WTC:Fire Department Lapses are Cited

The Fire Department's response to the Sept. 11 attack at the World Trade Center, while brave and aggressive, was plagued by problems in radio communication, lapses in discipline and a lack of coordinated efforts with the Police Department, according to a draft report by an independent consultant.

The draft report by the consultant, McKinsey & Company, concludes that problems with the radio system caused commanders to lose touch with many companies once firefighters ascended into the towers. The lapses in discipline led firefighters to rush to the scene without checking in with commanders at designated staging areas.

Even members of the department's 32-member executive staff exhibited too little restraint, the report concludes, with 26 of them showing up at the scene, a number of them without any defined role.

And the virtual absence of coordination with police officials, the consultants say, meant that fire commanders had no access to reports from police helicopters that hovered above the buildings, tracking their structural integrity and the progress of fires across the upper floors.

"This lack of information hindered their ability to evaluate the overall situation," the draft report says. The report, significant parts of which were obtained by The New York Times, acknowledges that the terrorist attack, in which thousands of people were trapped by fires in two of the world's tallest buildings, was an overwhelming event that required an unusual level of coordination.

But it states that to manage such events in the future the department must improve its planning, overhaul parts of its training, acquire substantial new technology and coordinate more effectively with other emergency agencies.

"We believe that the F.D.N.Y. cannot adequately fulfill its mission to the citizens of New York City unless the city or state governments establish a formal effective process of interagency planning and coordination," the draft says.

When it is released, perhaps as early as next week, the report will conclude a painful process in which department officials said they sought a penetrating review of procedures that would point the way to improvements without diminishing the sacrifices or valor of firefighters who responded that day.

The shortcomings identified in the report range widely. The report concluded that some of the department's senior chiefs had not received routine training for up to 15 years. It found that the department's effort to recall every firefighter to active duty that day was disorganized.

It said, too, that the department lacked any formal way of working with neighboring fire departments to coordinate coverage during an emergency.

And the department's Emergency Medical Service, the report makes clear, had serious problems deploying, tracking and controlling its ambulance and trauma personnel.

The consultant, which specializes in reviewing management practices, spent five months preparing the report.

The draft says the team interviewed more than 100 experts on emergency response and reviewed internal documents, including the transcripts of radio transmissions. A separate team working for the consultant has prepared a similar report for the Police Department.

The management reviews were prompted in part by the losses each agency suffered that day, in which 343 firefighters and 23 New York City police officers died.

A Fire Department spokesman, Francis X. Gribbon, declined to comment on the draft report. "The final report is not due to be completed until sometime next week," he said. A spokesman for Mayor Michael R. Bloomberg, Edward Skyler, said the administration also had no comment.

The 80-page report is written in a measured tone, does not single out individual fire officials for either praise or blame and suggests that, in some respects, the department's response was remarkable.

It states, for example, that despite deploying some 200 units to the World Trade Center, the department was able to maintain adequate fire coverage throughout the city. Response times to fires that day rose by only one minute, to an average of 5.5 minutes, the report says.

But the document focuses on an array of ways to improve the various shortcomings that were exposed on Sept. 11.

It urges the department to develop and abide by a formalized system of what is known as incident command to better direct strategy and share information with other agencies.

It says the department must improve and expand training and find the financing to expand its hazardous materials and special operations divisions.

And it says the department must make senior commanders and front-line firefighters more accountable and perhaps subject to sanctions for breaches of discipline.

The report also recommends that the department speed up its review of new handheld radios, and if they pass muster, distribute them for use by firefighters in as little as four months.

The new radios were pulled from service last year after an incident in which a firefighter's call for help went unheard.

That decision meant that the department was using old radios, some in use for more than a decade, when it arrived at the trade center, the draft says.

Radio communications that day were sporadic, the report concludes, and critical information was apparently never received by firefighters on upper floors in the building. The report, for example, says that when Assistant Chief Joseph Callan issued an evacuation order over the radios at 9:30 a.m. — roughly an hour before the north tower collapsed — "there was no acknowledgment by firefighters."

Similarly, when the south tower collapsed at 9:59 a.m., many firefighters did not realize the magnitude of the disaster.

"Our interviews indicate that many believed that a partial collapse within the lobby of W.T.C. 1 had occurred," the report says.

Problems with radio communications in high-rise buildings, as well as in subways, were well known for years, the report says, but were never satisfactorily addressed. To fix the problem, the department should equip companies with portable radio boosters they can use at high-rise fires, the report says.

In addition, the report says, the city should pursue changes in the building code that would require high-rises to install equipment that would help enhance the signal of fire radios.

The Emergency Medical Service, a division of the Fire Department, also suffered communication problems, the report says. Messages were lost because too many people used the system, causing congestion, according to the draft, and the loss of effective radio communications contributed to the agency's inability to measure its response.

"From 9:58 a.m. until at least midafternoon on Sept. 11, E.M.S. chiefs and officers did not have an accurate view of the number and location of resources deployed to the incident," the draft says.

The efforts to recall off-duty firefighters to the scene were also weakened by a general unfamiliarity with the process among firefighters. Lacking specific instructions on where to report when called in for duty, some went to their own firehouse, others went to firehouses near the trade center and still others responded to the scene itself.

The consultants estimated that it will cost the department $5 million to $7 million to retrain its members on how better to respond to complex, large-scale incidents.

But such training will be ineffective, the draft suggests, if the department is unwilling to enforce its regulations and discipline firefighters who do things like ignore instructions to report to a particular staging area.

Over all, the draft says, the department needs to be run with tighter standards. "Accountability needs to be increased at headquarters and in the field," the report says.

The report, in fact, appears to suggest that some units responded despite instructions to remain in quarters. As well, the report notes, many off-duty firefighters joined their on-duty colleagues in responding, in part because the attack occurred so close to the change in shifts that morning.

As a result, the presence of many of these firefighters was never officially recorded, a fact that created confusion when the department began to try to calculate its losses.