News & Contact

September 10, 2002

9-11 Lessons Learned

"It was a series of random events that killed thousands and saved hundreds."

(Lt. Brian Becker, FDNY, Engine Company 28;   New York Times, July 7, 2002.)

The recently released McKinsey & Company report on the Fire Department of New York’s (FDNY) fire and Emergency Medical Services (EMS) response to the World Trade Center (WTC) terrorist incident presents valuable lessons for all emergency responders and planners.  A brief summary of some of the major issues is provided here.  The entire report can be viewed on the FDNY web site at   http://www.ci.nyc.ny.us/html/fdny/html/mck_report/index.html.

As always, communications were cited as a major problem.  And, as usual, issues related to a lack of pre-planning and coordination, were also attributed to “communications problems”.  Many of the lessons learned can be divided into three categories: (1) Communications, (2) Command & Control, and (3) Coordination.

Communications

• The FDNY’s two-way radio system failed.  As a result, many firefighters in the North Tower were not aware that the South Tower had collapsed and never heard repeated orders to evacuate.  Despite the fact that the North Tower did not collapse for 29 minutes after the South Tower, one-third of the 343 firefighter deaths occurred in the North Tower. Of significance, the FDNY radio system had also failed during the 1993 WTC bombing.   

• While police officers in the North Tower learned of the South Tower’s collapse over the New York Police Department (NYPD) radio and heard the order to evacuate, police and fire personnel had no shared radio channel on which to communicate and coordinate, had the FDNY system been operational. 

Command & Control

• The FDNY did not use the Incident Command System (ICS), resulting in the planning/intelligence and logistics functions not being assigned until days after the incident.

• The FDNY command post (CP) was established in the lobby of the North Tower, while the NYPD CP was three blocks away.  In addition to the lack of a common radio channel, the location of the CPs precluded the sharing of intelligence and strategy between the two departments.

• A number of off-duty firefighters converged on the scene and did not report to the CP or Staging Area.  Consequently, the FDNY did not know the actual number or location of firefighters in the buildings.  This situation was exacerbated by the loss of the personnel tracking boards when the towers collapsed.

Coordination

• The FDNY and NYPD did not coordinate response plans and the Office of Emergency Management had never conducted an inter-agency exercise.  

• Recall and staging procedures had not been formalized or were not followed.  The NYPD left assigned posts unprotected and no ambulances were available for more than 400 calls.

• The lack of a complete and accurate personnel database resulted in a significant delay in notifying the firefighters’ next of kin.