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Overview: Conclusions 

and Findings 

1. Four overarching factors contributed to the failures of Hurricane Katrina: 

(i) long-term warnings went unheeded and government offi cials neglected their 

duties to prepare for a forewarned catastrophe; 

(ii) government offi cials took insuffi cient actions or made poor decisions in the 

days immediately before and aft er landfall; 

(iii) systems on which offi cials relied to support their response eff orts failed, and 

(iv) government offi cials at all levels failed to provide eff ective leadership. 

Th ese individual failures, moreover, occurred against a backdrop of failure, over time, to 

develop the capacity for a coordinated, national response to a truly catastrophic event, 

whether caused by nature or man-made. 

2. During a catastrophe, which by defi nition almost immediately exceeds state and local 

resources and signifi cantly disrupts governmental operations and emergency services, the 

role of the federal government is particularly important. 

3. It has long been standard practice that emergency response begins at the lowest possible jurisdictional level – typically the local government, with state government becoming 

involved at the local government’s request when the resources of local government are (or 

are expected to be) overwhelmed. Similarly, while the federal government provides ongoing 

fi nancial support to state and local governments for emergency preparedness, ordinarily it 

becomes involved in responding to a disaster at a state’s request when resources of state and 

local governments are (or are expected to be) overwhelmed. Louisiana’s Emergency Operations Plan explicitly lays out this hierarchy of response.

4. While several engineering analyses continue, the Committee has found deeply disturbing 

evidence of fl aws in the design and construction of the levees protecting New Orleans. For 

instance, two major drainage canals – the 17th Street and London Avenue Canals – failed 

at their foundations. Equally troubling was the revelation of serious disagreement – still 

unresolved months aft er Katrina – among offi cials of several government entities over 

who had responsibility, and when, for key levee issues including emergency response and 

levee repair. Such confl icts prevented any meaningful emergency plans from being put in 

place and, at the time of Katrina, none of the relevant government agencies had a plan for 

responding to a levee breach.

5. Top offi cials at every level of government – despite strongly worded advisories – did not 

appear to truly grasp the magnitude of the storm’s potential for destruction before it made 

landfall. Over the weekend, there was a drumbeat of warnings: FEMA held video-teleconferences on both days, where the danger of Katrina and the particular risks to New Orleans 

were discussed; Max Mayfi eld of the National Hurricane Center called the governors of the 

aff ected states, something he had only done once before in his 33-year career; President 

Bush took the unusual step of declaring in advance an emergency for the states in the impact zone; numerous media reports noted that New Orleans was a “bowl” and could be left 

submerged by the storm; the Department of Homeland Security’s Simulation and Analysis 

i

Hurricane Katrina: A Nation Still Unprepared
586

Group generated a report stating that the levees protecting New Orleans were at risk of 

breaching and overtopping; and internal FEMA slides stated that the projected impacts of 

Katrina could be worse than those in the “Hurricane Pam” exercise.

6. Beginning in 2004, the federal government sponsored a planning exercise with participation from federal, state, and local offi cials, based on a scenario whose characteristics foreshadowed most of Katrina’s impacts. While this hypothetical “Hurricane Pam” exercise 

resulted in draft plans beginning in early 2005, they were incomplete when Katrina hit. 

Nonetheless, some offi cials took the initiative to use concepts developed in the draft s, with 

some success in the critical aspects of the Katrina response. However, many of its admonitory lessons were either ignored or inadequately applied. 

7. Th e City of New Orleans, with primary responsibility for evacuation of its citizens, had 

language in its plan stating the city’s intent to assist those who needed transportation for 

pre-storm evacuation, but had no actual plan provisions to implement that intent.

8. Th e Louisiana Department of Transportation and Development, whose secretary had personally accepted departmental responsibility under the state’s emergency-operations plan to 

arrange for transportation for evacuation in emergencies, had done nothing to prepare for 

that responsibility prior to Katrina.

9. Some coastal towns in Mississippi went to extraordinary lengths to get citizens to evacuate, including sending people door-to-door to convince residents to move out of harm’s 

way. Th e State of Louisiana activated more than twice the number of National Guard troops 

called to duty in any prior hurricane, and achieved the largest evacuation of a threatened 

population ever to occur. Th e City of New Orleans issued its fi rst-ever mandatory evacuation order.

10. Th e U.S. Coast Guard conducted extensive planning and training for disasters, and put 

that preparation to use when disaster struck, leading to the successful and heroic searchand-rescue eff orts that saved more than 33,000 people.

11. FEMA was unprepared for a catastrophic event of the scale of Katrina. Well before 

Katrina, FEMA’s relationships with state and local offi cials, once a strength, had been 

eroded in part because certain preparedness grant programs were transferred elsewhere in 

the Department of Homeland Security; with its importance to state and local preparedness 

activities reduced, FEMA’s eff ectiveness was diminished. 

12. FEMA’s Director, Michael Brown, lacked the leadership skills that were needed for his 

critical position. Before landfall, Brown did not direct the adequate pre-positioning of critical personnel and equipment, and willfully failed to communicate with Secretary Chertoff , 

to whom he was supposed to report.

13. Th e Department of Homeland Security (DHS) leadership failed to bring a sense of 

urgency to the federal government’s preparation for Hurricane Katrina, and Secretary 

Chertoff himself should have been more engaged in preparations over the weekend before 

landfall. Secretary Chertoff made only top-level inquiries into the state of preparations, and 

accepted uncritically the reassurances he received. He did not appear to reach out to the 

other Cabinet secretaries to make sure that they were readying their departments to provide 

whatever assistance DHS – and the people of the Gulf Coast – might need.

14. Had Secretary Chertoff invoked the Catastrophic Incident Annex (CIA) of the National 

Response Plan, he could have helped remove uncertainty about the federal government’s 

need and authority to take initiative before landfall and signaled that all federal government 

Overview: Conclusions and Findings
587

agencies were expected to think – and act – proactively in preparing for and responding to 

Katrina.

15. DHS was slow to recognize the scope of the disaster or that FEMA had become overwhelmed. On the day aft er landfall, DHS offi cials were still struggling to determine the 

“ground truth” about the extent of the fl ooding despite the many reports it had received 

about the catastrophe; key offi cials did not grasp the need to act on the less-than-complete 

information that is to be expected in a disaster. DHS leaders did not become fully engaged 

in recovery eff orts until Th ursday, when, in Deputy Secretary Michael Jackson’s words, they 

“tried to kick it up a notch”; aft er that, they did provide signifi cant leadership within DHS 

(and FEMA) as well as coordination across the federal government. But this eff ort should 

have begun sooner.

16. Problems with obtaining, communicating, and managing information plagued many 

other aspects of the response as well. FEMA lacked the tools to track the status of shipments, interfering with the management of supplying food, water, ice, and other vital commodities to those in need across the Gulf Coast. So, too, did the incompatibility of the electronic systems used by federal and state authorities to manage requests for assistance, which 

made it necessary to transfer requests from the state system to the federal system manually.

17. Katrina resulted in the largest National Guard deployment in U.S. history, with 50,000 

troops and supporting equipment arriving from 49 states and four territories within two 

weeks. Th ese forces participated in every aspect of emergency response, from medical care 

to law enforcement and debris removal, and were considered invaluable by Louisiana and 

Mississippi offi cials. However, the deployments of National Guard troops were not coordinated with the federal Northern Command, which was overseeing the large-scale deployments and operations of the active-duty military.

18. While large numbers of active-duty troops did not arrive until the end of the fi rst week 

following landfall – although National Guard troops did – the Department of Defense 

(DOD) contributed in other important ways during that period. Early in the week, DOD ordered its military commanders to push available assets to the Gulf Coast. Th ey also streamlined their ordinarily bureaucratic processes for handling FEMA requests for assistance and 

emphasized movement based on vocal commands with the paperwork to follow, though 

some FEMA offi cials believe that DOD’s approval process continued to take too long. Th ey 

provided signifi cant support to search-and-rescue missions, evacuee airlift s, logistics management of buses arriving in the State for evacuation, and other matters.

19. Pervasive and widespread communications failures substantially hampered rescue and 

response eff orts.

20. Law enforcement was a problem, and was fueled by several contributing factors, including erroneous statements by top city offi cials that infl amed the public’s perception of the 

lawlessness in New Orleans. Without eff ective law enforcement, real or imagined safety 

threats interrupted virtually every aspect of the response.

21. Federal law-enforcement assistance was too slow in coming, in large part because the 

two federal departments charged under the NRP with providing such assistance – DHS and 

the Department of Justice (DOJ) – had done almost no pre-storm planning. In fact, they 

failed to determine even well into the post-landfall period which of the two departments 

would assume the lead for federal law enforcement under the NRP. As a result, later in the 

week, as federal law-enforcement offi cers did arrive, some were distracted by a pointless 

“turf war” between DHS and DOJ over which agency was in the lead. In the end, federal assistance was crucial, but should have arrived much sooner.

Hurricane Katrina: A Nation Still Unprepared
588

22. While both FEMA and the Department of Health and Human Services made eff orts to 

activate the federal emergency health capabilities of the National Disaster Medical System 

(NDMS) and the U.S. Public Health Service, only a limited number of federal medical teams 

were actually in position prior to landfall to deploy into the aff ected area. Only one such 

team was in a position to provide immediate medical care in the aft ermath of the storm.

23. Th e Committee also identifi ed signifi cant planning failures that predated Katrina. One 

of the most remarkable stories from this investigation is the history of planning for the 

100,000 people in New Orleans believed to lack the means to evacuate themselves.

24. Almost exactly four years aft er 9/11, Katrina showed that the nation is still unprepared 

to respond to a catastrophe.

Overview: Conclusions and Findings