By Alan S. Brown

The first responders who rushed into the burning World Trade Center one year ago changed the way Americans think of heroes.

They managed one of the largest evacuations in history, moving 25,000 people out of the towers and adjoining buildings, but paid a high price for their selfless behavior. Among the 2,823 lives claimed when the towers collapsed were 343 firefighters, 37 Port Authority police officers and 23 city cops.

The Fire Department of the City of New York (FDNY) and New York Police Department (NYPD) are two of the world's most effective emergency forces. Yet both harbored the knowledge that institutional flaws that had existed for years, even decades. On 9/11, those flaws cracked and ultimately failed. One year later, it may be time to consider whether changes in procedures and equipment could have saved first responder lives.

A New Picture

A new picture of the response to the attack began to emerge last January at an urban hazards forum at New York's John Jay College. There, Deputy Fire Chief Charles Blaich, a Ground Zero commander, stated that FDNY had "lost control of who was going into the buildings." He also said "rescuers inside the towers failed to receive information from a police helicopter flying above that might have saved lives."

A five-part series in the New York Times this past July highlighted many of the same issues. It led off with a transcript of an observer aboard a police helicopter who warned that the girders of the second tower were glowing red and close to collapse. FDNY never received the warning.

Although FDNY had issued an evacuation order moments earlier, it had only sporadic communications with the 121 firefighters in WTC 1. Many were close enough to evacuate, but did not realize the urgency of their plight. In fact, many did not know WTC 2 had already collapsed.

Familiar Failings

Ineffective communications and lack of interagency cooperation came as no surprise to those familiar with New York's fire and police departments. Their rivalry is legendary and stretches back generations. The agencies often show friction at emergency scenes.

FDNY communications failures also date back years. On 9/11, many firefighters relied on radios 10 or 15 years old. These same radios had already failed in 1993, when an explosion in an underground parking garage sent smoke billowing up the Twin Towers. Eight years later, communications issues would prove fatal to firefighters in WTC 1 who never heard evacuation orders.

Despite these and other well-known issues, New York City never launched a formal, comprehensive investigation of emergency response to the attack (the way Arlington, Va., did following the attack on the Pentagon). Instead, it asked McKinsey & Co., a well-known management firm, to review police and fire department actions, and recommend changes. The city issued the reports – separate ones for each department – on Aug. 19.

McKinsey did not attempt to construct an exhaustive, minute-by-minute account of the incident. But it did spend five months interviewing and surveying police and fire professionals, examining transcripts and records, listening to tapes, sorting through plans, and consulting outside experts.

The results present a detailed picture of emergency response the morning of Sept. 11. In the 102 minutes between the first strike and the collapse of the second tower, it shows first responders overwhelmed by both the magnitude of the crisis and their ability to manage the response.

Crisis

Both FDNY and NYPD responded within minutes of the 8:46 a.m. attack on WTC 1. The first chief on the scene established a staging area. He and other senior fire chiefs rushed to the lobby and directed firefighters up the building to ensure everyone got out.

By 9 a.m., the chief of the department arrived and set up an incident command post across West Street, an eight-lane highway, to protect against falling debris. The lobby of WTC 1 became the operations center. Although senior police chiefs had arrived on the scene, none went to either FDNY command post. The two agencies rarely coordinated actions or shared information that day.

Many FDNY senior chiefs and commissioners began arriving on the scene. Ultimately 26 of 36 senior chiefs came. Some chiefs, but no commissioners, had operational responsibilities in the response.

At 9:03 a.m., the second jet struck WTC 2. The crisis escalated, and more alarms sounded. Instead of reporting to staging areas, though, many units headed directly for the towers. Ultimately, 200 fire units – roughly half NYC's total force – and more than 100 ambulances responded. Many repeatedly badgered dispatchers for permission to go. Although only four fire units arrived without authorization, many EMS and private ambulances flooded downtown on their own.

Emergency traffic overwhelmed the police and clogged downtown's narrow streets. The fire chiefs lost track of many units. Without knowing their resources, they called for additional backup that added to the congestion. An attempt to recall thousands of off-duty firefighters and EMS personnel, the first in 30 years, ended in chaos because it had never been practiced.

Communications Problems

The communications crisis emerged early. The police had a modern and efficient communications system, but FDNY and EMS did not. The two EMS channels shared a single frequency. EMS dispatchers were deluged by massive radio traffic from ambulances showing little radio discipline. They proved unable to keep up with numerous, often duplicate, calls from 911, NYPD and their own chiefs.

FDNY faced an even greater crisis. Although a repeater system was installed in the WTC complex after the 1993 bombing to amplify and rebroadcast FDNY signals, it was either down or ineffective on 9/11. The department's mobile repeater was not up to the task either.

As a result, FDNY had only intermittent contact over its command and tactical channels. The chiefs had little idea of the drama playing out above their heads and scant ability to control it. They were reduced to relaying messages up the building from one squad to another.

While television images of burning buildings transfixed the nation, the chiefs had no external intelligence about the condition of the towers or progression of the fire. Nor did they receive information from an NYPD helicopter hovering nearby.

WTC 2 collapsed at 9:59 a.m. Neither the chiefs in the lobby nor the firefighters within WTC 1 realized what had happened. Dust and debris erupted through the lobby connecting the towers and blinded them. Yet most thought either elevators and other debris had crashed down from above or part of the building had caved in. It was only when they crawled through the pitch black lobby and into the street that they realized one of the towers had come down.

Confusion

Within moments of the collapse of WTC 2, the chiefs ordered firefighters in WTC 1 to evacuate. Some heard the order and left, picking up other crews along the way. Others never received the order. Not realizing their plight, they stayed to help the injured.

The collapse of WTC 2 also demolished the incident command center and field communications unit on West Street. Incident command moved a few blocks north. When the chief of the department and his executive staff returned to survey the scene, they were killed by the collapse of WTC 1 at 10:29 a.m.

All incident command vanished. After the second collapse, radio frequencies were overwhelmed by mayday calls and command traffic. Dispatch and staff chiefs could not tell who had survived or what resources were on the scene. Several chiefs reasserted order, but it took nearly an hour to re-establish a single incident command post. Only then could the city begin to move in the heavy equipment needed for rescue and recovery.

400-Pound Gorillas

The events on 9/11 would have strained any emergency organization. While first responders acted with selfless dedication, the sheer magnitude of the response exposed flaws in the institutions that supported them.

The true focus of the McKinsey report is on ways to mend these organizational flaws. Such institutional problems are not confined to New York City. In many other cities and counties, first responders contend with inadequate equipment, outdated management practices and frayed relations between emergency services. This is why the reports make essential reading for everyone.

The reports' most important sections focus on the need for the city's police and firemen to work with one another. "Interagency competition may be unavoidable, and even healthy to some extent, but it can never impair our ability to respond to emergencies. The stakes are just too high," said NYC Mayor Michael R. Bloomberg at a press conference when he released the reports.

Since Jan. 1, FDNY and NYPD have made some preliminary moves to improve coordination. They have assigned liaisons to one another's headquarters, established a committee of senior chiefs to resolve operational issues, enabled FDNY chiefs to fly on police helicopters in certain emergencies, and begun testing whether FDNY can use NYPD's powerful communications system to enhance radio communications.

McKinsey wants to go further. It recommends that FDNY, NYPD and other city, regional, state and federal agencies plan and train together. This would enable them to understand one another's roles, establish common command and control systems and deploy interoperable communications systems.

This is common practice in much of the country. In New York, it will take a cultural change, says Charles Jennings. An assistant professor of Fire Science and Public Administration at NYC's John Jay College of Criminal Justice, Jennings has taught and worked with fire officials.

"Sending chiefs to different headquarters doesn't mean the problem has been fixed," he explains. "In New York, the police and fire departments are like two 400-pound gorillas. In the past, no one in City Hall has had the political will and sustained interest to force these organizations to work together."

Communications and Technology

Improved communications is another pressing need highlighted by the McKinsey reports. While NYPD's system generally worked well on 9/11, FDNY's suffered a meltdown. In addition to revamping its entire communications and technology management process, McKinsey wants FDNY to address four immediate needs:

Capabilities. FDNY should speed testing and deployment of UHF portable radios purchased in 1999. Although they appear less than perfect, they support more channels than its existing radios. McKinsey also suggests hardwiring all the city's skyscrapers with repeaters – at a cost of $150 to $250 million – or finding a way to piggyback on NYPD's existing citywide infrastructure. FDNY should also have portable, mobile or airborne repeaters to deploy in buildings, subways and tunnels. McKinsey also suggested further training to ensure EMS personnel adhere to radio communications protocols rather than flooding the air with messages as they did on 9/11.

Information flow. On 9/11, fire chiefs were cut off not only from their crews but also from information on the status of the building above them. McKinsey recommends putting FDNY officers on police helicopters, providing links to news helicopters, and building an operations center capable of receiving and assessing multiple information sources. It also wants to reorganize EMS Dispatch.

Scene management. FDNY uses magnetic command boards to track resources. This works well at small fires, but does not provide the rich flow of maps, building plans and location characteristics available through modern electronics. Wireless backup might have allowed the chiefs to re-establish incident control more effectively after the towers fell.

Patient tracking. EMS lost its ability to track casualties of 9/11. As a result, many families had no clear idea of the whereabouts or safety of loved ones. EMS needs a system that can cope with high casualties.

Operations, Planning and Service

McKinsey sees room for improvement in FDNY and NYPD operations and planning. The FDNY report calls for expanded use of the incident command system, ongoing training for chiefs likely to face complex terror or HAZMAT incidents, and creation of two specialized 21-member teams to manage major incidents. It also wants to bulk up the FDNY operations center with modern communications so that senior chiefs can go there in an emergency to set operational priorities and manage citywide resources.

McKinsey also wants to see a more-efficient (and well-practiced) recall procedure, and strict enforcement of mobilization and staging procedures (with sanctions for those who do not comply). The report also notes that FDNY has only one HAZMAT unit and needs more to cope with complex or multiple incidents, such as terrorist attacks that use radioactive, chemical or biological agents.

On the police side, McKinsey calls for better operational leadership. On 9/11, many senior chiefs had unclear roles, while field commanders operated independently of one another and the chain of command. Although NYPD HQ had a modern command center within walking distance, senior leadership rushed to the site rather than use it to control response. A McKinsey NYPD survey found 25 percent of officers dissatisfied with supervision on 9/11.

Planning is another high priority. On 9/11, police plans called for protecting 2,600 sensitive locations – far too many – unranked by strategic importance or vulnerability to terrorist attack. Nor did NYPD have a terrorist response plan in place.

FDNY was similarly unprepared. McKinsey recommends the department conduct a citywide assessment of potential risks and preplan ways to manage emergencies at specific high-risk locations. It should also develop an all-hazards playbook to guide its response to large chemical, biological, radiological and other terrorist incidents. McKinsey also envisions a planning oversight committee of senior chiefs backed by a deep staff. It would coordinate cross-bureau initiatives and monitor department performance using explicit metrics and milestones.

FDNY should improve its ability to offer support to families of responders injured, killed or missing on duty. FDNY did not have updated contact information for many members, relying instead on the informal networks that bond first responders to one another. Nor did it have enough trained counselors to call on to provide emotional support to families of those who died and those who survived. This may be one reason why resignations from FDNY are running twice their normal rate this year.

Moving Forward

On 9/11, FDNY was cursed by size and experience, says John Jay College's Jennings. "The department is so large and has so much experience responding to routine fires, it never saw a need to work with outside agencies very often. Its mindset before 9/11 was self-confidence."

Jennings and others believe the department is still wrestling with the aftermath of 9/11. While some insiders believe their world has changed, others view 9/11 as an outlier, a disaster so unlikely to recur that it provides little guidance for the future.

Yet 9/11 exposed weaknesses that have long plagued the department. In fact, many findings in the McKinsey reports could have been written after the 1993 WTC attack, says Jennings. "To that extent, it's kind of discouraging to go through this and see issues raised that most people watching the department were already aware of."

Near-term, the department must straighten out its radio system and enforce such mundane command and control issues as staging, radio discipline and chain of command.

Long-term, says Jennings, FDNY will have to reinvent its command structure. He believes the department already provides officers with excellent technical training but needs to supplement that with more strategic and managerial studies. He would also like to see more responders with engineering backgrounds.

He also sees the need for a new, more responsive communications system that uses the latest technology to make responders more effective. For a department that struggled 10 years with a new dispatch system, it may be a reach.

Will it happen? "Only time is going to tell how it will play out," says Jennings. "It's really a cultural change, and that's not achieved overnight. ... It will take a sustained effort.

"A lot of what they have in the reports is not rocket science," he concludes. "But someone is going to have to be held accountable to see that it's done."