THE GRAND-JURY report on the deadly York Street fire that killed two firefighters is 110 pages long.
But it can be summed up in four words:
"A failure of government."
The people who bear the most blame for the April 2012 deaths of two firefighters in the dilapidated Kensington mill are the unscrupulous New York investors who bought it and turned it into a firetrap. Hell, make room for two.
But right behind Nahman and Michael Lichtenstein, the father-son owners of the former Thomas Buck Hosiery factory - perhaps hand in hand - are the city agencies whose negligence, incompetence and inaction allowed them to function with impunity. Put another way: People will only get away with what they are allowed to get away with.
The damning (and well-written) report details disgraceful and ultimately deadly bureaucratic ineptitude from the Department of Licenses & Inspections, along with the Revenue and Law departments that failed to hold the Lichtensteins accountable for numerous code violations and thousands of dollars in unpaid taxes.
"Inspections were performed, notices were issued - but nothing ever happened," the report states. Neighbors were left with an eyesore and "none of these departments . . . connected the dots to determine what was glaringly obvious - that the [Lichtensteins] had no intention of complying with the law."
And why would they? According to the report, L&I commissioners admitted that the department wasn't in a rush to take the owners of large properties to court because if the owners couldn't or wouldn't pay for repairs, the city could be on the hook. Saving money trumped saving lives.
That same report, which concluded that there isn't enough evidence to charge the owners criminally, offers a host of recommendations. Among them are expanding an ordinance that requires that contractors not be tax delinquent to include property owners and passing a law to allow criminal prosecution of property owners who refuse to correct dangerous conditions.
In a painfully hopeful, if delusional, note, the report states: "There are lessons to be learned."
Lots - but Philly doesn't learn its lessons.
If it did, it would have learned them after the fire at One Meridian Plaza in 1991 that killed three firefighters.
Or the 1997 incident where falling debris from a building previously cited by L&I killed a judge.
Or the deaths of three young women in 2000 after the collapse of a Delaware River pier.
If Philadelphia learned its lessons, the parties responsible - the investors and the city - would not have been allowed to set the deadly stage for the unnecessary deaths of Lt. Robert Neary and firefighter Daniel Sweeney.
If Philadelphia's leadership was really capable of learning its lessons, six people wouldn't have been buried under the rubble of the Market Street building collapse last year, which also prompted an L&I inspector to commit suicide.
Following that avoidable disaster, the administration named a special independent commission to review L&I practices, policies and procedure with recommendations expected in June. So let's all say a prayer that none of the thousands of blighted buildings in this city cost anyone else their lives until then.
There are lessons to be learned after every single tragedy. But we have to be willing to learn, and act, on them.
Just yesterday I heard from Heather Evans, an East Passyunk Avenue homeowner who has long been begging, cajoling and attempting to shame the city into helping her deal with a neighbor's neglected (and dangerous) home that is damaging her own.
She finally got their attention after her case got a little press in this column. But mostly a whole lot of nothing happened. So now, she wants to sell.
Good going, Philly; that's what we want to do - push responsible, taxpaying homeowners out of the city while we protect deadbeat leeches.
After the Market Street collapse, former L&I Commissioner Bennett Levin testified before City Council about the incompetence of local government. He said L&I could no longer be "a political backwater where money talks and people die."
My question: Who's going to stop them and other city agencies that continue to exercise callous disregard for the lives of our citizens?
Who in this city has the guts, the will and the power to finally put its people first?
Consider one more line from the grand-jury report: "The York Street tragedy stands as a symbol of the city's long practice of neglect."
On Twitter: @NotesFromHel