Actions in fatal ’07 fire faulted

The first supervisor to arrive didn’t adequately size up the situation or establish a command post, while the second ordered the windows broken before the fire had been properly ventilated, the report says. The water supply to a fire hose that could have prevented the fireball was delayed, and a backup hose was not used to protect escape routes from the restaurant.

Those missteps, along with an overall lack of communication between various teams of firefighters and supervisors, led to a disorganized scene that contributed to the deaths of Warren J. Payne and Paul J. Cahill, according to the report issued this week by the Firefighter Fatality Division of the National Institute for Occupational Safety and Health.

The 40-page report is the result of a two-year investigation of the fire at the Tai Ho Mandarin and Cantonese restaurant on Centre Street. An earlier investigation by the Boston Fire Department determined that the fire was caused by grease buildup in the restaurant’s ceiling; the new federal report focuses on how firefighters responded to the fire. Both reports called for improved training for firefighters.

The federal report does not address the role of alcohol and drug use in Cahill and Payne’s deaths because investigators were unable to obtain copies of testing done on the bodies.

“NIOSH repeatedly requested a copy of the autopsy reports through the fire department, district attorney’s office, and representatives of the families, but did not receive any toxicology reports; therefore, NIOSH is not able to comment on the alleged condition of the victims,’’ the report states.

The Globe has previously reported that Payne had traces of cocaine in his system and Cahill had a blood-alcohol content of 0.27, more than three times the legal limit to drive in Massachusetts.

Payne was killed instantly in the fireball, while Cahill was unable to escape from the kitchen, even though two others had made it out, raising questions about whether he was impaired by alcohol.

City officials and the firefighters union are currently battling over whether to institute random drug and alcohol testing of firefighters.

Boston Fire Commissioner Roderick Fraser said yesterday that the department has already addressed many of the problems raised by federal investigators, including insufficient training, but he said he and his commanders are still reviewing the recommendations.

“As we look at the details in this NIOSH report, anything that they recommend that we haven’t addressed so far, we will correct,’’ Fraser said.

Mayor Thomas M. Menino was hospitalized and recovering from knee surgery yesterday, and so was unable to comment.

The federal report is another blow to a fire department that has been rocked by scandal. Three reviews of the department conducted between 1994 and 2000 were largely ignored by Fire Department brass and the Menino administration until 2006, when Menino appointed Fraser, who has updated equipment and broadened the department’s management team to include civilians.

The federal investigators found that firefighters were inadequately trained about basic tactics, such as proper ventilation.

And the report says that nationally recognized command procedures were “not included in any of the training requirements at any level within the fire department or at the department’s fire academy.’’

Edward Kelly, Boston firefighters’ union president, said in a statement yesterday that the report clearly showed that “the training and oversight provided by management of the Boston Fire Department is in need of major reform.’’

“The report states that the only way to minimize the potential for another tragedy of this magnitude is for major changes to be made, including the implementation of improved command procedures and better training and equipment for firefighters,’’ Kelly said.

The federal agency investigates the deaths of firefighters on duty when it believes those deaths have policy implications. In often dry and bureaucratic language, the report offers a painstaking portrait of what went wrong the night of Aug. 29, after firefighters arrived at the Tai Ho restaurant.

The first firefighters to arrive, shortly after 9, saw flames erupting from the roof. As firefighters began setting up hoses, connecting them to hydrants and raising a ladder to the roof, the supervisor at the scene, instead of setting up a command post outside, proceeded inside.

“To effectively coordinate and direct firefighting operations on the scene, it is essential that the IC [incident commander] does not become involved in fire fighting efforts,’’ the report says.

The supervisor also did not conduct a sufficient assessment of the situation, investigators concluded.

Meanwhile, Cahill and another firefighter ran a small hose inside to the kitchen, but there was no water in the hose and it wasn’t large enough or powerful enough to control the fire, the report says.

“Fire departments should ensure that the initial attack line is charged and capable of controlling the fire conditions,’’ the report says.

In addition, there was no backup hose that could have been used to protect escape routes for the firefighters working inside, investigators concluded.

On the roof, a firefighter had problems cutting a hole that would allow the fire to burn upward and out of the building. But the firefighter did not tell the supervisor about his problems, nor did the supervisor ask whether the hole had been cut, the report says.

The second supervisor to arrive didn’t know how many firefighters were inside when he took over, the report says, and the lack of communication or proper supervision meant “separate and uncoordinated activities were taking place in multiple locations,’’ the report says.

The second supervisor then told an off-duty firefighter who wanted to help to break the front windows of the restaurant, which - because the hole in the roof had not been cut - drew the fire down from the ceiling and out toward the front windows in a massive fireball. In the understated words of the investigators: “This provided oxygen to the fire and led to a rapid fire event.’’

Donovan Slack can be reached at dslack@globe.com.