ASHULIA, Bangladesh ? The fire alarm shattered the monotony of the Tazreen Fashions factory. Hundreds of seamstresses looked up from their machines, startled. On the third floor, Shima Akhter Pakhi had been stitching hoods onto fleece jackets. Now she ran to a staircase.

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Deadly Fire in Bangladesh

But two managers were blocking the way. Ignore the alarm, they ordered. It was just a test. Back to work. A few women laughed nervously. Ms. Pakhi and other workers returned to their sewing tables. She could stitch a hood to a jacket in about 90 seconds. She arranged the fabric under her machine. Ninety seconds. Again. Ninety more seconds. She sewed six pieces, maybe seven.
Then she looked up.
Smoke was filtering up through the three staircases. Screams rose from below. The two managers had vanished. Power suddenly went out throughout the eight-story building. There was nowhere to escape. The staircases led down into the fire. Iron grilles blocked the windows. A man cowering in a fifth-floor bathroom called his mother to tell her he was about to die.
?We all panicked,? Ms. Pakhi said. ?It spread so quickly. And there was no electricity. It was totally dark.?
Tazreen Fashions Ltd. operated at the beginning of the global supply chain that delivers clothes made in Bangladesh to stores in Europe and the United States. By any measure, the factory was not a safe place to work. Fire safety preparations were woefully inadequate. The building itself was under construction ? even as sewing work continued inside ? and mounds of flammable yarn and fabric were illegally stored on the ground floor near electrical generators.
Yet Tazreen was making clothing destined for some of the world?s top retailers. On the third floor, where firefighters later recovered 69 bodies, Ms. Pakhi was stitching sweater jackets for C&A, a European chain. On the fifth floor, workers were making Faded Glory shorts for Walmart. Ten bodies were recovered there. On the sixth floor, a man named Hashinur Rahman put down his work making True Desire lingerie for Sears and eventually helped save scores of others. Inside one factory office, labor activists found order forms and drawings for a licensee of the United States Marine Corps that makes commercial apparel with the Marines? logo.
In all, 112 workers were killed in?a blaze last month?that has exposed a glaring disconnect among global clothing brands, the monitoring system used to protect workers and the factories actually filling the orders. After the fire, Walmart, Sears and other retailers made the same startling admission: They say they did not know that Tazreen Fashions was making their clothing.
But who, then, is ultimately responsible when things go so wrong?
The global apparel industry aspires to operate with accountability that extends from distant factories to retail stores. Big brands demand that factories be inspected by accredited auditing firms so that the brands can control quality and understand how, where and by whom their goods are made. If a factory does not pass muster, it is not supposed to get orders from Western customers.
Tazreen Fashions was one of many clothing factories that exist on the margins of this system. Factory bosses had been faulted for violations during inspections conducted on behalf of Walmart and at the behest of the?Business Social Compliance Initiative, a European organization.
Yet Tazreen Fashions received orders anyway, slipping through the gaps in the system by delivering the low costs and quick turnarounds that buyers ? and consumers ? demand. C&A, the European retailer, has confirmed ordering 220,000 sweaters from the factory. But much of the factory?s business came through opaque networks of subcontracts with suppliers or local buying houses. Labor activists, combing the site of the disaster, found labels, order forms, design drawings and articles of clothing from many global brands.
Walmart and Sears have since said they fired the suppliers that subcontracted work to Tazreen Fashions. Yet some critics have questioned how a company like Walmart, one of the two biggest buyers in Bangladesh and renowned for its sophisticated global supply system, could have been unaware of the connection.
The factory?s owner, Delowar Hossain, said his managers arranged work through local middlemen. ?We don?t know the buyers,? Mr. Hossain said in an interview. ?The local man is important. The buyer ? I don?t care.?
Bangladesh is now?a garment manufacturing giant, the world?s second-leading apparel exporter, behind China, which is no longer the cheapest place to make many basic goods. Bangladesh has the lowest garment wages in the world, and many of the Tazreen factory?s victims were young rural women with little education, who earned as little as $45 a month in an industry that now accounts for $19 billion in exports.
In Bangladesh,?public outrage about the fire?has boiled over. An estimated 100,000 people attended the burial ceremony of 53 workers whose bodies could not be identified. Industry leaders have promised financial support for survivors and the families of the dead. The Bangladeshi government has started inspecting the country?s 4,500 garment factories; it has already found fire code violations in almost a third of the hundreds it has examined.
?Now we have to do much more,? said Mohammad Shafiul Islam Mohiuddin, president of the Bangladesh Garment Manufacturers and Exporters Association, conceding past failures. ?We have learned. We start from here.?
In the United States, Labor Secretary Hilda L. Solis compared the Tazreen blaze to the 1911 Triangle shirtwaist factory fire in New York, which led to sweeping reforms of American sweatshops. In Bangladesh, factory fires have been a persistent problem, with the International Labor Rights Forum saying more than 600 garment workers have died in such fires since 2005.
And even before the Tazreen blaze, outside pressure was building on Bangladesh?s garment sector to increase wages and ease restrictions on union organizing. Secretary of State Hillary Rodham Clinton, along with European diplomats, has urged the government to investigate the?unsolved murder of a labor organizer, Aminul Islam.
In reconstructing the deadly blaze, The New York Times interviewed more than two dozen survivors; relatives of the victims; Bangladeshi fire officials; garment factory owners and managers; auditors; and others. In the end, analysts said, the conflagration was a tragic byproduct of an industry in which global brands and retailers, encouraged by hundreds of millions of consumers around the world, are still primarily motivated by the bottom line.
?We as consumers like to be able to buy ever-greater quantities of ever-cheaper goods, every year,? said Richard M. Locke, deputy dean of the M.I.T. Sloan School of Management. ?Somebody is bearing the cost of it, and we don?t want to know about it. The people bearing the cost were in this fire.?
?Precious? Escape Time Is Lost
Several months ago, Shima Akhter Pakhi was summoned to the sixth floor of Tazreen Fashions. Ms. Pakhi, 24, had worked at the factory for three years, and every month she sent money back to her family in rural Bangladesh. Now she earned a monthly base salary of $51, maybe $20 more with overtime. Up on the sixth floor, managers were tapping her for fire safety duty.
When Ms. Pakhi started at Tazreen, the factory had only three floors, but the owner was adding five upper floors in expectation that business would grow. The empty, unfinished sixth floor was nearly the size of a football field. Ms. Pakhi and a few other employees were handed fire extinguishers and taught to remove the pin, squeeze the handle and spray. They were also told that in the case of a fire on upper floors, employees should evacuate down the staircases in descending order from top to bottom.
?They did not tell us what we would do if the fire started on the ground floor,? Ms. Pakhi recalled.
Fire investigators say the blaze erupted on the cavernous ground floor after stacks of yarn and fabric caught fire. Had the fabric been stored in an enclosed, fireproof room, as required by law, the fire could have been contained and the workers could have escaped.
Instead, the blaze spread quickly, pushing up the staircases, along with toxic fumes from burning acrylic. Investigators discovered that few fire extinguishers had been used. And, finally, managers made a catastrophic mistake by initially dismissing the fire alarm.
?They killed time,? said Abu Nayeem Mohammad Shahidullah, the director general of Bangladesh?s national fire service. ?Time was so precious, so important. But they said it was a false alarm.?
Mr. Hossain, the factory owner, said in a separate interview with Bangladeshi news media that he did not know why managers on the floor would have tried to stop employees from leaving the factory. He added that none of the gates in the staircases were locked.
Managers had been preparing the factory for inspections from buyers and staged a drill a few days before the fire, several employees said. Ms. Pakhi said managers had even displayed photographs of the fire training session on bulletin boards.
?I think they took the pictures and hung them on the board to show the buyers,? she said. ?They would see the pictures and think they have trained people to fight fires. But personally, I don?t think I could fight fires with this training.?
Tazreen Fashions is part of a larger garment conglomerate, the Tuba Group, which owns at least half a dozen apparel factories in Bangladesh. Mr. Hossain said a team from Walmart?s local office conducted a compliance audit last year and faulted the factory for excessive overtime, while making no mention of fire safety or other issues. Moreover, he said, the local buying houses had also inspected and approved the factory, tantamount, he assumed, to approval from Walmart and the other global brands these middlemen represented.
Kevin Gardner, a Walmart spokesman, said the company stopped authorizing production at Tazreen ?many months before the fire.? But he did not say why. Accredited outside auditors inspected the factory on Walmart?s behalf at least twice in 2011, he said. That May, auditors gave the factory an ?orange? rating, meaning there were ?higher-risk violations.? Three months later, the factory?s grade improved to ?yellow,? meaning there were ?medium-risk violations.?
Sears, in a statement, said its supplier ?was not authorized? to produce goods at the Tazreen factory and that it had done so ?in violation? of Sears?s rules.
But David Hasanat, the chairman of the Viyellatex Group, one of the country?s most highly regarded garment manufacturers, pointed out that global apparel retailers often depend on hundreds of factories to fill orders. Given the scale of work, retailers frequently place orders through suppliers and other middlemen who, in turn, steer work to factories that deliver low costs ? a practice he said is hardly unknown to Western retailers and clothing brands. The order for Walmart?s Faded Glory shorts, documents show, was subcontracted from Simco Bangladesh Ltd., a local garment maker. ?It is an open secret to allow factories to do that,? Mr. Hasanat said. ?End of the day, for them it is the price that matters.?
A Friend Shouts, ?Save Us!?
On the sixth floor, Hashinur Rahman heard the screams and rushed to a staircase. He and others had been making satiny lingerie, but they pushed past a manager and began descending into thicker and thicker smoke. Ignoring the manager would save their lives.
The factory did not have ceiling sprinklers or an outdoor fire escape. Fire officials later concluded that the two staircases on the eastern side of the building were quickly overwhelmed with fire and toxic smoke. But officials say the lone western staircase remained passable for many minutes and provided an escape route for many survivors. About 1,150 people were working that night, and all of the roughly 300 workers on the second floor managed to escape down the stairs, fire officials said.
Mr. Rahman, 32, had barely made it out of the building, along with many of his colleagues, when his cellphone rang. It was a friend who worked on the third floor. Hundreds of people were trapped.
?Save us!? the friend shouted. ?Help us!?
Mr. Rahman said he ran to the narrow alley that separated the factory?s western wall from a building under construction. The gap was maybe five feet. Work crews had covered the western wall with rickety bamboo scaffolding so they could put plaster on the exterior of the still-unfinished Tazreen factory.
Mr. Rahman climbed the bamboo to a third-floor window covered with an iron grille. He leapt onto a concrete slab of the new building and found a brick. He began smashing the grille, trying to break it open. He looked inside and saw his co-workers? desperate faces. They were in the room where samples were made and sent to buyers for final approval, and they stood on sewing tables, pulling frantically on the grille.
One seamstress, who goes by a single name, Rahima, had tried to escape the third floor by a stairwell but began choking on smoke. As the smoke thickened, Ms. Rahima said, she fell to the floor. Then people trampled her.
?When I fell down, and the people were stepping on me, I did not think I would survive,? she recalled. ?But then I thought of my daughter.?
Ms. Rahima had been married to a husband who beat her. When their daughter was born five years ago, the husband fled. Ms. Rahima left her village to find work in the garment industry, which has provided an escape from grinding rural poverty for millions of women like her in Bangladesh and around the world. She moved into a rented room with her two sisters and got a job at Tazreen. In the village, Ms. Rahima?s parents cared for her daughter while she sent back money. Two days before the fire, the little girl arrived for a rare visit.
?I got my strength, and I stood up,? Ms. Rahima said. ?I ran to the sample room.?
Finally, the iron grille gave way.
A few men jumped to the concrete slab of the adjacent building. Leaning against the scaffolding, they reached across the gap to help co-workers make the leap. Women went first. Ms. Rahima made it across. So did Ms. Pakhi. On other floors, people smashed open windows or tore out exhaust fans and leapt into the darkness. Some landed on the metal roofs of nearby shanties. Some landed on the ground.
And some never made it out at all.
Son Phones ?Ma? Before Dying
As word spread, people raced to the factory: mothers, fathers, husbands, wives and gawkers. Soon a throng stood beneath the building, their faces glowing in the cruel brilliance of the flames. Golapi Begum left her own factory job and raced to Tazreen Fashions to find her son, Palash Mian. He was 18 and worked on the fifth floor. Ms. Begum stared up at the factory and shrieked.
Then her cellphone rang. It was her son.
?Ma, I have no way to save my life,? he told her. ?I cannot find any way to get out. I am in the bathroom of the fifth floor. I am wearing a black T-shirt. And I have a shirt wrapped around my waist. You will find me in the bathroom.?
He hung up. He called his father, as well as several friends. Then his phone went dead.
?I became insane,? his mother said. ?I spent the whole night in front of the main gate of the factory. I was screaming all the time.?
She found him the next day. Rescuers had lined up all the recovered bodies on the grounds of a nearby school. Family members unzipped bag after bag, searching. One husband looking in vain for his young wife said the charred human remains looked like chunks of coal.
But Ms. Begum unzipped a bag and found her son. She recognized his face. And he was wearing a black T-shirt.
She collected his body and returned it to their village, where he was buried.
Julfikar Ali Manik contributed reporting from Ashulia, and Steven Greenhouse from New York.