9-11 The Response Lessons Learned
Acknowledgement • Nobody questions the bravery or the dedication of the first responders who answered the call to duty at the World Trade Center on 9-11. • However, when you lose first responder lives, there is a duty to question the policies and the operational systems of public safety agencies so that we don’t needlessly lose more responder lives in future operations.
Lessons Learned in PREPAREDNESS Planning, Training, Exercising, and Evaluating Plans
Plans, Training, and Exercises • New York City did not have, or use, ICS. • NYC police and fire departments have a long history of independent response planning. • Fire and police response plans are not particularly compatible.
Plans, Training, and Exercises • There were no fire department response plans for multiple complex events. • There was no system for evaluating problems associated with multi-complex events. (Joint Exercises and Joint AAR) • There were no formal fire department plans at the operational level.
Plans, Training, and Exercises • There was an agreement (signed in 1993) for fire and police to share police helicopter services during high-rise fires, and to train together for fighting high-rise fires. • There was one known “familiarization flight” prior to 9-11. (No record). No joint training occurred.
Plans, Training, and Exercises • Fire department response plans above the “tactical” level are largely handled “on-the-fly” with serious gaps in command and control. • “Nobody had a plan.” (Aide to Fire Chief killed in the collapse of the north tower.)
Plans, Training, and Exercises • The attacks exceeded anything emergency planners had anticipated. (Why?) • 1945 Aircraft versus Empire State Building • 1993 Bombing of the World Trade Center • Disaster drills rarely drew more than 100 firefighters. Over 1000 firefighters responded to the World Trade Center.
Plans, Training, and Exercises • Firefighters who survived, stated that they went into the towers with no clear mission. • NYC first responders do not train together, and the fire department does not trust the police.
Plans, Training, and Exercises • Fire Department Perception of the Police • “Most agencies try to be cooperative, helpful, but the police have a very limited ability to cooperate.” • “They report to nobody and they go and do whatever they want.” (Chief Turi, NYFD)
Plans, Training, and Exercises • Senior Fire Chiefs talking about interagency cooperation. • “There was none.” • “You will never change the P.D.” • “There’s a reason people hate cops.”
Plans, Training, and Exercises • Police Perception of the Firefighters: • “If someone tells them (firefighters) to do something, they say, ‘I don’t work for him,’ however, if a sergeant tells a group of cops to hold up, they do.” (Lt. John McArdle, Police Emergency Service Unit)
COMMAND Lessons Learned
Command • A Unified Command was not established. • Fire Chiefs set up command in the lobbies of the towers. • The police set up command three blocks away at the corner of Church and Vessey Streets.
Command • “The police did not hook up with the Fire Department, I don’t know why” (Thomas Von Essen, Fire Commissioner, 1996 – 2001.) • Police and fire managers barely spoke and did not coordinate strategies.
Command • “The Fire Commissioner has limited authority to hold senior fire chiefs accountable, because they all enjoy Civil Service protection.” • (Thomas Von Essen, Fire Commissioner 1996 – 2001.)
CONTROL Lessons Learned
Control • Individual firefighters jumped on overcrowded fire trucks against policy. • When ordered off of the trucks, they rode to the towers in private cars and on subways. • Port Authority police officers deserted their posts at bridges, tunnels, and ports.
Control • Too many firefighters were sent into towers. • Many firefighters entered without being deployed. (60 off-duty firefighters died). • Many of the firefighters self-deployed and bypassed staging areas. Command did not know which firefighters were in the towers.
Control • The Police Department’s Emergency Service Unit (ESU) sent teams into both towers. • The Police ESU is trained in rescue tactics, and often performs the same functions as firefighters.
Control • In the stairwells, fire department and police ESU members helped each other carry equipment, administer first aid and pass messages. • ESU members did not check in with fire commanders who were in charge of the rescue.
Control • We need a much more controlled response… because we have to be concerned about secondary events. • (Police Commissioner Raymond W. Kelly)
COMMUNICATION Lessons Learned
Communication • The fire department radio system failed, just as it did in those same buildings eight years earlier during the response to the 1993 bombing of the trade center. • No other agency lost communications on September 11th as broadly as did the fire department.
Communication • Assistant Fire Chief Donald J. Jones, who had fought the trade center fire following the bombing in 1993, wrote, “Pre-plan and build contingency plans.” • Chief Burns also wrote in the 1994 federal report, “Our effectiveness is only as good as our ability to communicate.”
Communication • While enroute to the WTC, Chief Burns reminded his colleagues of the severe communications problems experienced during the 1993 response to the WTC bombing. • On September 11th, he took command of operations in the south tower, the second building to be hit but the first building to crumble. Chief Burns was killed when the building collapsed.
Communication • During the final minutes, most firefighters in the north tower did not know that the South Tower had crumbled. • Most firefighters in the north tower did not know how urgent it was for them to get out.
Communication • A repeater installed at 5 World Trade Center after the 1993 bombing did not appear to be working, according to the fire department. • A post-incident review of tapes determined the repeater was working. (Training Issue?)
Communication • A fire chief arriving at the trade center tried to use a mobile repeater that was located in his vehicle. He reports that it did not work. • Early in 2002, the fire department replaced old analog radios with digital radios. The new radios worked on a higher frequency and were better at penetrating buildings.
Communication • However, several firefighters said they had been unable to communicate during emergencies, so the digital radios were pulled from service in March 2001. • They went back to the old radios that years before the September 11th attacks were proven to be inadequate in the trade center.
Communication • The fire department did try to make some improvements after the 1993 bombing, such as installing the new repeater at 5 World Trade Center. • NYPD and Port Authority police have repeaters similar to the fire department, and neither agency experienced significant radio problems on September 11th. (Training/Exercise Issue?)
Communication • Some firefighters were on one channel while evacuation orders were passed on another channel. • Firefighters on higher floors were able to communicate. However, numerous firefighters said they never got the order to leave because the radios were intermittent.
Communication • One Fire Chief reported that he could not talk with the fire dispatcher because a vital radio was missing. Phone lines were jammed. No one answered (phones or radios). • When helicopter pilots saw that the north building was near collapse (21 minutes before it fell) their warnings reached police on the street and inside the tower – but not firefighters.
Communication • After years or bickering, the police and fire agencies did not squabble on September 11th. They simply did NOT communicate. • Fire officials don’t know where many firefighters died, in part because the magnetic command boards used to track companies were lost in the collapsed buildings.
INTELLIGENCE Lessons Learned
Intelligence • Police and fire supervisors and managers did not share intelligence about building conditions. • When radios failed, supervisors failed to do the one thing that they could do easily – meet and discuss conditions eye-to-eye.
Intelligence • No one in authority ever realized that a stairwell was open in the south tower. • At least 18 people escapedfrom above the impact area by way of the stairwell, but word of their escape route never reached the hundreds of people trapped above them.
Lessons Learned (Again)
Lessons Leaned (Again) • The jurisdiction’s Emergency Operations Plan (EOP) should describe basic functions and responsibilities for every agency (not just first responder agencies). • It identifies lead and support agencies for each hazard -- for both response and recovery operations. (Plan to recover.)
The Five Basic Assessments of Emergency Management Hazard Assessment Vulnerability Assessment Risk Assessment Capability Assessment Special Needs Assessment
Understand the Differences • Hazard – a natural or man-caused occurrence that impacts human habitation. • Vulnerability – The degree of destructive impact on people and property including buildings and infrastructure. • Risk – Quantification of vulnerability and hazard frequency. (How often does it occur?)
Understand the Differences • The basic plan is a legal document that explains how government will function during major emergencies and disasters. (Strategic – available to the public.) • Annexes describe how specific agencies will respond to a major emergency or disaster. (Tactical - Not for public release.)
Understand the Concepts • The basic plan must describe the incident management system that will be employed. • Unified Command should be established when more than one jurisdiction responds to an emergency or disaster. • Train like you fight – fight like you train.
Emergency Support Functions (ESF) Annexes to the Idaho State Plan • ESF-1 Transportation • ESF-2 Communications • ESF-3 Public Works and Engineering • ESF-4 Firefighting • ESF-5 Information and Planning • ESF-6 Mass Care • ESF-7 Resource Support • ESF-8 Health and Medical Services
Emergency Support Functions (ESF) Annexes to the Idaho State Plan • ESF-9 Urban Search and Rescue • ESF-10 Hazardous Materials • ESF-11 Food • ESF-12 Energy • ESF-13 Law enforcement • ESF-14 Agriculture • ESF-15 Military Support
Plan, Train, and Exercise for Terrorism and CBRNE Hazards • Agroterrorism • Arson and Incendiaries • Assassination of high profile personnel • Chemical Agents (C) • Bioterrorism (B) • Radiological contamination (R) • Nuclear Detonation (N) • Explosives (E) • Cyber-terrorism
What Was Learned (Again) • Planning separately = lives lost. • Training separately = lives lost. • Exercising separately = lives lost. • Failure to communicate = lives lost.
Lessons Leaned (Again) • Exercise “The Plan” • If the plan is wrong – change it (in writing). • Exercise multi-agency tasks TOGETHER. • Exercise Unified Command (Together)
Lessons Leaned (Again) • Require responders to use staging areas – self deployments must never be tolerated. • Volunteer fire agencies may require firefighters to self-deploy to the scene. (Written policy) • Volunteers must be trained to check in with command before engaging in operations. (Written policy) • Ensure that managers have the tools, (and authority) in writing, to manage an incident.