Surprising and Important Ways
New York Was Unprepared for Disaster
NYTimes.com - May 19, 2004
By JIM DWYER
A number of the most stinging new revelations from the hearing yesterday on the Sept. 11 attacks came from 911 tape recordings that Mayor Michael R. Bloomberg and his administration have tried to keep from public inspection for more than two years.
The tapes showed that a number people inside the towers - isolated without public address announcements - turned to the 911 emergency system for advice but were steered terribly wrong by the Police Department and fire dispatchers, according to a report by the staff of the independent commission investigating the attacks.
Many of those callers were told to stay in their offices, the commission found, even after both planes had struck and after senior rescue chiefs in the complex had decided that everyone should evacuate.
These were not simply errors by operators working in the frenzy of crisis, but a symptom of a broken emergency response system, several commissioners suggested yesterday. The Police and Fire Departments had no method for relaying fresh information to the 911 operators, information that might have shaped the advice and instructions they were giving to people in the buildings.
Questions about that problem, in fact, led to contentious exchanges yesterday between members of the 9/11 commission and the former leaders of the city's police, fire and emergency management departments.
"Calling 911 was pointless," Slade Gorton, a commissioner, said at one point. "The 911 operators were clueless."
The 911 tapes were heard by the commission's staff only after an unusually sharp public disagreement between the city and the federal investigators. Last fall, Mayor Bloomberg said that he would not allow the commission to hear them, arguing that it was his duty to protect the privacy of people who made the calls as they were about to die. The panel, which includes several members with top-secret clearance for the nation's most sensitive intelligence, declared that Mr. Bloomberg and the city were "significantly impeding" its inquiry and issued a subpoena.
To settle the dispute, the city agreed to permit the commission's staff to listen to the 911 tapes in a city building. It would not permit them to remove the tapes. The New York Times and a number of victims' families have sued the city for access to the recordings.
According to the accounts provided by the commission, which agreed to limit the identifying details, the 911 tapes proved to be a source of disturbing insights, revealing a systemic failure in New York's emergency response. With the public address systems destroyed inside the towers, the 911 system was completely unprepared to provide anything but general guidance about high-rise fires. Thus, a number of people in the buildings were advised to stay where they were.
"One of the few ways to communicate to people in the building was through calls to the 911 or other emergency operators," the staff report stated. "We found no protocol for communicating updated evacuation guidance to the 911 operators who were receiving calls for help. Improvising as they learned information from callers, some operators advised callers that they could break windows. Some operators were advising callers to evacuate if they could."
Members of the commission appeared surprised that no one in the Police or Fire Departments on Sept. 11 had the job of making sure that the 911 operators had reliable information to offer people calling in from the towers, and knew whether the situation had changed at all.
The staff report did not criticize individual 911 operators who spoke to people calling from inside the trade center; many of them were praised for the solace they provided to people who feared their lives would soon end.
Instead, the commission identified the gap in the information passed to the operators.
That set off an angry exchange with senior members of the administration of former Mayor Rudolph W. Giuliani, including Bernard B. Kerik, the former police commissioner; Thomas Von Essen, the former fire commissioner; and Richard J. Sheirer, the former commissioner of the New York City Office of Emergency Management. All three men now work in Mr. Giuliani's consulting firm, Giuliani Partners.
"There's a 911 supervisor on duty around the clock," Mr. Kerik said when asked what formal mechanism existed to keep 911 operators supplied with critical information from the field. He added, "Whether there was communication from the field, I personally don't know."
Mr. Gorton, the former senator from Washington State, asked Mr. Von Essen if the "Fire Department had any institutionalized way, any formal way of communicating" to 911 operators?
Mr. Von Essen replied, "Institutionally, I really don't know what you mean." He added that he believed it would be the task of the supervising fire dispatcher to "do the best he could."
The answers did not satisfy Mr. Gorton, who said he was more troubled than when he had begun the line of questioning. How, he wondered, could it be that no one was or is responsible for getting good information to the people who called 911?
Several of the former city officials began to speak at once, until Mr. Kerik interrupted by saying that if the panel wanted to know about the current policies, the inquiries should be made to the current police and fire commissioners, who would be testifying later in the day.
"You have to ask them what's going on today," Mr. Kerik said.
From the audience came loud protests and hisses, with one voice calling out that Mr. Kerik should tell them about the conditions on Sept. 11, when he was in charge.
"I'm asking the two of you about what was going on Sept. 11," Mr. Gorton said.
"On Sept. 11 there was a supervisor in 911," Mr. Kerik replied. "That supervisor had ability to listen" to the police radio channels. He said he did not know if the supervisor had listened to fire channels. (Later in the day, the current police commissioner, Raymond W. Kelly, said that a police official was now taking on the responsibility of ensuring that reliable information was given to callers. He declined to say the problem was fixed.)
The tapes revealed other problems in effective and detailed communication of information between and among the 911 operators, the people in the buildings and the rescuers in the field.
The report said that "911 operators and F.D.N.Y. dispatchers had no information about either the location or magnitude of the impact zone and were therefore unable to provide information as fundamental as whether callers were above or below the fire." It added that "911 operators were also not given any information about the feasibility of rooftop rescues. In most instances, 911 operators and F.D.N.Y. dispatchers, to whom the 911 calls were transferred, therefore relied on standard operating procedure for high-rise fires."
Those procedures called for people in a high-rise fire to remain on their floor, unless it was on fire - a policy overridden by the decision of fire chiefs to evacuate all the buildings.
The tapes showed another kind of communication breakdown, as well. At 9:37, about 22 minutes before the south tower collapsed, a person on the 106th floor called 911 and told the operator that a floor was collapsing. At 9:52, a police dispatcher sent word to officers: "The 106th floor is crumbling."
Yet on a morning when information often meant survival, that word about a collapsing floor was evidently never passed along to the Fire Department, which was leading the rescue effort inside the two towers. Hundreds of firefighters were climbing up the stairs of both buildings. One fire commander told the commission that word of collapsing floors would have been valuable information to have about the deteriorating condition of the towers, and might have affected his thinking on the best course of action.
One of those who escaped from the south tower, Brian Clark, also told the commission about seeing a man on the 44th floor who had been badly injured and was being cared for by a security guard who had no working phone lines. Mr. Clark, who had already pulled one person from rubble on the upper floors, promised to call for help as soon as he could find a working telephone
"I had a very frustrating experience calling 911," Mr. Clark said. "It was, I am sure, over three minutes in duration my conversation with them. Not five minutes, but certainly over three minutes where I told them when they answered the phone, where I was, that I had passed somebody on the 44th floor, injured, they need to get a medic and a stretcher to this floor, and described the situation in brief, and the person then asked for my phone number, or something, and they put me on hold.
"You gotta talk to one of my supervisors," he said the operator told him. "and suddenly I was on hold. And so I waited a considerable amount of time. Somebody else came back on the phone, I repeated the story. And then it happened again. I was on hold a second time, and needed to repeat the story for a third time. But I told the third person that I am only telling you once. I am getting out of the building, here are the details, write it down, and do what you should do, and put the phone down."
The commission listened to Mr. Clark's phone call and found his description accurate.
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