extra hose was already pulled up onto the 14th floor. The
Engine Company 24 Back-Up Firefighter then told the Squad Company 1 Officer that he
was ready for water. The Squad Company 1 Officer started back to the elevator lobby area
to relay this information to Battalion 41.
At 1642 hours Division 11 informed Car 15 that he was located on the l3
th
floor and
that there was no access via the stairways to the floor above. He also stated that anyone
13
th
corning down must take the elevator to the floor and then they could walk down.
Battalion 2 transmitted an URGENT message that the elevators were needed on the
15
th
floor to evacuate the members.
At approximately 1642 hours members of Ladder Company 1 and the Engine
Company 7 Nozzle and Back-Up Firefighters exited the 15
th
floor from the Q - decking area
onto the scaffold. The TAC I Firefighter transmitted an URGENT message but didn't
complete his message for another 71 seconds due to numerous handie-talkie transmissions
at that time.
At 1643 hours the TAC 1 Firefighter completed his message to the Rescue 2 Officer
stating that he was on the rear scaffold. He also said that there was heavy fire on the
14th floor and possibly fire on the l3
th
floor. The Rescue "Company 2 Officer acknowledged
this transmission.
Battalion 4 transmitted a message to Battalion 41 informing him that he could have
water anytime he wanted it. The Squad Company 1 Officer reported back to Battalion 41
that they were ready for water in the hoseline on the 14th floor. He also informed Battalion
68 of 176
everybody down below this fire, and we'll start all over again. I want to make sure we
have everybody accounted for. "
Rescue Company 2 completed their search on the 15
th
floor. The Rescue Company
2 Officer contacted his members and ordered them to drop down. The Rescue Company 2
Officer with two of his members exited onto the scaffold from the Q - decking area on the
15
th
floor. The Rescue Battalion dropped down to the 13
th
floor via the elevator to check
conditions.
The Engine Company 9 Officer told Battalion 41 that he could have water whenever
he wanted it. The Squad Company 1 Officer spoke to the Engine Company 24 Back-Up
Firefighter who was positioned at the nozzle on the 14th floor outside the B stairway. He
told the Squad Company 1 Officer that he needed more hose and water. The Squad
Company 1 Officer told him that extra hose was already pulled up onto the 14th floor. The
Engine Company 24 Back-Up Firefighter then told the Squad Company 1 Officer that he
was ready for water. The Squad Company 1 Officer started back to the elevator lobby area
to relay this information to Battalion 41.
At 1642 hours Division 11 informed Car 15 that he was located on the 13
th
floor and
that there was no access via the stairways to the floor above. He also stated that anyone
coming down must take the elevator to the 13
th
floor and then they could walk down.
Battalion 2 transmitted an URGENT message that the elevators were needed on the
15
th
floor to evacuate the members.
At approximately 1642 hours members of Ladder Company 1 and the Engine
Company 7 Nozzle and Back-Up Firefighters exited the 15
th
floor from the Q - decking area
onto the scaffold. The TAC I Firefighter transmitted an URGENT message but didn't
complete his message for another 71 seconds due to numerous handie-talkie transmissions
at that time.
At 1643 hours the T AC 1 Firefighter completed his message to the Rescue 2 Officer
stating that he was on the rear scaffold. He also said that there was heavy fire on the
14th floor and possibly fire on the 13
th
floor. The Rescue Company 2 Officer acknowledged
this transmission.
Battalion 4 transmitted a message to Battalion 41 informing him that he could have
water anytime he wanted it. The Squad Company 1 Officer reported back to Battalion 41
that they were ready for water in the hoseline on the 14th floor. He also informed Battalion
68 of 176
..
Company 24 Back-Up Firefighter passed the nozzle up to Firefighter Robert Beddia who
was on the stairs between the half landing and the 15
th
floor. The Rescue Company 2 Can
Firefighter entered the B stairway from the 15
th
floor to drop down to the 14th floor. The
15
th
Engine Company 24 Back-Up Firefighter continued up the stairs to the floor and
assumed the Back-Up position on the hoseline at the doorway leading to the 15
th
floor.
At approximately 1646 hours the Engine Company 24 Officer moved up to the front
of the hoseline and spoke to Firefighter Robert Beddia, positioned on the nozzle. The
Engine Company 24 Officer entered the 15
th
floor and headed north out of the stairway to
search for fire.
The Engine Company 3 Officer arrived on the] 5
th
floor landing behind the Nozzle
Team. He observed that they had water and were positioned to operate the hoseline. He
then headed back down to the ] 4th floor to locate the two members of Engine Company 3
who had helped stretch the hoseline onto the 14th floor.
At approximately 1647 hours the Engine Company 24 Officer's vibralert activated.
He returned to the B stairway and told Firefighter Robert Beddia that he was low on air and
was going to drop down. He followed the charged hoseline to the half landing between the
14th and 15
th
floors.
At 1648:17 the Engine Company 24 Officer transmitted, "MAYDAY-MAYDAY
MAYDAY. Engine 24 to anybody." (THIS TRANSMISSION WAS ACKNOWLEDGED BY AN
UNKNOWN MEMBER.) The Engine Company 24 Officer then transmitted, "I'm lost. I'm
trying to exit on the charged hoseline, running out ofair. "
At 1648:30 the Engine Company 24 Back-Up Firefighter made the following
transmission, "24 Back-Up to 24, lookfor the hoseline. We're in the stairs." (THE ENGINE
COMPANY 24 BACK-UP FIREFIGHTER BELIEVED THAT HIS OFFICER WAS STILL ON THE
15TH FLOOR. HE DIDN'T KNOW THAT HIS OFFICER WAS IN THE B STAIRWAY BELOW HIM.) The
Engine Company 24 Officer found his way down to the 14th floor and followed the charged
hoseline toward the elevator lobby. While following the hoseline he noticed daylight to his
right. He left the hose line and made his way through a breached opening in the plywood
wall to the Q decking area. The Engine Company 24 Officer then attempted to clear his
MAYDAY. (THIS TRANSMISSION WAS NOT HEARD BY ANY MEMBER. DUE TO THE
NUMEROUS HANDlE-TALKIE TRANSMISSIONS AT THAT TIME, THE ENGINE COMPANY 24
OFFICER'S MESSAGE MAY HAVE BEEN STEPPED ON.)
70 of 176
"

At 1648 hours the Rescue Company 2 Can Firefighter was in the B stairway on the
14th floor and had difficultly finding his way out. After being unable to contact his
company via handie-talkie he activated the Emergency Alert Button on his remote

microphone. At 1648:51 the Rescue Company 2 Can Firefighter transmitted an URGENT
message stating, "I'm in the stairwell. I need help." The Rescue Company 2 Officer
acknowledged the URGENT message and asked "What floor are you on?" The Rescue
Company 2 Can Firefighter gave his location as, "Floor below." The Rescue Company 2

Officer notified Car 15 that he was missing one member. The Rescue Company 2 Can
Firefighter exited the B stairway on the 14th floor and met up with the Engine Company 3
Officer. As they made their way to the Q - decking area they came upon some members of

Rescue Companies 1 and 2 who were searching for the Rescue Company 2 Can Firefighter.
At approximately 1651 hours the Rescue Company 2 Can Firefighter exited safely to the
Q - decking area. The Rescue Company 2 Officer notified Car 15 that the Rescue Company
2 Can Firefighter was found. Communication on the Tactical Channel was difficult because

there were numerous handie-talkie transmissions being made.
At approximately 1649 hours shortly after Engine Company 24's Officer left the
15
th
floor, Firefighter Robert Beddia told the Engine Company 24 Back-Up Firefighter that

they were going to drop down to the 14th floor. They started backing down the B stairway
bringing the hoseline with them. Despite the heavy smoke condition in the B stairway there
was no urgency as they descended to the 14th floor. After he left the 15
th
floor landing, the

Engine Company 24 Back-Up Firefighter had no further contact with Firefighter Robert
Beddia.
When the Engine Company 24 Back-Up Firefighter reached the 14th floor landing he

encountered Firefighter Joseph Graffagnino who was gasping. Firefighter Joseph

Graffagnino stated that he needed air. The Engine Company 24 Back-Up Firefighter
removed his regulator in an attempt to attach it to Firefighter Joseph Graffagnino's
facepiece. As he placed the regulator near Firefighter Joseph Graffagnino's face he realized

that Firefighter Joseph Graffagnino's facepiece was not on. The Engine Company 24 Back
Up Firefighter opened the purge valve of his regulator to give Firefighter Joseph
Graffagnino some air. The Engine Company 24 Back-Up Firefighter quickly felt the effects

of the heavy acrid smoke. He reconnected his regulator to his facepiece with great difficulty
because his coordination was being affected by the smoke.
71 of 176

Firefighter Joseph Graffagnino was standing up. The Engine Company 24 Back-Up
Firefighter told him to get down low. Firefighter Joseph Graffagnino remained standing.

The Engine Company 24 Back-Up Firefighter attempted to pull Firefighter Joseph

Graffagnino to the floor, however Firefighter Joseph Graffagnino resisted this attempt.
While pulling on Firefighter Joseph Graffagnino, the Engine Company 24 Back-Up
Firefighter lost his grip and fell toward the door leading out of the stairway. His hand
landed on a garden type hose that he knew led to the elevators. Firefighter Joseph
Graffagnino fell back toward the stairs. The Engine Company 24 Back-Up Firefighter
called for Firefighter Joseph Graffagnino and Firefighter Robert Beddia to follow him. He

shouted to them that he knew the way out.

At 1650:33 the Engine Company 24 Back-Up Firefighter, while still at the 14th floor
stairway landing, transmitted the following, "MAYDAY-MAYDAY. 24 Back-Up with a
MAYDAY." Battalion 2 on the scaffold between the 14th and 15
th
floor acknowledged,
"Unit with the MAYDAY, go ahead." The Engine Company 24 Back-Up Firefighter then
transmitted, "24 Back-Up... There were two members on the 14th floor, out of air... at the

stairwell... gonna make some noise by the entrance." (THE INVESTIGATION REVEALED
THAT THIS MAYDAY TRANSMISSION WAS NOT HEARD BY ANY MEMBERS OPERATING ON THE
14TH FLOOR AND WAS GIVEN AT THE SAME TIME AS ANOTHER MISSING MEMBER WAS BEING
REMOVED TO THE Q - DECKING AREA.) After completing the MAYDAY transmission the

Engine Company 24 Back-Up Firefighter left the B stairway to get help.

At approximately 1651 hours the Engine Company 24 Officer reached the
Q - decking area. The Engine Company 24 Officer, completely exhausted, told the Rescue
Company 1 Officer and the Battalion 2 Firefighter that his members were still operating
inside.

At 1652 hours a third alarm was transmitted by Car 15. This was 75 minutes after
the alarm was transmitted.
At approximately 1653 hours the Engine Company 24 Back-Up Firefighter exited to
the Q - decking area. The Engine Company 24 Back-Up Firefighter informed the Rescue
Company 1 Officer, the Rescue Battalion Firefighter and Battalion 41 that there were still

members inside. (THE ENGINE COMPANY 24 BACK-UP FIREFIGHTER WAS PHYSICALLY
EXHAUSTED, NAUSEOUS AND VOMITING.)
72 of 176

The Engine Company 3 Officer attempted to account for his two Firefighters on the
14th floor. Due to the numerous handie-talkie transmissions he was unable to contact them.
At 1653 hours he transmitted an URGENT message stating that he couldn't account for all

his members and that they were on the floor with Engine Company 24. Battalion 2
acknowledged the URGENT message. Battalion 41, on the 14th floor, exited the access
corridor to search for the missing members of Engine Company 3.

At 1654 hours Battalion 2 informed Car 15 that Battalion 2 was located on the
scaffold. He also asked Car 15 if he could confirm if members of Engine Company 24 were
missing.

At approximately 1655 hours Division 11 arrived on the 14th floor via the elevator.
After a short period of time he entered the Q - decking area. He made contact with the
Engine Company 24 Back-Up Firefighter who informed him members of Engine Company
24 were still inside.

At 1656 hours the Engine Company 3 Officer transmitted a MAYDAY because he
couldn't account for two of his members. This MAYDAY was acknowledged by Battalion
2. Thirty one seconds later Battalion 41 reported that he had the two members of Engine

Company 3 with him near the elevators on the 14th floor.
Ladder Companies 11 and 18 were assigned and designated as additional FAST
units.

THE SEARCH FOR AND REMOVAL OF }l'IREFIGHTER JOSEPH GRAFFAGNINO
At approximately 1657 hours there were no units operating above the 14th floor.

The only remaining units operating on the 14th floor were: Engine Company 24, Rescue
Company 1, Rescue Battalion, Battalion 41 and Division 11. The Engine Company 3
Officer and two of his members were also on this floor. Car 15 was still attempting to
account for all members. At 1657:52 Battalion 2, on the scaffold at the 14th floor level,

contacted Battalion 41 stating, "There's a report of Engine 24 missing members, also.
Can you confinn that?" Battalion 41 stated he was checking on it.
At 1658:44 the Rescue Battalion Firefighter made the following transmission,

"Rescue Battalion Alpha, I'm on the llh floor with 24 Back-Up. He said the rest of his
company is missing. Are they accounted for?" Car 15 replied, "That's what we're trying
to find out. "
73 of 176

Rescue Company 1 had been in the fire building for approximately one hour. These
members had changed their SCBA cylinders and were staged in the Q - decking area on the

14th floor. The Rescue Company 1 Officer did not hear any of the MAYDAY transmissions

given by members of Engine Company 24 but did hear that members of Engine Company
24 were unaccounted for. Although completely exhausted the Rescue Company 1 Officer
left the Q - decking area and entered through an opening in the plywood wall to search for
the missing members of Engine Company 24. He was followed by the Rescue Battalion and
the Rescue Battalion Firefighter. The Rescue Company 1 Hook Firefighter was positioned
at the opening in the plywood wall with a thermal imaging camera. He was monitoring the

members conducting the search. Shortly after entering, the Rescue Company 1 Officer

heard a PASS Alarm sounding. He turned and informed the Rescue Battalion. The Rescue
Battalion returned to the Q - decking area and ordered the other members of Rescue
Company 1 to enter and assist their Officer. Division 11 also entered through the opening
in the plywood wall. Division 11 located Firefighter Joseph Graffagnino on the north side
of the north turnstile just across from the B stairway. Firefighter Joseph Graffagnino was
unconscious in the supine position. His facepiece was not donned. His PASS Alarm was in

full alarm (Diagram 15).




74 of 176
-------
Oecootaminatior>
Area
Dollad Lines Irdicat.
Hanging Plastc Sheets
Soull1 Tumstikl
North Turnstle ---------'
\', &_w..
Hanging Piastic sn""ls'\
(25) Exhaust Fans
Access Corridor \
\ -------r-........
,
,
.
,
. -.

DrowlngnOl
fOSCJiJI.
" " Q DeC!<ing Am,.
.....
Liberty Slreet
exposure .1
..
Diagram 15
Dashed Line Indicates Firefighter Graffagnino's
Path of Removal from the 14t Floor
Division 11 transmitted the following URGENT message to Command at 1701:59,
"/ got a member down. We're trying to get him out of here on the 14h floor. His PASS
Alarm is going off, non responsive." Car 15 acknowledged the message. The Rescue
Company 1 Officer attempted to remove Firefighter Joseph Graffagnino as Division 11
made his transmission.
At 1702:33 the Rescue Company 1 Officer made the following transmission, " ...come on
in, give us a hand. We got a big guy to pull out. Hurry up." The Rescue Company 1 Hook,
Can and Forcible Entry Firefighters entered through the opening in the plywood wall and assisted
with the removal of Firefighter Joseph Graffagnino. While Firefighter Joseph Graffagnino was
being removed through the opening in the plywood wall to the Q - decking area, the Rescue
Company 1 Officer remained on the south side of the opening for about a minute. He wanted to
ensure that all members were out. He did not hear a PASS Alarm sounding from the core area.
The Rescue Company 1 Officer then exited to the Q - decking area
75 of 176












After Firefighter Joseph Graffagnino was removed to the Q decking area CPR was
started by the Rescue Company 1 Roof Firefighter. The Engine Company 24 Back-Up

Firefighter emphatically stated that another member of Engine Company 24 was still inside.

The Engine Company 24 Back-Up Firefighter, with several other members, carried
Firefighter Joseph Graffagnino from the Q - decking area to the elevator. CPR continued in
the elevator while Firefighter Joseph Graffagnino was transported to street level. (FIVE
MINUTES AFTER FIREFIGHTER JOSEPH GRAFFAGNINO WAS LOCATED, HE HAD BEEN REMOVED
A DISTANCE OF APPROXIMATELY 100' TO THE ELEVATOR.)
EMS, on the scene, was ordered by Division 1 to be in position near the elevator at
street level. They were at that location when Firefighter Joseph Graffagnino was brought
down. EMS took control of Firefighter Joseph Graffagnino's care and transported him to
Beekman Downtown Hospital. The Engine Company 24 Chauffeur assisted EMS with CPR

in the ambulance in route to the hospital.
At 1707 hours a signal 10-66 was transmitted.

THE SEARCH FOR AND REMOVAL OF FIREFIGHTER ROBERT BEDDIA

The Engine Company 3 Officer believed there was another member still
unaccounted for and informed the Rescue Company I Officer. Together they moved from
the Q decking area to the opening in the plywood wall where the Rescue Company I
Officer now heard a PASS Alarm sounding. At 1707 hours the Rescue Company 1 Officer
made an URGENT handie-talkie transmission stating, "I think I'm hearing another PASS
device in there. I'm gonna bring a guy in with me and see what we can find out. We


might have another guy in there. See if we can get them to shut off all the other PASS
devices. I can hone in on it." The Engine Company 3 Officer and the Rescue Company 1
Officer left the Q - decking area and entered through the opening in the plywood wall to
initiate a search. The Rescue Company 1 Hook Firefighter monitored their search from the
opening with a thermal imaging camera. The Engine Company 3 Officer believed that the
missing member was probably in the vicinity of the hoseline. He found the hoseline and
followed it toward the B stairway. The Rescue Company 1 Officer initially followed a

search rope. As they got closer to the core area they moved toward the sound of the PASS
Alarm.
76 of 176
North Turnstile ----------'
L.bGrty SIno"t
Expoa ..... '1

The Engine Company 3 Officer located Firefighter Robert Beddia in the core area
between the two turnstiles. He was on the edge of the platform that covered the original
building elevator shafts on the east side of the core area. Firefighter Robert Beddia was

unconscious in the prone position. His facepiece was not donned. His PASS Alarm was in
full alarm. (Diagram 16)
Albany Street
Expoau... ,3

Decontamination
Area
Dotted Lines Indicate
Hanging Plasuc Sheets
Sou1l1 Turnstile



;
(25) Exhaust Fans
Drawing nol

to scale
Diagram 16

Dashed Line Indicates Firefighter Robert Beddia's
Path of Removal from the 14th Floor
At 1710:12 the Engine Company 3 Officer transmitted the following message,

HMAYDAY-MAYDAY-MAYDAY. Engine ... MAYDAY, MAYDAY." Car 15 replied,
"Unit with the MAYDAY." The Engine Company 3 Officer stated, "Engine 3 with a
MAYDAY. I have an unconscious fireman." At 1710:41 the Rescue Company 1 Officer

called for members to assist with the removal of the unconscious Firefighter. Upon hearing
a MAYDAY transmission members of Squad Company 18 returned to the 14th floor. The
Rescue Company 1 Officer attached webbing to Firefighter Robert Beddia's SCBA. The
77 of 176

Rescue Company 1 Hook Firefighter entered through the opening in the plywood wall and
moved towards his officer. The Rescue Company 1 Officer placed the webbing in his hand.

The Rescue Company 1 Hook Firefighter used the webbing to move Firefighter Robert
Beddia toward the opening in the plywood wall. Several other Firefighters assisted with
Firefighter Robert Beddia's removal to the Q - decking area. In the Q - decking area the
Squad Company 18 Can Firefighter, formerly a member of EMS, initiated rescue breathing.
The Squad Company 18 Roof Firefighter initiated chest compressions. The elevator was
waiting on the 14th floor when Firefighter Robert Beddia was brought to it. At 1717:16
Division 11 made a handie-talkie transmission that the unconscious Firefighter was being

placed into the elevator. (SEVEN MINUTES AFTER FIREFIGHTER ROBERT BEDDIA WAS
LOCATED, HE HAD BEEN REMOVED ADISTANCE OF APPROXIMATELY 125' TO THE ELEVATOR.)
EMS was waiting by the elevator at street level. There also was an EMS physician

at this location. Firefighter Robert Beddia was placed on a stretcher. The physician

ventilated Firefighter Robert Beddia using a Bag Valve Mask (BVM) as they moved toward
the ambulance. The physician stated that Firefighter Robert Beddia appeared hypoxic (had
not received oxygen for some time) and had no pulse. The physician assisted with CPR in
the ambulance on the way to Beekman Downtown Hospital. At the emergency room this
physician recommended to the emergency room physician that both Firefighter Joseph
Graffagnino and Firefighter Robert Beddia be treated for exposure to potential carbon

monoxide and cyanide toxicity.

Despite the efforts of the Beekman Downtown Hospital Emergency Room medical
staff, Firefighter Joseph Graffagnino and Firefighter Robert Beddia succumbed to their
lllJunes.

As noted on the Certificate of Death for Firefighter Joseph Graffagnino the date of
death was August 18, 2007. The cause of death was smoke inhalation.
As noted on the Certificate of Death for Firefighter Robert Beddia the date of death
was August 18, 2007. The cause of death was smoke inhalation.

78 of 176

VII. FINDINGS


1. On August 18, 2007, 130 Liberty Street did not meet the NYC Building Code
requirements for buildings undergoing alteration or demolition. Some provisions of
the NYC Building Code not followed were:
The sprinkler system was out of service.
The standpipe system was out of service.
The means of egress were blocked.


The fire rated construction comprising the stairway enclosures was either
compromised or completely removed at many locations.
2. A demolition application for 130 Liberty Street was not filed and the New York City

Department of Buildings did not issue a demolition permit. A demolition permit for
this building would have required a working standpipe system, sprinkler system,
enclosed stairs, an unobstructed means of egress, and fire guards.

3. The New York City Department of Buildings issued alteration permits, generally
one or two floors at a time, for 130 Liberty Street. Several alteration permits were
issued for each floor that was removed. Alteration permits require building systems
to be maintained and operational, excluding the floor(s) covered by the alteration

permit. This required a standpipe system, sprinkler system, enclosed stairs and an
unobstructed means of egress.
4. The Fire Department did not conduct the inspections of 130 Liberty Street as

required by section 5.8 of the Fire Prevention Manual. This section requires
buildings undergoing construction or demolition to be inspected every 15 days.
Note: Procedures are now in place to ensure that buildings under construction or

demolition greater than 75' are inspected every 15 days as required.

5. At the time of the fire, there was no formal notification to the Fire Department when
a building was undergoing demolition or construction. The Fire Department
identified buildings undergoing demolition or construction as a result of units
discovering these buildings in their administrative areas.

Note: Section 5.8.2 of the Fire Prevention Manual states, "Notice of demolition
operations about to commence shall be forwarded by the Bureau of Fire
79 of 176
I

Prevention on Form A-102 to Divisions and District Offices." It is not known why
this section of the Fire Prevention Manual was not being complied with. (THE
INVESTIGA TION TEAM DID NOT INVESTIGATE THE REASON WHY THIS WAS NOT BEING

COMPLIED WITH DUE TO THE ONGOING INVESTIGATION BY THE MANHATTAN DISTRICT
ATTORNEY'S OFFICE.)
Procedures are now III place which automatically notifies the administrative

company anytime a permit is issued for the construction or demolition of a building
greater than 75' in height. In the future automatic notification will be made to the
administrative company anytime a permit is issued for the construction or
demolition of any building.

6. At the time of the fire, there was no formal procedure for notification to the Fire
Department when a building was undergoing asbestos abatement.
7. At the time of the fire there was no written Fire Department procedure for inspecting
buildings undergoing asbestos abatement.
8. The Bureau of Fire Investigation determined that this fire was caused by careless
discard of smoking materials. There was a delayed notification of approximately

13 minutes to the Fire Department. The delayed notification to the Fire Department
and the absence of a functioning sprinkler system enabled this fire to rapidly
increase in intensity. The fire originated in the decontamination area on the south

side of the 17th floor.

9. The standpipe system could not be used for firefighting purposes due to the
following problems:

The standpipe system had a 42 foot section of pipe missing on Sub Level A.
This prevented water from being supplied to the standpipe risers via the
siamese connections.

When water was supplied to the second floor outlet in the A stairway, the water

flowed into Sub Level A due to the missing section of pipe as well as a failed
coupling which separated during the attempt to supply the standpipe system.

The standpipe outlets in the B stairway were removed which rendered this

standpipe riser unserviceable for Fire Department use.

The fire pumps that supplied the standpipe system were out of service.
80 of 176

10. The inability to supply water to the upper floors in a timely manner for firefighting
purposes:


Allowed the fire to extend above and below the original fire floor.

Allowed incipient fires on the 14th and 15th floors to grow in magnitude
causing an emergency evacuation of members from the 15th floor due to the
rapidly changing fire conditions.

Allowed an IDLH atmosphere to develop on the 14th floor which was three
floors below the original fire floor.

11. There was a major delay before a charged hoseline could be positioned to attack the fire
because the standpipe system was not operational. A charged hoseline was in position
67 minutes after transmission of the initial alarm. As a last resort this hose line had to be
stretched via the exterior of the building. The reasons for the delay were:


The standpipe system was not operational.

Construction workers provided inaccurate information regarding the
serviceability of the standpipe system. This delayed the implementation of
other options.

Blocked stairways precluded a hoseline from being stretched from the
ground level up the interior stairways to the upper floors.
Difficulty in positioning the manifold in front of the building.


Difficulty in pulling the hose up the exterior of the building.
The large floor area which required additional lengths of hose.
12. The fire building, 130 Liberty Street, was undergoing simultaneous asbestos

abatement and demolition. The conditions created by both these operations
occurring simultaneously caused unique problems and complicated the firefighting
operation.

13. There were several problems encountered during operations at 130 Liberty Street

due to the asbestos abatement process. The conditions listed below created
unusually dangerous conditions for the members operating in this building. These
included:
Access and egress was blocked by sealed wooden platforms on most even
numbered floors. As a result members on the 14th floor were prevented from
dropping down to the safety of the 13
th
floor via the A and B stairways. The
810f176

sealed wooden platforms on the 16
th
floor in the A and B stairways delayed
access to the 16
th
and 17
th
floors. It was very difficult and time consuming to
open the hatches in these platforms on the 14th and 16
th
floors.

Combustible wood structures, approximately 675 square feet, were built on
several floors within the building. These combustible wood structures added
significantly to the fire loading of each floor.

Maze like conditions existed in the building due to plywood walls and
hanging plastic sheets in the access corridor areas and the decontamination
areas.

Stairway enclosures above the 15
th
floor were removed. The lower half of
the stairway enclosure on the 14th floor was removed.

Exhaust fans were operating on the 13
th
to 17th floors. There was no remote

shut off for these exhaust fans. Exponent Inc., an independent testing
company, was hired to determine what effects the exhaust fans had on fire
and smoke movement during this fire. At the time of the printing of this
report, the result of Exponent's analysis was not yet available.
Fireproofing was removed from some sections of the structural steel. The
beams supporting several floors directly above the south decontamination
showers bowed significantly creating a serious collapse potential.

14. There were several problems encountered during operations at 130 Liberty Street
due to the demolition project. These included:

The original building elevators were no longer operational.

The personnel/construction hoists on the north side of building were used to
gain access to the upper floors. Construction workers were required to
manually operate these hoists.

Large open unenclosed areas on floors being demolished.

Piles of construction debris throughout the 14th and 15
th
floors.
15. A 130 Liberty Street Implementation Plan was developed by the John Galt
Corporation to set forth the asbestos abatement and demolition procedures for this

building. The Fire Department was not included in the planning process and review

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of the final 130 Liberty Street Implementation Plan. Some of the provisions listed in
the 130 Liberty Street Implementation Plan were:


A dry standpipe system shall be maintained.
The two existing building stairways be maintained free of obstructions and
shall be used to provide access between floors within containment areas.


All interior stairs shall be accessible in the event of an emergency.


At work area containment boundaries, stairways shall be isolated using
minimum 2x4 studs 16" on center, sheathed with 3/8" plywood and two
layers of 6 mil polyethylene, secured with duct tape.

Kick-out panels shall be installed in containment barrier walls and within
stairwells to maintain emergency egress throughout the duration of the

project. Kick-out panels shall be clearly marked with adequate signage.

25 exhaust fans to be spaced throughout the floor being abated.
Contrary to the approved 130 Liberty Street Implementation Plan the following
conditions were found:
A functioning dry standpipe system was not maintained.


Emergency egress was not maintained within stairways.
Containment barrier walls with kick out panels were not constructed on the
14th floor. Instead there were sealed wooden platforms present in the
stairways on most of the even numbered floors in the building which blocked
access and egress.
16. Several construction workers at the site provided inaccurate information about the
building to Chief Officers and operating units. This inaccurate information delayed

operations and caused confusion on the scene. These inaccuracies included:

The standpipe system was operational.

There was water in the B stairway standpipe available for firefighting
operations.
The fire pumps were operating.


The hatches in the sealed wooden platforms in the stairways could be opened
easily by pushing them up.
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The siamese on the Albany Street side of the building would supply the
standpipe system.
17. The CIDS information was inaccurate but did correctly inform responding units that

the sprinkler system was out of service and that asbestos and hazardous materials
were present throughout the building.
18. Firefighter Joseph Graffagnino was located unconscious on the north side of the

north turnstile just opposite the B stairway on the 14th floor. When discovered by
members he was in the supine position with his facepiece removed and his PASS
Alarm in full alarm. There was 0 psi of compressed air remaining in his cylinder.

19. Firefighter Robert Beddia was located unconscious in the core area on the 14th floor
between the north and the south turnstiles on the edge of the platform that covered
the elevator shafts on the east side of the core area. When discovered by members
he was in the prone position with his facepiece removed and his PASS Alarm in full
alarm. There was no air escaping from his regulator when he was found. There was
800 psi of compressed air remaining in his cylinder.
20. The investigation was unable to determine why either Firefighter Joseph


Graffagnino or Firefighter Robert Beddia did not leave the IDLH atmosphere when
their vibralerts activated.
21. Numerous members became lost or disoriented on the 14th and 15
th
floors because of

the heavy smoke condition and the many obstacles that impeded their attempt to
leave the IDLH atmosphere. Some of these obstacles included:

Sealed wooden platforms in both stairways that prevented members from
dropping down to the safety of the 13
th
floor.

Piles of demolition debris throughout the 14th floor and 15
th
floor. This
debris was comprised of metal studs, ductwork, piping, conduit and other
materials.

Metal turnstiles located at both ends of the core area on the 14th floor.
Floor jacks located on the decking which covered the original building
elevator shafts in the core area on the 14th floor.

22. At approximately 1647 hours the smoke condition in the B stairway was so severe
that some members operating within the stairway became disoriented. There were
six members, including Firefighter Joseph Graffagnino and Firefighter Robert
84 of 176

Beddia, operating in close proximity inside the B stairway between the 14th and
15
th
floors. The charged 2 lh" hoseline was stretched up the stairway from the

14th floor. There were also two uncharged lengths of 2 ]12" hose within the

stairway. The charged hoseline was entangled with the uncharged hose. One
member who attempted to follow the charged hoseline to the 14th floor became
disoriented and gave a MAYDAY transmission. Within 29 seconds, a second
member became disoriented within the same stairway and gave an URGENT
transmission. Due to the heavy smoke condition some members operating at this
location were not aware that other members were within a few feet of them in the

same stairway. The sealed wooden platform on the 14th floor prevented these
members from descending to the safety of the l3
th
floor.
23. The Safety Command impounded SCBA Engine 24-5 worn by Firefighter Joseph

Graffagnino at the scene of the fire. This SCBA was a Scott 4.5 positive pressure

breathing apparatus with an EZ flow II regulator and a 45 minute cylinder. The
SCBA was tested by the Mask Service Unit on 812012007. It was subjected to visual
and functional tests using the PosiChek3 testing procedures. The facepiece attached
to the SCBA was marked Ladder 5-5. The cylinder contained 0 psi of compressed
air when confiscated and tested. This SCBA passed both the visual inspection and
the functional tests which included the PASS Alarm. The SCBA was sent to

Intertek Testing Services for independent analysis. It was found to be compliant
with National Fire Protection Association (NFP A) standards.

24. The Safety Command impounded SCBA Engine 24-3 worn by Firefighter Robert
Beddia at the scene of the fire. This SCBA was a Scott 4.5 positive pressure
breathing apparatus with an EZ flow II regulator and a 45 minute cylinder. The
SCBA was tested by the Mask Service Unit on 812012007. It was subjected to visual
and functional tests using the PosiChek3 testing procedures. The personal facepiece

attached to SCBA Engine 24-3 was issued to a Firefighter assigned to Engine

Company 24 who was not working on the day of the fire. The cylinder contained
800 psi of compressed air when confiscated and tested. This SCBA passed both the
visual inspection and the functional tests which included the PASS Alarm. The
SCBA was sent to Intertek Testing Services for independent analysis. It was found
to be compliant with NFP A standards.

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25. SCBA policy and procedures were not strictly followed during fire operations at 130
Liberty Street in the following instances:

Some members attempting to exit to a safe area removed their facepieces in

an IDLH atmosphere.
Some members operating in an IDLH atmosphere attempted to conserve their
air supply by not keeping their facepieces continuously donned.
Some members did not notify their Officer and immediately leave the IDLH
atmosphere with another member when their vibralert alarms activated.
A member attempted to share his air supply in an IDLH atmosphere and was
nearly overcome by the toxic atmosphere.

The working and exit time that could be expected when using 45 minute
cylinders was exceeded. Members, at all levels, did not monitor the
operating time in an IDLH atmosphere.

Members operated in a building that was undergoing asbestos abatement and
did not have their facepieces continuously donned.
An important attribute found within the culture of the NYC Fire Department is the

"can do attitude". The "can do attitude" has enabled the FDNY to protect life and
property at a superior level of excellence since the Fire Department's inception.
This attitude can also cause Firefighters and Officers to ignore written policies and
procedures such as SCBA usage, in order to get the job done. When operating in an

IDLH atmosphere many Fire Department members continue to operate after their
vibralert alarm activates. Many Fire Department members also remove their
facepiece in an IDLH atmosphere exposing themselves to carbon monoxide and

other toxic gases.

26. The Primary Tactical Channel was overwhelmed with routine and emergency
transmissions. As a result many transmissions were not heard. Three separate
MA YDA Y messages were recorded over a 2 minute and 36 second time span when

conditions deteriorated rapidly on the 15
th
and 14th floors. From 1614 hours to
1717 hours there were a total of 14 MAYDA Y AND 19 URGENT messages
recorded on the Primary Tactical Channel.

Five MAYDAY messages were transmitted by members who believed they

were in a potentially life threatening situation.
Three MAYDAY messages were transmitted to locate missing members.
86 of 176


Two MAYDA Y messages were repeated because they were not acknowledged
or heard due to the heavy use of the Primary Tactical Channel.


Two MAYDAY messages were transmitted to gain control of the Primary
Tactical Channel.
One MAYDAY was transmitted when an unconscious Firefighter was located.


One MAYDAY was transmitted informing Car 15 that the unconscious
Firefighter being removed was the Engine Company 24 Nozzle Firefighter.

27. Emergency handie-talkie communications made at this fire were at times effective
and, at other times, ineffective. Some examples are listed below:
Some MAYDAY messages were transmitted properly and quickly cleared.
Radio discipline was not always maintained. Well intentioned members
attempted to communicate with the members transmitting the emergency

messages instead of allowing the Incident Commander to acknowledge and
address the emergency transmissions.


Some MAYDAY messages were transmitted properly, but the specific
information transmitted in the following portion of the emergency
transmission never reached the Incident Commander.

28. Some members standing fast near the Command Post reported hearing MAYDA Y
transmissions given by Firefighter Joseph Graffagnino and Firefighter Robert
Beddia. Battalion Handie-Talkie Recorders on the scene did not record any
transmissions from either Firefighter Joseph Graffagnino or Firefighter Robert
Beddia at the time the members reported hearing them. The Engine Company 24

Officer and the Engine Company 24 Back-Up Firefighter did transmit MAYDAY
messages in the same time period.

29. The handie-talkie worn by Firefighter Joseph Graffagnino, MX3500 Engine 24-5
(Control), was confiscated by the Safety Command and taken to the FDNY Radio
Shops for testing. The external microphone cable was separated from the remote
microphone. The remote microphone was never recovered. This damage was
believed to have occurred during Firefighter Joseph Graffagnino' s removal from the

14th floor. The handie-talkie was found to be in good working condition and within
manufacturer's specifications when tested without the remote microphone. The
handie-talkie worked correctly when tested with a replacement remote microphone.

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The handie-talkie was also sent to Intertek Testing Services for independent
analysis. The handie-talkie passed a functionality test.
30. The handie-talkie worn by Firefighter Robert Beddia, MX3500 Engine 24-3

(Nozzle), was confiscated by the Safety Command and taken to the FDNY Radio
Shops for testing. This handie-talkie was found to be in good working condition and
within manufacturer's specifications when tested. The handie-talkie was also sent to

Intertek Testing Services for independent analysis. The handie-talkie passed a
functionality test.
31. Members operating on the 14th floor did not hear the MAYDAY transmissions given

by the Engine Company 24 Officer or the Engine Company 24 Back-Up Firefighter.

These two handie-talkie transmissions were captured by several Battalion Handie
Talkie recorders. The New York City Fire Department's Research and Development
Unit conducted an onsite test at 130 Liberty Street using MX3500 handie-talkies.

The test attempted to determine if there were any building features that adversely
affected the transmission or receipt of messages. All members involved in the test
received the transmitted messages clearly, except the member riding in the elevator.

He was unable to clearly receive the transmitted messages because of the

background noise from the elevator's operation.
32. The remote Emergency Alert Button located on the microphone of the handie-talkie
was used by a member transmitting an emergency message. This modification of
the MX3500 handie-talkie was part of an ongoing pilot program. This increased the
output of his transmission from two to five watts and he was able to effectively
communicate his location. He was located and guided to safety. Another member

attempted to use the Emergency Alert Button located on the base of radio and was

unable to successfully activate it because his Personal Protection Equipment was
being properly worn. His radio was not equipped with the remote Emergency Alert

Button. The members of Engine Company 24 were not equipped with hand ie-talkies
with the remote Emergency Alert Button.
Note: All MX 3500 handie-talkies have been equipped with an Emergency Alert
Button on the remote microphone.

The Command Channel was not established when the signal 10-76 was transmitted.
Later, just as the Command Channel had been ordered into use, numerous

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emergency transmissions reporting members in distress began. Chief Officers
continued to communicate with the Incident Commander on the Primary Tactical

Channel. Proper use of the Command Channel would have reduced the amount of
radio traffic on the Primary Tactical Channel possibly allowing for more effective
communications.

33. Many members demonstrated initiative and capability in several areas while
operating at this fire:

They quickly supplied the standpipe siamese.

They supplied the standpipe outlet on the second floor in an attempt to get

water up to the fire floor after it became known that the building siamese
would not supply the standpipe system.


They sought out and consulted building construction personnel in an effort to
resolve the water supply problem with the standpipe system.

They performed the arduous task of pulling additional 2 112" hose up to the
14th floor via the exterior of the building.

Engine Company Chauffeurs repositioned two ladder apparatus and raised
'. the aerial ladders to the scaffold providing emergency egress for members.

Engine Company Chauffeurs utilized a hoseline and multiversal appliances
to extinguish fires that had ignited at ground level on the south side of the

building.

Units operated for an extended period of time due to the numerous
emergency situations.


Although the members were physically exhausted, they removed the two
unconscious members from the IDLH in a timely manner.
34. Several members immediately transmitted MAYDAY and URGENT messages as
soon as they realized that they were in a potential life threatening situation. This

allowed adequate time for nearby members to assist them to safety. The response to
the training members have received on transmitting MAYDAY and URGENT
messages had a positive effect on the safety of these members.

35. Several messages were transmitted reporting that fire had extended to the 14th floor.

Some of these messages were intermixed with other emergency handie-talkie
transmissions. Due to numerous reports of missing members and the advanced fire
condition on the 15
th
floor, the escalating fire problem on the 14th floor was not fully
89 of 176

realized by members. As a result, the fire on the 14th floor was not immediately
addressed.
36. The scaffold was used by members as a means of egress. The distance from the

building to the scaffold was approximately 4 feet. There was a platform on the
15
th
floor that allowed for safe egress from the building to the scaffolding. There
was no such platform on the 14th floor. When the conditions deteriorated rapidly

some members were forced to evacuate the 14th floor to the scaffold. Some
members exiting the building to the scaffold were secured with the PSS or a Life
Saving Rope. Other members were unsecured by any safety device as they moved
onto the scaffold.

37. Members vented windows on the 15
th
floor contrary to Section 6.3.8. of Firefighting
Procedures High-Rise Office Building Fires which states, "Ventilation of high-rise
office buildings shall be supervised and implemented by the Incident Commander. ..

Horizontal ventilation should be the last consideration as its effects are least likely to
be beneficial."
38. Carbon Monoxide (CO) Monitors (GasAlert Extreme) have a retrievable memory.

One of Ladder Company 1's CO monitors reached the maximum recordable level of
999 ppm at approximately 1614 hours when the conditions changed drastically on
the 15
th
floor.

39. A member performed a dangerous action when he climbed on top of the elevator
while it was positioned at the 14th floor. He rode on top of the moving elevator as
the exterior hoseline was lowered to street level. This was an unsafe act because the
member could have received an electrical shock, been struck by the ties that secured

the elevator to the building, or fallen off the descending elevator.
40. Both elevators on the north side of the building were not always staffed with a
Firefighter.

41. There are no set Fire Department guidelines or training for operating construction
hoists/elevators in buildings under construction or demolition.
42. Some members were given an assignment which they were unable to complete.

They did not inform their Officer or the Incident Commander that they were unable
to complete their assignment.

90 of 176

43. Unit integrity was not maintained due to rapidly changing fire conditions which
forced an emergency evacuation. This further complicated the Incident

Commander's attempt to account for all members.
44. Member accountability was extremely difficult because numerous members became
separated from their units. The Resource Unit Leader and the Field

Communications Unit Officer did not team up to work effectively to account for all
members in a timely manner. The use of the Primary Tactical Channel to complete a
roll call was ineffective because it was overwhelmed with numerous transmissions.

45. The communications systems required in high-rise office buildings (Fire Command
Station, In-House Phones, Class E System, Standpipe Phones, etc.) were not
available at this fire.

46. Three Engine Companies were teamed up to stretch the hoseline via the exterior of
the building. There was confusion on the 14th floor as to which unit was in overall
control of this hoseline. A Battalion Chief and the Engine Company Officers ,
involved in the stretch never established which unit would take control and initiate

the advance to extinguish the fire.
15
th
47. The Engine Company 24 Officer was forced to leave the floor when his
vibralert activated. He had entered the 15
th
floor alone from the B stairway to search

for the location of the fire. Shortly after commencing the search, the Engine
Company 24 Officer's vibralert activated. He returned to the B stairway where the
Engine Company 24 Nozzle Team was located with a charged hoseline. The Engine
Company 24 Officer informed Firefighter Robert Beddia (the Nozzle Firefighter)

that he was low on air and that he was dropping down. While attempting to exit, the
Engine Company 24 Officer became disoriented in the heavy smoke within the
B stairway and transmitted a MAYDAY. Eventually he was able to follow the

hoseline out of the stairway and make his way to the Q decking area on the
14th floor. He immediately notified several Officers and Firefighters that his unit
was still operating inside.

48. Progress Reports from the scene of the fire were not in accordance with section
10.3.2 of the Communications Manual. Progress Reports provide a continuing
history of the development, control and extinguishment of a fire or emergency.
Oftentimes, as operations become more complex and conditions deteriorate, Chief
91 of 176

Officers have less time to focus on the transmission of the required progress reports.
As a result the progress reports are not always transmitted within the required
frequency. It is at these times that the transmission of a detailed progress report is

even more critical to convey a clear and accurate picture of the conditions existing at
the fire or emergency.
49. The first due Deputy Chief was a Battalion Chief acting Out of Title. The second

arriving Battalion Chief was a Captain acting Out of Title and was the Company
Commander of Engine Company 24.







92 of 176

VIII. CAUSES

DIRECT CAUSE
1. Smoke Inhalation
INDIRECT CAUSES

1. Construction of combustible structures on numerous floors within a fireproof
structure with a non-functioning sprinkler system.
2. Careless discard of smoking material.
3. Failure to maintain an operational sprinkler system as required by the New York
City Building Code.

4. Failure to maintain an operational standpipe system as required by the New York
City Building Code.

5. Failure to maintain emergency fire exits as required by the New York City Building
Code. The sealed wooden platforms on the 14th floor prevented egress to the safety
of the 13
th
floor.
6. SCBA Policies and Procedures not followed regarding:
Immediately leaving the IDLH atmosphere on activation of the vibralert alarm.

Removal of SCBA facepiece in an IDLH atmosphere.
BASIC CAUSES

1. Delayed notification to the Fire Department.
2. Failure of the contractor(s) to ensure that fire protection systems remained
operational.


93 of 176

IX. RECOMMENDATIONS

1. Ensure that Firefighters are trained annually by the Division of Training and
demonstrate competence in the following five areas:

All Scott 4.5 SCBA Policies and Emergency Procedures (reduced profile,
quick release, use of the purge valve, etc.).

All Personal Safety System (P.S.S.) Evolutions.

How to properly transmit your own MAYDAY or URGENT handie-talkie
transmissions. Emphasis shall be placed on the procedures outlined in
Communications Manual Chapter 9.

How to react when a MAYDAY or URGENT transmission is given by

another member. Emphasis shall be placed on procedures outlined in the

Communications Manual Chapter 9. Proper handie-talkie discipline on the
fire ground must be included III this training. Reinforce that only
emergency transmissions should be made when the Incident Commander
orders all handie-talkie traffic to cease.

All Life Saving Rope Evolutions.
These five areas are so vital to personal survival on the fireground, that they must

be repeated annually by an fuB duty members.
2. Ensure that Chief Officers are trained annually by the Division of Training and
demonstrate competence in the following areas:

All Unit Circular 320 (Procedures For Managing Lost, Trapped or
Seriously Injured Members Requiring Extrication).

Communications Manual Chapter 9, Section 9.4 (Emergency Handie-
Talkie Communications).
These topics are so vital for the effective management of operations when
members are in distress, that they must be repeated annually by all Chief Officers.
3. Strictly enforce policies and procedures of All Unit Circular 220, Self-Contained

Breathing Apparatus (SCBA) Policy, and All Unit Circular 329 FDNY
Policy/OSHA Respiratory Standards as they relate to the use of the Scott 4.5
SCBA, including the following:
94 of 176

When the vibralert alarm activates the member must notify their Officer
and immediately leave the contaminated area. This member MUST be
accompanied to a safe area by another member using an SCBA.

The SCBA facepiece must be continuously donned when in an IDLH
atmosphere. Removal of the facepiece to conserve air, to increase visibility, or
to improve communication is dangerous and this practice must not be allowed

to continue. As per Training Bulletin SCBA, Addendum 3, "Exposure to 1.3%
of carbon monoxide will cause unconsciousness in two or three breaths and
wi1l cause death in a few minutes. Exposure to small concentrations for only a
few seconds inhibits one's ability to think clearly, rapidly causes disorientation,
and gives a feeling of euphoria compounding the risk hazard."

All members must be teamed-up when entering, leaving or operating within
an IDLH atmosphere as per All Unit Circular 329, FDNY Policy/OSHA

Respiratory Standards.
Facepiece sharing with other members and/or civilians is PROHIBITED.
Facepiece sharing hampers the search for an exit, increases the exposure to

airborne contaminates such as carbon monoxide, and depletes the limited
air supply in less time, thus posing risk to both victim and rescuer.
Therefore, victims should be removed from the contaminated area as soon

as possible, to a location where proper first aid can be administered. If

victims are unable to be removed from the IDLH, air should be provided by
FAST Pak, Air Cart, Universal Air Connection or spare SCBA strictly for
the victim (no sharing).

Each member should inspect and attach their personal facepiece to their
assigned SCBA at the beginning of each tour.
4. Re-evaluate All Unit Circular 220, Self-Contained Breathing Apparatus (SCBA) Policy,

Section 1.5, with respect to the practicality and safety of an Officer maintaining the
supervision of members of their unit from a safe location when the Officer is required to
leave the IDLH to change hislher SCBA cylinder. Consider which situations would

require the entire Nozzle Team (Engine) or the entire Inside Team (Ladder) exiting
together when the Officer is forced to leave the IDLH area.
95 of 176

5. Re-emphasize to all members that the actual working and exit time achieved from an
SCBA will vary considerably depending upon physical conditioning, type of work

load, physical characteristics, training and a number of other factors. Each member
must be aware of their individual consumption rate when using an SCBA and how this
effects their work and exit times. The Fire Department should establish the means for

members to determine their personal air consumption rates when using an SCBA.

6. Research new technologies which would allow the air supply of operating members to
be monitored from a remote location. This technology should be utilized and
procedures should be established to ensure compliance with existing SCBA policies.
7. Reinforce to all members the importance of immediately transmitting a MAYDAY
message when faced with a potentially life threatening situation.

8. Equip all handie-talkies with an Emergency Alert Button on the remote
microphone. The Emergency Alert Button on the body of the handie-talkie is
difficult to access when properly wearing PPE.
Note: All MX 3500 handie-talkies have been equipped with an Emergency Alert

Button on the remote microphone.

9. Re-emphasize the use of the handie-talkie Emergency Alert Button for any
MAYDAY or URGENT transmission. The use of this button will boost the
wattage of the transmitted message from two to five watts. The use of the
Emergency Alert Button will cause the Emergency Alert Tone to sound signaling
the Incident Commander and other members at the scene that there is a MAYDAY
or URGENT situation in progress. If a member transmitting a MAYDAY or

URGENT message does not use the Emergency Alert Button, then the Incident
Commander should use hislher Emergency Alert Button to gain control of the
handie-talkie network and alert members on the scene of the emergency situation.

10. Amend the Communications Manual and other appropriate documents to require

that every time a MAYDAY is transmitted, the Incident Commander must
announce the MAYDAY on the handie-talkie and on the appropriate Department
borough radio frequency. This notification must be made because incoming units
and different levels of command must be made aware that a life threatening
situation has developed. An announcement shall also be made on both radios when
the MAYDAY situation has been resolved.
96 of 176

11. Re-emphasize to all members that a message transmitted on the handie-talkie
network must be directed to a specific member by unit number and position.
Names should not be used during routine transmissions. Members transmitting a

message must identify themselves by unit number and position. Any message not
acknowledged must be considered as not having been received. This message
must be transmitted again until it is acknowledged.

12, Develop a system to track the inspections by units of buildings undergoing
construction or demolition as required by section 5.8 of the Fire Prevention
Manual.

Note: Procedures are now in place to ensure that buildings under construction or
demolition greater than 75' are inspected every 15 days as required.
13. Develop a system of notification between the Fire Department and the Department
of Buildings which will ensure that timely notification is made when a permit is
issued for the construction or demolition of a building.
Note: Implementation of this recommendation is being addressed in the
"Strengthening the Safety, Oversight and Coordination of Construction,

Demolition and Abatement Operations" report by Mayor Michael R. Bloomberg.
This report was developed by the Construction, Demolition & Abatement Working
Group which included the Fire Department of New York.

14. Develop a system of notification between the Fire Department and the Department
of Environmental Protection which will ensure that timely notification is made
when a pennit is issued for asbestos abatement within a building.
Note: Implementation of this recommendation is being addressed in the

"Strengthening the Safety, Oversight and Coordination of Construction, Demolition
and Abatement Operations" report by Mayor Michael R. Bloomberg. This report
was developed by the Construction, Demolition, & Abatement Working Group

which included the Fire Department of New York.
15. Establish written guidelines to be followed by units when required to conduct
inspections in buildings undergoing asbestos abatement.

16. Incorporate and develop where necessary all pertinent information and procedures
into a single guide pertaining to buildings under construction and demolition with
emphasis on high-rise buildings. Numerous Fire Department documents currently
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address different areas relating to this subject. This guide would provide for all
related information to be incorporated into an inclusive publication for reference.

This guide should include but not be limited to the following:
Construction hoists/elevators.
Scaffolds: types, dangers and the use of.


Temporary shoring for recently poured concrete.
Common hazards found at construction sites. (Open shafts, cranes, wind,
tar kettles, propane use etc.)

17. Train FDNY members to become familiar with and safely operate construction
hoists/elevators at construction sites. Drills should be conducted at construction
sites to familiarize members with the safe operation of hoists/elevators. The
hoists/elevators would still be available for Fire Department use even if civilian

workers were not present to operate them.
18. Ensure that a handie-talkie equipped member is always assigned to any fireman
service or manually operated elevator being used for firefighting operations.

19. Analyze alternate means of providing water to the upper floors of a high-rise
building when the standpipe system is out of service. This should include:

Procedures to provide an emergency repair to a damaged standpipe system.


Guidelines and limitations of using FDNY hose as an exterior standpipe
system.
20. Re-emphasize to all members the importance of communicating to their Officer or
the Incident Commander that an assigned duty has not been completed. This may

be more critical than communicating the results of a completed assignment.
21. Reinforce the importance of not venting windows in a high-rise building unless
approval is given by the Incident Commander.

22. Reinforce the importance of maintaining unit integrity during high-rise operations.

23. Emphasize the importance of units verifying CrDS information at least on an
annual basis and updating as necessary.
NOTE: Administrative units can access this information on the intranet.
24. Reinforce to all Chief Officers that there are alternative means of broadcasting
emergency transmissions to gain control of the handie-talkie network:
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Use of the emergency alert button on the handie-talkie to boost power to five
watts

Use of the 40 Watt UHF Mobile Radio in the Battalion and Division

vehicles.
Use of the Post Radio on the Primary Tactical Channel to broadcast a
message at 45 watts.

25. Re-emphasize to all Chief Officers the importance of transmitting preliminary and
progress reports particularly when conditions are deteriorating.
26. Reinforce that Battalion vehicles must remain on with the motor running during
operations so that the Battalion Handie-Talkie Recorder will continue to record for
the duration of the incident. Presently, the Battalion Handie-Talkie Recorder stops
recording handie-talkie messages approximately 30 minutes after the vehicle's
motor is turned off.

27. Analyze the feasibility of eliminating Acting Out of Title for the ranks of Deputy
Chief and Battalion Chief except on an emergency basis after the start of a tour.
This analysis should include the effect this situation creates at fire operations. It

should also analyze the effect on administrative efficiency when the Company
Commander or the Battalion Chief is not working in their assigned unit.
28. Research the feasibility that an handie-talkie radios be equipped with a short term

recoverable memory of all transmitted messages. If every message transmitted by

each individual handie-talkie radio could be stored internal1y and recovered, this
capability would be of great assistance in future investigations.
29. Establish a periodic training program to adequately prepare Battalion Chiefs to

operate effectively as the Resource Unit Leader.
30. Establish a periodic training program to adequately prepare a pool of Company
Officers to become familiar with and operate effectively in the Field

Communications Unit.
31. Emphasize to aU members that while the gathering of information from civilians at
fire and emergency operations is a vital part of size up, it is important to realize

that information received from civilians at operations can be inaccurate.

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Create a resource page on the FDNY intranet that contains articles and infonnation
sources relating to the fIre service.







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