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In our continuing investigation into who dropped the ball, we now examine FDNY institutions. By an FDNY institution we mean, a persistent, time honored, long-standing practice, procedure or way of doing business within FDNY.  In doing so, we find that if anything failed - and we steadfastly maintain that FDNY was not at fault - FDNY institutions failed not FDNY fire officers.  Furthermore, FDNY institutions are the responsibility of the FDNY commissioner not the Captain of the local firehouse. Hence, the ball was dropped by the FDNY Commissioner and not the Captain of the local fire house.

CONTINUITY OF LEADERSHIP 

Continuity of leadership is important for the proper functioning and stability of any organization including FDNY.  Yet, officers commanding a firehouse come and ago.  Sometimes, officers are assigned to a firehouse for a while. At other times, when no permanent officer is assigned to a firehouse,  the position is "covered" by a temporary officer. There is an ebb and flow of commanders. The rapidity of this ebb and flow varies from firehouse to firehouse and time to time. Because there is an ebb and flow of commanding officers, it is a mistake to equate leadership solely with rank.  Leadership does derive from rank but it also derives from experience especially at a firehouse where 'rank' comes and goes.

THE CHANGE OF COMMAND 

Despite the ebb and flow of commanding officers, FDNY has no formal procedure for a change of command.  There is no formal exchange of information between the exiting commanding officer and the incoming commanding officer.  The old guy doesn't hand the new guy a portfolio of what is going on at the firehouse.  There is no transition period in which the exiting officer shows the entering officer the lay of the land. The new guy is just dropped cold into a hot environment. So what does the new guy do to get himself up to speed? Due to lack of a formal change of command procedure, a new Captain is compelled to rely on the information he gets from the lieutenants that are already in place as well as the firefighters in the fire house.  Experience teaches inexperience. The "old hands" teach the new. Those already in place show the new Captain the lay of the land.

There is nothing wrong with this.  If a Captain cannot rely on his lieutenants and firefighters, who can he rely on? Certainly not the Commissioner. He just throws innocent firefighters to the wolves. This is how it has been done in FDNY for generations.  This oral tradition from the experienced to the inexperienced, from the old to the new regardless of rank is a legitimate pathway for the passage of knowledge and know-how, custom and practice within a firehouse.  It is an FDNY institution.  Not only is it a persistent, time honored, long-standing practice, it is necessary given the absence within FDNY of a formal change of command procedure by which knowledge and know-how, custom and practice pass.

When Captain Peter Bosco arrived at the Ten House in late December 2006 early January 2007, there was no formal change of command. The oral tradition - an FDNY institution - educated him on the knowledge and know-how, custom and practice within the TEN HOUSE. Already established at the TEN HOUSE before Captain Bosco arrived was a policy of non-inspection of the uber-toxic Deutsche Bank Building. Bosco did not invent it himself. He inherited it. It predated him. It originated from orders from superior officers.  Stay out of this toxic hell hole.  There were no contradictory orders. No superior office either orally or in writing ever told Bosco to inspect the toxic hell hole or even questioned him about its inspection - although superior officers from Chief to Commissioner had multiple opportunities to do so through personal contact with Bosco at the TEN HOUSE before the fatal fire of August 18, 2007. All Bosco was told was there were orders not to go in.  No-one told him otherwise. And the ban on entry made sense. There were no Tyvek suits hanging up in the equipment racks at the Ten House.  There were no drills scheduled to initiate the new captain about the proper inspection procedure for this toxic building.  There was no site specific training offered to the new captain upon his arrival at the TEN HOUSE.  Everyday, workers were seen entering and exiting 130 Liberty Street in astronaut suits.  A superior officer told Bosco that the NYC Building  Department had multiple inspectors on site --- and did not even suggest let alone order him to inspect.  Years before Bosco arrived at the TEN HOUSE, a memo was sent up the chain of command asking for help in figuring out how to handle 130 Liberty street. No memo ever came back down the chain of command telling the TEN HOUSE what to do.  etc. etc.

AND THEY'RE OFF ... 

There is something more that you must keep in mind. 

Have you ever been in a firehouse when a run comes in?  It's like you see in the movies when the Captain of a submarine yells 'Dive' and the klaxons sound. It's like the bridge of the Starship Enterprise under enemy attack when Kirk yells, 'Red Alert' and the lights flash and the alarm rings.  It is like the start of a horse race where the bells go off and the horses bolt from the gate.  Sight and sound and movement and action mark the beginning of a run.  Everyone instantaneously knows that a run has begun. There is no ambiguity.  Let me repeat: there is no ambiguity.  FDNY is very good at signalling its firefighters about the start of a run. 

Have you ever been in a firehouse when a building is put under a 15 day inspection regimen? 

There is nothing.

Silence.

Everything is still. 

No lights flash.

No bells go off.

No one runs around like a chicken without its head.

There is no movement.

There is nothing.

Not even any paperwork.

Before August 18, 2007 - FDNY issued no paperwork to the firehouse signalling the start of a 15 day inspection regimen. 

Unlike runs, FDNY was very bad at signalling its firefighters about the start of 15 day Inspections.

There was much ambiguity. 

How FDNY signaled a run and how FDNY did not signal 15 day inspections were both FDNY institutions. They were persistent, time honored, long-standing FDNY practices.

CONCLUSION

If there was any fault - and we have consistently maintain that there was none -  the fault is with the FDNY institutions not with the FDNY fire officers.  The FDNY Commissioner was in charge of the FDNY institutions. If anyone dropped the ball it was the FDNY Commissioner. It was not the result of a rogue Fire Captain or rogue Battalion Chief or rogue Division Chief.  The Captain, Battalion Chief and Division Chief wanted to do their jobs. They were honest men who wanted to do their best.  The established FDNY institutions instructed the Captain of the local firehouse not to inspect 130 Liberty Street. The oral tradition of a change of command from the experienced to the inexperienced, from the old to the new - an FDNY institution -  got Captain Bosco up to speed and told him about the pre-existing policy of staying out of 130 Liberty Street.  If the FDNY institutions gave the wrong signal, blame the institutions that gave the wrong signal not the fire officers who listened to the wrong signal.  FDNY institutions let them down. It is not right to blame honest, hardworking men for defective institutions.

FDNY knows how to signal the beginning of an FDNY operation.  FDNY had an unambiguous signal for runs; FDNY did not have an unambiguous signal for 15 day inspections.  If FDNY had in place an unambiguous signal - like the signal it uses for runs - to announce the start of 15 days inspections, does anyone really think that these three diligent and dedicated fire officers would have ignored it? Come on now. It would be just as hard to ignore it as it would be to ignore the signal for a run.  That FDNY had no mechanism to 'sound the alarm' to indicate the commencement of 15 day inspections tells how little importance FDNY placed on 15 day inspections.  FDNY 'sounded the alarm' for runs but not for 15 day inspections. Hmmm.  Let's blame a Captain, a Battalion Chief and a Division Chief for failing to act on a signal that was never given. Something doesn't make sense here. How can FDNY blame the fire officers when it was another FDNY institution that was defective? Perhaps it is because  the person in charge of FDNY institutions is the Commissioner himself and to deflect blame from himself he points the finger of blame at the hired help?

Furthermore, suppose the oral tradition on a change of command signaled Captain Bosco to not inspect and FDNY had indeed sounded an alarm signaling Captain Bosco to inspect.  Don't you think upon arriving at the TEN HOUSE that Captain Bosco would have sought to clarify such a conflict?  Isn't that what the TEN HOUSE tried to do years before Captain Bosco arrived by sending a cry for help up the chain of command (Click Here)?  When Captain Bosco arrived at the TEN HOUSE there was no conflict. It had already been resolved.  Not inspecting was the policy already in place and it was a policy that made sense. 

Recall also that this was ground zero.  Everything was topsy-turvy at ground zero. If this was another place, say Queens, of if this was another time, say pre-9/11/2001, or if the building was not toxic, then the progression of events might have been different (Click Here). However, this was not Queens but ground zero; this was not pre 9/11/2001 but post 9/11/2001; this was not a clean building but a toxic building.  Because of all of this, the progression of events was ineluctable.

Any Captain of the whole cadre of Captains placed in the TEN HOUSE in late December 2006 early January of 2007 in lieu of Captain Bosco, would have done the same thing as Captain Bosco: not inspect 130 Liberty Street.  To besmirch Captain Bosco by accusing him of not doing his duty is to besmirch all Captains of FDNY nay all commanding officers of FDNY regardless of rank.  This is just not fair. It all boils down to this: if you saw people coming out of 130 Liberty Street ... (click Here)