Staff Statement No. 14 

Crisis Management

Members of the Commission, with your help, your staff is prepared to report its 

preliminary findings regarding the lessons learned from the emergency responses on 

September 11, 2001, to the attacks on the World Trade Center and the Pentagon. These 

initial findings may help frame some of the issues for this hearing and the development of 

your judgments and recommendations. 

This report represents the results of our work to date. We remain ready to revise our 

current understanding in light of new information as our work continues. Sam 

Caspersen, Emily Walker, Mark Bittinger, Kevin Shaeffer, George Delgrosso, Jim Miller, 

Madeleine Blot, Cate Taylor, Joseph McBride, and John Farmer conducted most of the 

investigative work reflected in this statement. 

We begin this statement with profound admiration for the first responders of 9/11: the 

civilians, firefighters, police officers, emergency medical technicians and emergency 

management professionals, living and dead, who exhibited steady determination and 

resolve under horrifying, overwhelming conditions. Along with the passengers and crew 

aboard the airplanes, the first responders on 9/11 were the first soldiers on the frontlines 

of a new kind of war. Some of them became its first casualties; some of them became its 

first heroes. 

Civilian/Private Sector Preparedness 

Unless a terrorist’s target is a military or other secure government facility, the “first” first 

responders will almost certainly be civilians. The private sector controls 85 percent of 

the critical infrastructure in the nation. Homeland security and national preparedness 

therefore often begins with the private sector. 

Private sector preparedness should include: (1) a plan for evacuation; (2) adequate 

communications capabilities; and (3) a plan for continuity of operations. All three 

elements were tested in the private sector experience at the World Trade Center (WTC). 

Evacuation 

The centerpiece of preparedness is an evacuation plan. One of the lessons learned from 

the 1993 bombing was that evacuation procedures were inadequate. Although an 

estimated 50,000 civilians were evacuated, it took over four hours to complete the 

general evacuation of the buildings, with specific rescues going on for hours more. By 
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all accounts, many steps were taken to improve evacuation procedures in the years 

between 1993 and 2001. 

The evacuation effort on 9/11 was largely successful on floors below where the planes 

hit. Some of the evacuees have told us that the pre-9/11 drills helped them that morning; 

others indicated that the drills had not helped, or could not recall having participated in 

pre-9/11 drills. The Port Authority’s post-1993 installation of glow strips on the stairs 

and emergency lighting in the stairwells was cited by evacuees as significantly assisting 

their progress, as was the Port Authority’s provision of flashlights to some tenants. 

 

Some who worked in the WTC told us that fire drills conducted by the Port Authority 

were extremely useful in their evacuation on September 11. Others, however, felt that 

the drills were formalities which did not engage the full attention or participation of most 

office workers on the floor. 

A former fire warden labeled the office workers as “very uncooperative,” claiming that 

most people refused to leave their offices because they were too busy and that those who 

did participate did not pay attention. 

The WTC complex did not conduct a full evacuation training exercise. Individual 

companies had practiced drills isolated to their floors. In no case, to our knowledge, did 

any tenant in the WTC practice a drill where the employees walked down the stairs and 

exited the building. They did not know that the rooftop doors were kept locked, and that 

there was no plan for rooftop evacuation. They did not know they should not evacuate 

up, and so some people began climbing stairs instead of trying to find clear paths of 

descent. 

Some companies in the WTC had developed their own evacuation plan separate from the 

Port Authority Plan. Particularly notable was the plan in place for Morgan Stanley. 

Employees had practiced the plan; some had a copy both at the office and at home. 

Generally speaking, however, companies located in the WTC did not have independent 

evacuation plans. 

Communications 

The second part of private sector preparedness is communications. Once a decision is 

made to react to an emergency, there must be an effective way to communicate that 

decision to tenants and/or employees, to account for tenants and employees in the 

aftermath of an event, to communicate with concerned family members, and to continue 

operations. The tenants of the WTC varied widely in their success in meeting these 

challenges. 

Like the first responder community, tenants at the WTC experienced severe 

communications problems on 9/11. The phone system in the WTC continued to work 

immediately after the planes struck both towers, perhaps with the exception of the floors 

that were hit and those above them. During the time between 9:03 and 9:59 a.m., 
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however, there was abnormally high calling volumes and the network, both landline and 

wireless, could not successfully respond to every request for service which affected those 

placing 9-1-1 calls. When the South Tower collapsed, the Verizon switching station went 

down, and all phone service was lost in the 16-acre WTC complex. 

Blackberries worked well during the day of September 11 when other means of 

communication were failing. This was because the control channel on the wireless 

network had a great deal more capacity than the wireless voice channel. 

Once evacuated, companies needed to locate their employees. Finding employees and 

accounting for those missing became a full-time mission for several days. Most 

companies did not have any record of who was in the office on September 11, 2001. 

There were few cases where employees were given a place to congregate following an 

evacuation or a location to call. Few companies had a crisis communications plan in 

place before disaster struck. 

Continuity of Operations 

Once employees have been evacuated and accounted for, the third pillar of private sector 

preparedness is continuity of operations. The response to 9/11 illustrates that continuity 

is among the most difficult challenges because many of the people involved in continuity 

are also closely involved in the event. 

Some companies had backup sites and redundant facilities that were outside Lower 

Manhattan, and, although it was difficult for some employees to reach them, these 

preparations provided the best opportunities for resuming business operations. In those 

cases where there were usable and operable backup spaces, the issues the companies 

faced included lack of plans for personnel, equipment, files, and training to use these 

redundant facilities. 

Those tenants that did not have backup facilities located outside of Lower Manhattan 

faced the additional challenge of scrambling for new locations. 

The spirit of cooperation was, however, enormous. Companies offered competitors their 

space. Suppliers rerouted supplies such as computers and phones to those in need. 

Corporations were donated time, expertise, and valuable equipment to the entire City of 

New York’s physical operations as it tried to regroup days after the event. The Mayor’s 

Office of Emergency Management, by all accounts, did a superb job coordinating these 

efforts. 

The Current State of Private Sector Preparedness 

At a hearing held at Drew University last November, witness after witness told the 

Commission that despite 9/11, the private sector remains largely unprepared for a 

terrorist attack. We were also advised that the lack of a widely embraced private sector 

preparedness standard was a principal contributing factor to this lack of preparedness. 
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The Commission responded by asking the American National Standards Institute (ANSI) 

for help. To develop a consensus, the Institute convened safety, security, and business 

continuity experts from a wide range of industries and associations, as well as from 

federal, state, and local government, to consider the need for standards for private sector 

emergency preparedness. It has recommended to the Commission a voluntary National 

Preparedness Standard, based on prior work of the National Fire Protection Association, 

with a common framework for emergency preparedness. The Commission will be 

considering whether to endorse this standard. 

Public Sector Emergency Response: Developing an Integrated Command System

We now turn to the public sector emergency response. In this statement we step back 

from the specifics of the tactical decisions on the scene. We focus on potential lessons in 

three areas: 

-- Develop an integrated command system; 

-- Size up the situation and keep reevaluating it; and 

-- Communicate and implement decisions 

We will first discuss incident command at the Pentagon. On any other day, the disaster at 

the Pentagon would be remembered as a singular challenge, an extraordinary national 

story. Yet the calamity at the World Trade Center included catastrophic damage 1,000 

feet above the ground that instantly imperiled tens of thousands of people. The two 

experiences are not comparable. Nonetheless, broader lessons in integrating multiagency response efforts are apparent in analyzing the Pentagon response. 

Emergency response at the Pentagon represented a mix of local, state, and federal 

jurisdictions. The response was generally effective. It overcame the inherent 

complications of a response across jurisdictions because the Incident Command 

System—a formalized management structure for emergency response—was in place in 

the National Capital Region on 9/11. 

Because of the nature of the event—a fire and partial building collapse—the Arlington 

County Fire Department served as Incident Commander. Different agencies had different 

roles. The incident required a major rescue, fire and medical response from Arlington 

County at the U.S. military’s headquarters—a facility under the control of the Secretary 

of Defense. Since it was a terrorist attack, the Department of Justice was the lead federal 

agency in charge (with authority delegated to the FBI for operational response). 

Additionally, the terrorist attack impacted the daily operations and emergency 

management requirements for Arlington County and all bordering and surrounding 

counties and states. 

At 9:37 a.m., the west wall of the Pentagon was hit by the hijacked American Airlines 

Flight 77, a Boeing 757. The crash caused immediate and catastrophic damage. All 64 
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people aboard the airliner were killed, as were 125 people inside the Pentagon (70 

civilians and 55 military service members). Approximately 110 people were seriously 

injured and transported to area hospitals. 

While no emergency response is flawless, the response to the 9/11 terrorist attack on the 

Pentagon was mainly a success for three reasons: first, strong professional relationships 

and trust established among emergency responders; second, the adoption of the Incident 

Command System; and third, the pursuit of a regional approach to response. Many fire 

and police agencies that responded to the Pentagon had extensive prior experience 

working together on regional events and training exercises. Indeed, just before 9/11 

preparations were underway by many of these agencies to ensure public safety at the 

annual meetings of the International Monetary Fund and the World Bank that were 

scheduled later that month in Washington, DC. 

Local, regional, state, and federal agencies immediately responded to the Pentagon 

attack. In addition to county fire, police, and sheriffs departments, the response was 

assisted by the Metropolitan Washington Airports Authority, Ronald Reagan Washington 

National Airport Fire Department, Fort Myer Fire Department, the Virginia State Police, 

the Virginia Emergency Management Agency, the FBI, the Federal Emergency 

Management Agency, the National Medical Response Team, the Bureau of Alcohol, 

Tobacco, Firearms and Explosives, and numerous military personnel within the Military 

District of Washington. 

Command was established at 9:41 a.m. At the same time, the Arlington County 

Emergency Communications Center contacted the Fairfax County, Alexandria, and the 

District of Columbia fire departments to request mutual aid. The incident command post 

provided a clear view of and access to the crash site, allowing the Incident Commander to 

assess the situation at all times. 

At 9:55 a.m., the Incident Commander ordered an evacuation of the Pentagon impact area 

because of imminent partial collapse, which occurred at 9:57 a.m. No first responder was 

injured in the partial collapse. 

At 10:15 a.m., the Incident Commander ordered a full evacuation of the Command Post 

because of the warning of an approaching hijacked aircraft passed along by the FBI. This 

was the first of three evacuations caused by a report of incoming aircraft. This first 

evacuation order was well communicated and coordinated. 

Several factors facilitated the response to this incident, and distinguish it from the far 

more difficult task in New York. There was a single incident. The incident site was 

relatively easy to secure and contain. There are no other buildings in the immediate area. 

There was no collateral damage beyond the Pentagon. 

As noted yesterday in Staff Statement No. 13, in July 2001 Mayor Giuliani signed a 

directive entitled “Direction and Control of Emergencies in the City of New York.” Its 

purpose was “to ensure the optimum use of agency resources while...eliminating 
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potential conflict among responding agencies which may have areas of overlapping 

expertise and responsibility.” 

To some degree, the Mayor’s directive for Incident Command was followed on 9/11. It 

was clear that the lead response agency was the FDNY, and that the other responding 

local, federal, bi-state, and state agencies acted in a supporting role. As we described 

yesterday, there were instances of coordination at high levels of command. In addition, 

information was shared on an ad hoc basis, such as when NYPD rescue teams passed 

their evacuation order to FDNY units they encountered in the North Tower. 

Any attempt to establish a unified command on 9/11 would have been frustrated by the 

lack of communication and coordination among responding agencies. The Office of 

Emergency Management headquarters, which could have served as a focal point for 

information-sharing, was evacuated. Even prior to its evacuation, moreover, it did not 

play an integral role in ensuring that information was shared among agencies on 9/11. 

Certainly, the FDNY was not “responsible for the management of the City’s response to 

the emergency,” as the Mayor’s directive would have required. 

One question looking forward, in light of the experience of 9/11, is whether establishing a 

single Incident Commander is possible or appropriate in a city like New York, or at an 

incident like the World Trade Center. The Incident Commander point is important. 

More important, though, is to embrace the concept of an integrated command system. On 

9/11, the problem was less about turf battles on the scene. It had more to do with 

command systems designed to work independently, not together. 

 

Since 9/11, a consensus is emerging within the emergency response community that a 

clear Incident Command System should be required of all response agencies. As of 

October 1, federal homeland security funding will be contingent upon the adoption and 

regular use of such a system by emergency response agencies. In New York City, the 

Mayor’s office announced a new Incident Command System plan last week. 

Regional mutual aid, as in Northern Virginia, could become a formal joint response plan 

with neighboring jurisdictions working together, along with state and federal 

representatives, to be sure they have the collective capability to respond to catastrophic 

events. In other words, every county may not need its own HAZMAT team. States are 

also considering Emergency Management Assistance Compacts to help insure that 

regional resources are available for a comprehensive response, so every city does not 

need to buy the capacity to deal with extreme events. 

Sizing Up the Situation 

The FDNY command structure immediately grasped the massive scale of the catastrophe. 

The commanders called for a large number of units. 

The FDNY commanders also immediately and correctly judged that the North Tower 

should be evacuated as quickly as possible. The decision to evacuate the still intact South 
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Tower was a more difficult judgment which they made, after they talked with Port 

Authority police and building personnel in their tower, about five minutes after these 

chiefs arrived at the scene. 

The FDNY commanders also had to decide whether they should try to fight the fires. 

They rapidly and accurately judged that this was impossible, so they should concentrate 

on evacuation and consider firefighting only in the context of freeing trapped civilians. 

The FDNY commanders needed information on the situation within the buildings. Here 

they encountered more difficulty. They did not have good information on which building 

systems were operating, or which—if any—stairwells were open. As ascending 

firefighters discovered situations, they could not always communicate this information to 

others. But if they could have communicated it, there was not a protocol in place for 

receiving and integrating this information in order to enhance the situation awareness for 

all the fire commanders, including those beyond the lobby command post. As evacuees 

descended, there was no protocol for quickly debriefing them on what floor they came 

from, what the conditions were like on that floor, and how they got down. Again there 

was no focal point to receive and integrate this information. Such a field intelligence 

setup, suggested by military experience, could be valuable in large and complex 

incidents, though it might not be necessary for more ordinary situations. 

Lacking adequate situation awareness, the FDNY made key decisions about how to 

deploy personnel to help in the South Tower after it was hit. The commanders decided to 

dispatch more units to the scene, assigning them to the South Tower. If they had 

understood that units were still arriving at the North Tower or were already there but still 

in the lobby, they could have considered whether to reassign some of the units already at 

the scene to render immediate assistance in the South Tower. The decision to handle the 

South Tower by dispatching new units meant that the number of firefighters available to 

help evacuees in that tower was relatively small for at least the first 20 minutes after the 

tower was hit, though that number sadly was rising in the minutes before that tower 

collapsed. 

 

As the conditions deteriorated, the FDNY commanders had to judge whether the 

buildings were in danger of collapse. Building collapse, like other dangers to response 

personnel, is a constant concern in firefighting. Specific chiefs are tasked with 

responsibility for tracking these safety issues. The best estimate of one senior chief, 

provided to the Chief of the Department sometime between 9:25 and 9:45 a.m., was that 

there might be a danger of collapse in a few hours, and therefore units probably should 

not ascend above floors in the sixties. We did not see any evidence that this assessment 

had any impact on operations before the collapse of the South Tower effectively disabled 

every FDNY command post. Even after the South Tower collapsed, another senior chief 

reportedly thought that the North Tower would not collapse because its corner frame had 

not been struck. 

Other than observation from the ground and a Fire Department boat in the Hudson River, 

the only other source of information on the building condition was from the air. NYPD 
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aviation had helicopters observing the situation. There was no video feed from these 

helicopters to the overall command post. With the evacuation of the Office of 

Emergency Management headquarters, their radio observations were not readily available 

to chiefs either. Repeated updates from the NYPD aviation unit were not communicated 

to the FDNY. 

NYPD aviation did not foresee the collapse of the South Tower, though at 9:55 a.m., four 

minutes before the collapse, a helicopter pilot radioed that a large piece of the South 

Tower looked like it was about to fall. Immediately after the collapse of the South 

Tower, a helicopter pilot radioed that news. This transmission was followed by others, 

beginning at 10:08 a.m., warning that the North Tower might collapse, beginning at 

10:08, 18 minutes before the building fell. These calls reinforced the urgency of the 

NYPD’s evacuation of the area. 

Although evacuation orders were also transmitted immediately by FDNY commanders, 

we earlier mentioned that those orders did not reflect the situation awareness reflected in 

the NYPD transmissions. The NYPD warning could not be relayed to the overall FDNY 

command post, since that post was disabled. Nor was there any capacity to relay this 

warning directly to the chiefs trying to regroup near the North Tower. 

Looking forward, a fully integrated Incident Command System will assure that evolving 

situation awareness is shared among responding agencies and will assist first responders 

in sizing up the situation at hand. 

Communicate and Implement Decisions 

Effective decision-making in New York was hampered by limited command and control 

and internal communications. Beyond the point we made earlier about a command 

system integrated across agencies, the FDNY had limited command and control of its 

own personnel. This was true for five main reasons: 

(1) the magnitude of the incident was unforeseen; 

 (2) commanders had difficulty communicating with their units; 

(3) FDNY personnel who were not dispatched self-dispatched and units which 

were dispatched consistently “rode heavy” with extra firefighters, a particular 

problem in some of the scarce elite units; 

(4) more units were actually dispatched than were ordered by the chiefs; and 

(5) once units arrived at the WTC they were not accounted for comprehensively 

and coordinated. 

The NYPD’s 9-1-1 operators and FDNY Dispatch were not adequately integrated into the 

emergency response. This is an issue for an integrated command system, but it 
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manifested itself as an inability to communicate key decisions to the people who most 

needed to hear about them. 

In several ways, the 9-1-1 system was not ready to cope with a major disaster. As we 

explained yesterday, these operators and dispatchers were one of the only sources of 

communication with individuals on the damaged floors. Once the seriousness of the 

situation was apparent and evacuation decisions had been made, this guidance should 

have been made available to these operators and dispatchers. If it had been, individuals 

could have been told to evacuate. They could have been told not to go upstairs, which 

might have helped people in the South Tower. In future disasters, it is important to 

analyze how victims or the public will attempt to get information and help, and to be sure 

the people giving that information are part of the emergency response team. 

The Port Authority’s response was hampered by inadequate communication. For 

example, although the FDNY commanders at the North Tower advised Port Authority 

police and that tower’s building personnel to evacuate the South Tower, shortly before 

9:00 a.m., there is no evidence that this advice was communicated effectively to the 

building personnel in the South Tower. A vital few minutes may have been lost and, 

when that tower did make its announcement to evacuate at 9:02 a.m., it was the 

ambiguous advice that everyone may wish to start an orderly evacuation if warranted by 

conditions on their floor. The Port Authority’s Jersey City Police desk was also unaware 

of the evacuation decisions when, at 9:11 a.m., it advised workers on the 64th floor of the 

South Tower to stay near the stairwells and wait for assistance. 

In general it was the practice of the Port Authority’s differing commands to use localized 

frequencies. When officers reported from the tunnels and airports, they could not hear 

the commands being issued over the WTC command frequency. 

The NYPD experienced comparatively fewer internal command and control and 

communications issues. Because the department has a history of mobilizing thousands of 

officers for major events requiring crowd control, its technical radio capability and major 

incident protocols were more easily adapted to an incident of the magnitude of 9/11. 

In addition, its mission that day lay largely outside the towers themselves. Although 

there were rescue teams and a few individual police officers climbing in the towers, the 

vast majority of NYPD personnel were staged outside assisting with crowd control and 

evacuation and securing other sites in the city. 

The Pentagon response too was plagued with difficulties that echo those experienced in 

New York. As the Arlington County After-Action Report notes, there were significant 

problems with both self-dispatching and communications: 

Organizations, response units, and individuals proceeding on their own initiative 

directly to an incident site, without the knowledge and permission of the host 

jurisdiction and the Incident Commander, complicate the exercise of command, 

increase the risks faced by bonafide responders, and exacerbate the challenge of 

accountability. 
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With respect to communications, the Arlington County After-Action Report concludes: 

Almost all aspects of communications continue to be problematic, from initial 

notification to tactical operations. Cellular telephones were of little value.... 

Radio channels were initially oversaturated..... Pagers seemed to be the most 

reliable means of notification when available and used, but most firefighters are 

not issued pagers. 

It is a fair inference, given the differing situations in New York City and Northern 

Virginia, that the problems in command, control, and communications that occurred at 

both sites will likely recur in any emergency of similar scale. The task looking forward is 

to enable first responders to respond in a coordinated manner with the best situational 

awareness possible. 

Summary 

Much of this statement has focused on the FDNY. We must therefore also note that the 

FDNY has responded with particular energy to the lessons of 9/11, and has acted to 

address many of the concerns we have identified. 

There may be a need, however, to expand the understanding of these lessons across the 

nation. The President’s National Strategy for Homeland Security called for national 

standards in emergency response training and preparedness. Many experts have cited the 

National Fire Academy training program as a useful benchmark. We hope this hearing 

will contribute to education about the kinds of challenges emergency response agencies 

may face in the future.