A lack of training to fight wind-whipped fires, inadequate Fire Department staffing, and failure to adequately assess risk contributed to the deaths of two Boston firefighters in a 2014 Back Bay inferno, federal investigators conclude in a report completed this month.
The findings from the National Institute for Occupational Safety and Health raise troubling questions about tactics used to fight a fire that stunned the city.
The report also paints a chilling portrait of firefighters without water and a series of seemingly innocent acts — doors left open, flammable materials stored in cabinets — that led to tragedy.
The Boston Fire Department is preparing Thursday to make public the results of its own inquiry into the actions of firefighters who battled the March 26, 2014, blaze that claimed the lives of Lieutenant Edward Walsh and firefighter Michael Kennedy.
Both reports, obtained by The Boston Globe, present an official accounting of the chain of events inside the basement and outside the four-story brownstone, where Kennedy and Walsh became trapped.
Fire investigators had previously linked the cause of the blaze to fast-moving winds and the unintentional actions of welders installing a railing on a nearby building.
The federal report outlined a series of factors that led to the deadly blaze. It cited uncontrolled ventilation, lack of fire hydrants on a private street, absence of a sprinkler system, and the unrestricted path of the fire, which also resulted in 13 firefighters being injured.
Federal investigators offered 15 recommendations, urging the department to follow standard procedures for sizing up risks at fire scenes, develop training and tactics for wind-driven fires, and ensure adequate staffing for deploying firefighters in tightly populated areas.
The report said the Fire Department should provide an incident commander with a mayday tactical checklist in the event of such future crises.
“When a mayday is transmitted for whatever reason, the incident commander has a very narrow window of opportunity to locate the lost, trapped, or injured member(s),” the agency’s report said.
The federal report said that as part of the “analysis process” of the fatal blaze, the Boston fire commissioner has launched a “ ‘back to basics’ training program” in which all companies will be required to participate in live-fire training annually at the fire academy.
The training will be completed by each shift in every district.
The Boston Fire Department declined to respond Wednesday night to the federal findings, saying it was waiting for formal release of the report Thursday.
The first indication of impending tragedy on that windy day in March 2014 arrived via a call from Fire Box 1579. There was a raging blaze at 298 Beacon St.
Walsh, 43, and Kennedy, 33, and two other crew members on Engine 33 were the first fire company to arrive at the brownstone at 2:45 p.m.
Walsh took command, telling the fire alarm office that received the 911 call that smoke was billowing from the first floor.
“Engine 33 is in command, and we have a four-story with smoke showing from the first floor,’’ Walsh said, according to the report.
Federal investigators said that given the “active and dynamic situation” and urgent concerns about the possibility of people being in the building, Walsh took a “fast-track” command mode, selected in situations that require “immediate action,’’ the report says.
The lieutenant and Kennedy, serving as the pipeman, stretched an uncharged 1¾-inch hose up the front of the steps into this first floor, the agency report said.
The driver of Engine 33 filled the line with water as Walsh and Kennedy raced down the steps to the rear of the basement apartment. But the rapid progression of the fire caused the line to burn and lose pressure.
“The water never reaches the nozzle,’’ the federal report said.
Other firefighters were quickly on the scene, including a commander who took charge. Another fire engine stretched a hose toward the front steps.
Investigators said fire and heat rose from the steps, after a maintenance worker investigating a smoke detector alarm left open the rear door of the attached shed.
The interior door at the top of the basement step was also open and a basement window failed.
Another responding crew, on Engine 7, tried to supply water, but the conditions became untenable and they had to leave the building. Their hose was also burned, the report said.
“Once the rear door or window burned through, this created an unrestricted flow path from the basement to the first floor, plus the floors above, thereby triggering a rapid progression of fire conditions,’’ the federal report said. “This trapped the officer and the firefighter from Engine 33 in the basement.”
The federal report says that when Engine 33 arrived, the hose “could not be stretched to the hydrant due to the lack of staffing.”
Those staffing issues, the report says, also resulted in the first units that responded having to rescue building occupants, which caused teams of firefighters to be split.
The federal report credited the Fire Department’s Fire Alarm Office for its “positive impact” during the blaze.
The Boston Fire Department’s own 218-page report details the findings of its Board of Inquiry. It says Walsh and Kennedy were not directly exposed to open fire until right before their final radio transmission, based on Walsh’s repeated references to smoke but no explicit mention of fire in his initial calls.
The department’s Board of Inquiry supported the findings of an earlier Boston Fire Department investigation “that the unpermitted and improperly performed welding operation at 296 Beacon St. initiated the fire when windswept slag ignited the shed attached to 298 Beacon St.,” the department’s report said.
The Board of Inquiry noted that because of the building’s age, 298 Beacon was not required to install an automatic sprinkler system, as all new apartment buildings must.
Investigators believe “that voluntary installation of an automatic sprinkler system in the basement and shed of 298 Beacon St. would have prevented the tragedy and destruction that occurred on March 26, 2014,” the report said.
The document stressed that the Board of Inquiry “considers the unpermitted and improperly performed welding operation to be the primary cause of the fire, but the wind-driven conditions were the primary contributory factor to the entrapment and subsequent deaths” of Walsh and Kennedy.
Investigators also cited a cabinet at the top of the basement stairs that the building manager said he thought contained items including old paints, lacquers, and spray cans.
The building manager told investigators he thought the previous owner may have stored the items in the cabinet.
“The specific contents of the cabinet and the degree they may have contributed to the extension or severity of the fire remains undetermined,” the report said.
Another factor cited was security grates placed on windows in both basement apartments.
The grates, which were properly installed in the 1980s, were forcibly removed from the rear windows during the rescue attempt, according to the report.
The Fire Department’s Board of Inquiry said it could not “determine if the window grates were a factor that may have prevented escape from the rear apartment by Lieutenant Walsh and Fire Fighter Kennedy.”
Meghan E. Irons can be reached at firstname.lastname@example.org.