"don't go native"

 “THROUGH THE BLOODY September twilight, aftermath of [a hundred] rainless days, it had gone like a fire in dry grass…”[i]—William Faulkner, Dry September

it started on fish ranch road

The summer of 1970 was the hottest anyone could remember. In the foothills and mountains away from the coast it hit a hundred degrees, day after day. California has seen its share of legendary droughts, but as the summer wore on, it kept not raining. Not a drop of rain since June.

Then came the Diablos—those high, hot winds that blow west from the inland deserts, sometimes gusting to hurricane strength. They blew all day long, transforming the forests and everything in them—shrubs, bark, branches, even the soil itself—into fuel.

September rolled around. The wind kept blowing, and the terrain kept getting drier. When the humidity dropped below two percent, firefighters sensed the epic battle ahead. They tied up loose ends, poured coffee, and settled in, waiting for the other shoe to drop.

And then, finally, it did…

“OAKLAND, Calif. Sept. 22, 1970. A wind-driven fire, believed to be set by arsonists, roared out of the Berkeley Hills today…”—The New York Times

Someone set a match to tinder-dry grass along Fish Ranch Road in the Oakland Hills east of the University of California, Berkeley campus. Within minutes, the flames, feeding on dry coyote brush and pine trees and whipped by those Diablo winds, swept to the ridgetop and leaped into homes perched on the steep hillside above San Francisco Bay.

In less than two hours, thirty-six homes were gone, and thirty-seven others were aflame. The heat was so intense that the houses exploded before the fire even got to them. And it was just getting started. It would be two weeks before it was done. By then, 580,000 acres would be burned, sixteen people would be dead, and 722 homes would be destroyed.

After thirteen days of fire, firefighters managed to stabilize the disaster. It ended slowly, stubbornly, when the fire boss of the 34,000-acre Meyers Fire in the hills north of San Bernardino announced that his fire had been wholly surrounded by a cleared line.

The firefighters did a remarkable job considering the conditions they faced. Despite their Herculean efforts, the public was stunned by the scale of the devastation. The fire services were criticized for what was widely perceived to be a mismanaged response.

Formal investigations found that a series of mistakes had compounded the disaster. These were not tactical mistakes or a lack of resources but management and communication failures.

To find a way forward, President Nixon created the National Commission on Fire Prevention and Control. In May 1973 it issued a report entitled “America Burning,” which concluded that “fire is a major national problem.”

Congress ordered the US Forest Service to fund a five-year research program called the Firefighting Resources of Southern California Organized for Potential Emergencies program, or FIRESCOPE.[iii] The FIRESCOPE research team concluded that “because the fire disaster was reaching such widespread proportions and involved the firefighting apparatus of so many separate fire departments, there was need for a coordinating body.”

So, FIRESCOPE created a new fire management system. It called this new system the Incident Command System, or ICS.

putting ics to the test

Within ten years, ICS would be in use throughout Southern California and spreading across the country.

Because it worked.

It was simple to learn and use and versatile enough to bring order to the chaos of any type of disaster, not just wildfires. And it was scalable, meaning it could handle everything from a car accident to a catastrophic earthquake.

In New York City, OEM was an early adopter of ICS because it knew that in the parallel universe, ICS was the key to managing the massive city bureaucracy and especially its longstanding rivals, NYPD and FDNY.

In the fall of 2001, OEM was preparing to put ICS to the test in a citywide disaster exercise.

As in most other big cities and all states, New York City had a plan for how it would distribute prophylactic (or protective) antibiotics or vaccines to people during epidemics or after a bioterror attack. Such medications could have to be provided to every one of the 8.4 million residents of the city, and quickly.

The citywide exercise was dubbed Operation Tripod, with “Tripod” being a sort of acronym for “trial point of dispensing.” According to the exercise scenario, terrorists had released a large quantity of an anthrax “agent” in the subways. Pier 92, at the New York Passenger Ship Terminal on West 53rd Street, had been outfitted as a massive point-of-dispensing, or POD, site. OEM had recruited hundreds of Police Academy cadets and Fire Department trainees to act as civilians who had come to the POD for their medications. It had even bought 70,000 M&Ms to be handed out as fake medicine.[iv]

Operation Tripod was scheduled for Wednesday, September 12. High-profile VIPs from around the city, including Mayor Giuliani, the police and fire commissioners, the FBI, and FEMA, were invited as observers.

On Tuesday, September 11, many of the OEM staff had come to work early to prepare for the exercise. They were expecting a busy day.[v] Nobody had the slightest inkling of just how busy it was going to get.

attack

It began at 8:46 a.m., when hijackers crashed American Airlines Flight 11 into the northern face of the World Trade Center’s Tower 1. It ended when World Trade Center 7 collapsed at 5:21 p.m. and the Twin Towers, along with more than a dozen other nearby buildings, lay in ruins.

In the early hours after the attacks, as firefighters, construction workers, and volunteers dug through the smoldering pile of debris, an alphabet soup of federal, state, and city agencies poured into Lower Manhattan. Many of these agencies—including EPA, OSHA, HHS, NIOSH, PESH and COSH (Environmental Protection Agency, Occupational Health and Safety Administration, Department of Health and Human Services, CDC’s National Institute of Occupational Safety and Health, New York State Department of Labor’s Public Employees Safety and Health Bureau, NYC Citywide Occupational Safety and Health)—were responsible, in one way or another, for the health and safety of people affected by disasters.

But in those dark days, the stakes—and the risks—were sky high. The media placed a laser-focus on Ground Zero. Every act, every statement, was magnified and overanalyzed. Mistakes could be career-ending.

In the case of the workers on the pile and the residents of the neighborhood, the agencies wanted desperately to be involved, but they were equally desperate to avoid any mistakes for which they could be blamed.

Issues like worker safety and environmental health were burning white hot in Lower Manhattan in the early days after the attacks, so hot that the bureaucrats who, on a normal day, were responsible for these things suddenly wouldn’t touch them.

the tail of the response

One of the reasons you don’t see a lot of emergency managers in disaster movies is because, instead of “running toward the boom,” they run into carpeted conference rooms to huddle over laptops with cellphones stuck to their ears.

The most important work, by far, in the parallel universe is done by police officers and firefighters and humanitarian aid workers in the field. This is known as the tactical level, or “teeth,” of the response.

At the same time, a team of teams is gathered in and around operations centers, supporting the teeth of the response with critical information and resources and solving the problems that the tactical-level can’t solve on the ground.

From the outside, the EOC—the “tail” of the response—looks boring. But that tail work can have a profound effect on outcomes in the field.

the morning after

In the early morning after the attacks, as the Associate Commissioner for Environmental Health at the New York City Department of Health, I was assigned to the makeshift Emergency Operations Center in the second-floor library of the city’s Police Academy on East 20th Street, six blocks above the evacuated city—the so-called “Red Zone.”

Some of my colleagues from the Health Department had traveled downtown overnight and were still at the scene. Their reports narrowed the Health Department focus that morning to the hazards faced by the first responders fighting fires and digging in the rubble in and around the massive site.

We knew that standard protocols called for every workplace to be assessed for hazards to the workers before any job could start. According to those protocols, once the hazards are known, workers are given the equipment and the training needed to keep them safe. That is standard practice. Unfortunately, in the case of Lower Manhattan on September 12, 2001, standard practice was out of the question.

Overnight my boss, Dr. Ben Mojica, Deputy Commissioner of Health, had issued a safety advisory recommending that workers at Ground Zero be outfitted with N95 respirators (close-fitting face masks that cover the mouth and nose), hard hats, neoprene gloves, goggles, and steel-toed boots. When Mojica read the advisory to me over the phone, I was puzzled:

“Ben, why did we issue this? FDNY has its own Safety Chiefs. They don’t need us to tell firefighters to wear steel-toed boots.”

He explained that all kinds of people were downtown trying to help, including construction workers who had been working nearby and civilians who showed up out of nowhere.

“Who’s controlling all of those people? Fire?”

“FDNY is in charge,” Mojica said. “But it’s huge site and parts of it are pretty chaotic right now.”

I hung up and turned to the flood of issues that were landing on my desk. CDC had dropped a Push Package[vi] of drugs and medical supplies at Kennedy airport and we worked to get it downtown to the World Trade Center site; we got pulled into a conversation about rescue workers being bitten by rats; we were besieged by requests from people trying to get downtown.

Just before 8 a.m., Randy Price, vice president of environmental health and safety at Consolidated Edison (the power company), pushed his way over to my desk. He handed me a piece of paper with four lines of data on it. The top line was a laboratory result from an air sample collected the day before at Ground Zero. A Con Edison worker wearing a sampler had walked the perimeter of the site, just a couple of hours after the buildings fell. The other three lines were lab results for samples of debris from the street that the worker had collected at the same time. The data showed low levels of asbestos in the air and the debris.

Laboratory results that are above legal thresholds are easy to interpret. Those that are not are harder. Since these results fell into that second category,[vii] I wanted Con Edison’s interpretation.

“Okay, we got less than 1 percent in the dust, and we’re below OSHA in the air. What are you doing with your folks down there?” I asked Price.

“We got them suited up in Level C,” he replied.

“Moon suits? At these concentrations?” I asked.

“Well, we just got this data, and we wanted the higher protection factor in case the levels went higher,” he replied.

“What about respirators?” I asked.

“Half-face P100s right now,” Price said.

I pressed him further: “What would you recommend for firefighters?”

Price had brought along his deputy, George Corcoran, a burly Bronx native and veteran emergency manager. Corcoran looked at me and gestured passionately, talking with his hands. “It’s tough to say with this data. Ya gotta look at the big picture, though. You’re probably talking P100s on those guys.”

“Do we need that?” I said. “OSHA doesn’t require them at these concentrations. I don’t even know if the Fire Department has any.”

“It’s a tough call,” Corcoran admitted, “but at our shop we have to be careful. All we got is one data point. It ain’t the universe. But it could get worse down there.”

Con Edison had ordered all of its employees working in and around the World Trade Center site to wear protective coveralls[viii] and P100 respirators. The P100 is a molded face-piece respirator with two cartridge filters that remove 99.97 percent of airborne particles. It is more protective but harder to wear and maintain. As it would do at any worksite, Con Edison was requiring maximum protection for its workers until it had data to prove that it wasn’t needed.

I stared at the air sample result at the top of the page and struggled with the idea that we would recommend that FDNY pull its firefighters off the pile. How could we slow the rescue, with perhaps 15,000 people there, trapped in the rubble?

To put workers into P100s meant we would have to make sure they were physically capable of wearing them. They would have to be fit-tested and trained. And besides, how many P100s could we even get our hands on?

All of this based on a single data point—one that showed levels below the legal threshold, what OSHA called the permissible exposure limit? A single data point that wouldn’t be enough to require workers at a normal construction site to wear P100s?

It wasn’t enough data to be statistically meaningful; not enough to draw conclusions about the conditions everywhere around an outdoor 16-acre construction site.

But this was not a normal construction site.

I called Ben Mojica, and we changed our safety advisory. From that moment, the New York City Department of Health recommended that all workers at Ground Zero wear P100 respirators.

Then I went to find some. I weaved over to Department of Citywide Administrative Services,[ix] the city’s procurement agency. It was five people huddled around a small desk talking into their cellphones and writing furiously. One of them looked up. It was Lisa Sacks, assistant commissioner.

“Lisa, I need ten thousand P100 half-face dual-cartridge respirators with replacement filter cartridges.”

“Where and when?” she asked. “And oh, by the way, what is a P100 respirator?”

I pushed my way to the front of a line waiting to talk to OEM’s shift commander, Richard Rotanz.

I told him what we were doing.

“What the hell is a P100 respirator?” Rotanz asked.

When I told him, he said, “How are they going to talk to each other?”

“They gotta yell,” I replied. “I don’t know, Richie, but the air tests I’m looking at tell me they have to wear them.”

“Make it 20,000 then. You’re gonna need ’em. You get them downtown. I’ll let FDNY know they’re coming.”

We had taken the first step, but with hundreds of construction workers, first responders, and volunteers crawling over the remnants of the World Trade Center, underneath which fires still burned, we needed to figure out how to make it happen.

too hot to handle

Around noon, Rotanz steered the Environmental Protection Agency, in the form of its on-scene coordinator, Brett Plough, over to me. Plough was the agency’s first responder, a tall, thin forty-year-old engineer in a bright blue polo shirt with a red, white, and blue logo that read “EPA Emergency Response.” I told him about Con Edison’s air data and asked him for EPA’s data.

Brett looked confused. “What do you mean?”

“What do you guys have?” I said. “Have you characterized the site?”

“No. We don’t characterize your site,” he said. “We are here to support the city. What is the city requesting at this time?”

“Look,” I said, “We need to test for anything hazardous that could be in the air, all around the site.”

"When do you want this done? And for how long?” he asked.

“How about around the clock from now until forever,” I said.

“What does ‘forever’ mean?”

“Six weeks, six months, six years, who the hell knows?” I said. “Just get going and keep going.”

A few minutes later he pushed through the crowd and gave me a thumbs-up sign. “I got your data. It’s on its way.”

An hour went by, but the data didn’t show. That hour stretched into two. Still nothing.

I began to search harder everywhere else, looking for safety officers and their data. Surely there were more agencies, not just the EPA, on the scene collecting samples of the air and debris. Only data could tell us whether the air at the World Trade Center site was hazardous. How could we be thirty hours into this disaster and not have good data?

The afternoon sped by and every so often I’d hear a different excuse from Brett: EPA couldn't reach the right person, the sampling equipment had malfunctioned, or the samples were delayed getting to the lab. Every report ended the same way: “It will be here in an hour.”

Finally, around 5 p.m., Plough arrived, waving a sheet of paper containing air data from one location in Jersey City, New Jersey, and two in Brooklyn. When I asked to see results from the World Trade Center site, or anything in Manhattan, he had nothing to show me.

“Oh,” he said. “We didn’t sample there.”

What was going on with these guys?[x]

I was baffled. Based on my fifteen years of experience with the United States Environmental Protection Agency, I would have expected it to seize the reins of the investigation, calling all the shots. After all, it was the chief architect and protector of the Clean Air Act. The EPA had defined acceptable air quality everywhere in the United States and had been arresting violators for over 30 years. Now, the agency that literally wrote the book on air sampling didn’t seem to know how to do it. As we were soon to discover however, somebody at the EPA was testing the air somewhere.

air that is safe to breathe

The next day, EPA administrator Christine Todd Whitman announced that “short-term, low-level exposure of the type that might have been produced by the collapse of the World Trade Center buildings is unlikely to cause significant health effects.” Whitman went on to express the agency’s relief “that there appears to be no significant levels of asbestos dust in the air in New York City.”

If the EPA had data to make that claim, it wasn’t showing it to New York City. The rumor in the EOC was that the White House had directed the EPA to reassure New Yorkers—those working at the World Trade Center site and those anxious to return to their homes and jobs downtown—to fast-track the recovery.

The impact was immediate. Our Health Department teams were already bringing the P100 order out into the field, handing out flyers during shift changes and explaining to workers the new requirement for P100s and how to get them. In the EOC, we began every report in the Daily Agency Briefing with a reminder of the P100 order. But after the announcement by the EPA administrator, FDNY and NYPD began to call us out in these meetings. They wanted to know why, if the EPA said the air was fine, our own Health Department was telling workers to wear these face masks. It was a good question.

We needed proof. Since nobody had it, and all the people who on a normal day were responsible for these things suddenly wouldn’t touch them, we would have to go and get it.

into the red zone

The next day, a Health Department caravan loaded with environmental technicians and air-sampling equipment drove south through the empty streets of Lower Manhattan.

I had made an ask. I called an old friend, Alex Lempert, who was in charge of environmental issues at the NYC School Construction Authority. Lempert had huge air-sampling resources at his command. When I told him that I was going to test the air at the World Trade Center site and needed his help, he said, “Let’s go. What do you need?”

It was late in the afternoon. We traveled through multiple checkpoints manned by NYPD and National Guard with machine guns at the ready. All along the way, buildings and sidewalks were covered in a thick coat of dust; stores were empty, frozen in time.

Finally, we reached the FDNY Incident Command post. Across the street was the pile, a hundred-foot-tall tangled mass of I-beams and concrete; stainless steel shards that used to be the exterior walls were tilted and askew amidst the debris. Tiny figures of firefighters were scattered across the face of the mountain.

I stepped out of the van and a teenage girl appeared out of nowhere wearing shorts, flip-flops, and a T-shirt. This girl had apparently evaded NYPD and its machine guns. Without a word she reached into a white five-gallon bucket and offered me a sandwich in a Ziploc bag with a red, white, and blue ribbon that read “God Bless You.”

I looked around and saw other visitors. In addition to police officers, firefighters, and soldiers doing their jobs, there were people from random federal agencies like the Department of the Interior, Commerce, and Veterans Affairs, all of whom happened to be in the city on unrelated business and had used their government-issued IDs to get downtown. They stood around gazing at the surreal scene, doing nothing except to put themselves in harm’s way.

The FDNY Incident Command post was a collection of brightly lit white tents in the middle of the intersection at West at Vesey Streets. I waded into the crowd to present myself to the Incident Commander. When I found him, he was standing in front of a whiteboard with a hand-drawn map showing the World Trade Center site as a grid of 16 one-acre quadrants, with a battalion chief assigned to each one. I started to introduce myself, but he cut me off. He knew who I was and why I was there. He walked away, and I stood there, waiting…

Then, one by one, the battalion chiefs appeared.

They stood stock-still as we described what we were doing-they had that thousand-yard stare (that blank, unfocused gaze of soldiers who have become emotionally detached from the horrors around them) as we strapped the air samplers, each about the size of an old portable tape player, onto their waist belts and clipped intake tubes to their collars. Then they disappeared back into the pile.

We strapped samplers to everybody we could: construction workers, crane operators, police officers, and FBI agents. We took the rest of the samplers we’d brought and taped them to streetlight poles and fences, anywhere we could pull a decent sample.

At the same time, the formal requests that I, and others at the Health Department, had made for air sampling were starting to bear fruit. Over the next two weeks, OSHA would collect more than 250 samples for asbestos and began sampling for silica; carbon monoxide; heavy metals like lead, cadmium, mercury, and arsenic; and volatile organic compounds like benzene, toluene, and formaldehyde. The City’s Department of Environmental Protection had set up testing stations all around the site and was collecting hundreds of air samples.

The data we collected that day convinced us that P100 respirators needed to be worn at the World Trade Center site. Unfortunately, it wasn’t enough to convince the people who needed to wear them.

plugging into the great machine

Throughout those long early days, dozens of experts from an alphabet soup of city, state and federal agencies, including the Department of Health and Human Services and the Centers for Disease Control (in particular its National Institute of Occupational Safety and Health, or NIOSH) had come together at the Department of Health’s temporary headquarters on First Avenue. They had compiled a laundry list of public health and worker health issues that needed to be immediately addressed at the World Trade Center site.

So, we dispatched a separate team to the EOC on a mission to create order out of the chaos. We were assigned to work with Sam Benson, OEM’s Health and Medical Director to convene all the organizations who were working on health and safety issues at the site, including FDNY and NYPD, the city’s Department of Design and Construction, Port Authority, Bovis and the Operating Engineers, Bechtel, CDC/ NIOSH, OSHA, EPA, Deparment of Sanitation, FBI, and many others. We came together as a team—in a dingy upstairs conference room we called the “martini sky lounge”—and dubbed ourselves the WTC Health and Safety Task Force. And we kept the mission front and center in everything we did: protect workers and first responders and improve health and safety conditions on the ground at the World Trade Center site.

We worked around the clock,[xi] coming together twice a day to solve problems and to gauge our progress. In the beginning, the meetings were raucous. We struggled to keep order as the standing-room-only crowd, which included construction bosses, Army colonels in fatigues, FDNY chiefs in uniform, congresspeople, and agency heads in business suits, all trying to comprehend and contribute as we worked through our list of tasks and problems. The meetings started big and got bigger, and within a week we went from a handful of data points to hard drives full of data. Information management quickly became a huge job, with dozens of Health Department staff vetting, analyzing, and presenting the data to us.

In the early days, immediate life safety was our biggest concern. Hundreds of people worked on the pile day and night using cranes, excavators, and grapplers to remove the mountain of steel and debris. Firefighters worked alongside the heavy equipment, manually digging through unstable mounds of debris and climbing down into the smoking voids. The risk of serious injury or death was extreme. The World Trade Center site was, in the words of OSHA Administrator John Henshaw, “the most dangerous workplace in the United States.”

At the same time, we kept a laser focus on the hazards in the air. We sent roving teams of safety inspectors in “Gator” vehicles to patrol the site. One of their main jobs was to make workers wear respirators.

When we heard that workers were confused about where respirators were required, we posted maps showing a perimeter around the site (the famous “green line”) within which respirators had to be worn. We even painted a green line on the streets and sidewalks. We established a dust-suppression program that included a nonstop spray of water on the pile and wash-down stations for workers and vehicles.

We worked to make sure respirators were available everywhere and at all times. We dispatched teams to conduct fit-testing. By September 16, we had a formalized fit-checking schedule in place at various locations near the site staffed around the clock with doctors and nurses conducting medical clearances for fit tests.[xii]

We mounted a massive safety education campaign with official advisories, pamphlets, laminated cards, and huge signs affixed to every entry location at the site. We worked with the Operating Engineers[xiii] to create a mandatory eight-hour safety course that educated workers on the hazards at the World Trade Center site and what they needed to do to protect themselves.[xiv]

three strikes and you’re still working on the pile

But the missing piece was enforcement; we needed a way to enforce the respirator requirement on the pile. Some have questioned the need for this. They say that the individual first responders and construction workers were responsible for keeping themselves safe by wearing their respirators. But they couldn’t be more wrong. The first responders and construction workers were selflessly dedicated to a solemn mission and, like everyone else, they were confused by mixed signals.

“If the EPA says the air is safe, why do I have to wear this face mask?”

“Nearly every person around me, every police officer and firefighter and construction worker, has a mask hanging around their neck instead of over their mouth and nose. Why should I be the odd person out?”

“I see OSHA and the New York State Department of Labor here. If the rules require all of us to wear these face masks, why is nobody getting kicked off the site?”

From the beginning, we knew that we needed a three-strikes rule that would permanently bar workers from the site for refusing to wear a respirator. We knew this worked, because it was working all day long on Staten Island.

Every day, debris from Ground Zero was trucked from the site through the Brooklyn Battery Tunnel into Brooklyn and across the Verrazano-Narrows Bridge. Once it arrived at the former Fresh Kills landfill site on Staten Island, NYPD oversaw sifting through the debris for evidence and human remains. Deputy Inspector James Luongo was the Incident Commander. At its peak, as many as nine hundred law enforcement officers worked around the clock there.

Luongo did not need anybody to help him enforce the rules. Anyone caught not wearing a respirator was immediately relieved of his or her duties and kicked off the site permanently. There were no exceptions.

“Ladies and gentlemen, this ain’t baseball,” Luongo liked to say. “In my game, you only get one strike.”

Those debris trucks hauled nearly two million tons of contaminated World Trade Center dust and debris off the site and through city streets. Although the Department of Health couldn’t enforce worker safety regulations, we had broad authority to enforce our own rules that prohibited trucks from contaminating the tunnels, bridges, and streets along the route.

We used that authority to issue hundreds of tickets (each with a 500-dollar fine) to debris trucks that left the site unsealed or unwashed. This earned me the dubious distinction as “the most hated man at Ground Zero.” But it worked. We enforced a zero-tolerance policy for contaminated World Trade Center dust on the streets of New York City. Unfortunately, as we shall see, we couldn’t use health inspectors to issue tickets to workers.

Despite a massive effort, we could not force all the first responders and construction workers to wear a P100 respirator at all times at the World Trade Center site. We needed a zero-tolerance policy to keep them safe. We saw it working on Staten Island and on the streets around the WTC site and knew that it would work on the pile.

But very early on, at the highest levels of government, a policy decision was made: no enforcement. This no-enforcement policy is to blame for failing to protect the first responders and workers at the World Trade Center site.

going native

Legislators create laws, and agencies write regulations that implement the authority of those laws. Those regulations are enforced by the agencies that write them and only the agency that authored a regulation can enforce it. In the case of Ground Zero, OSHA and the New York State Department of Labor were responsible for worker safety; the New York State Department of Labor wrote the rules for public sector workers, such as firefighters and police officers, and OSHA wrote them for everyone else.

OSHA and the New York State Department of Labor would not conduct “enforcement activities” at the World Trade Center site, despite repeated requests by the city of New York they do so. The members of the WTC Health and Safety Task Force were frustrated. We called out the OSHA and New York state representatives at every safety briefing and demanded that they justify their failed policies.

They were all there: EPA, OSHA, and the New York State Department of Labor Public Employee Safety and Health Bureau (PESH) staff and supervisors had been with us, on the ground and in the EOC, from the first day. They were worked as hard as we did, and they cared.

But they could not explain, only apologize. OSHA, for instance, had been directed to “pursue collaboration while suspending enforcement…”[xv] Their decision-makers, high up on the federal org chart, wanted to be involved, but they were desperate to avoid any mistake for which they could be blamed. These decision-makers stayed away from the safety briefings, so we tracked them down. One said to me, off the record: “We were told, in no uncertain terms, ‘Don’t go native.’”

For New York City and the WTC Health and Safety Task Force, and especially for the police officers and firefighters and construction workers in and around the World Trade Center site, this was not good enough.

in a bacon, egg and cheese, the cow and chicken are involved, but the pig commits

In every disaster, the ultimate authority is the top elected official, be it the mayor, governor, or president. In the disaster business, this person is affectionately referred to as “the Boss.”

It would be easy to lay the 9/11 worker health failures at the feet of Mayor Giuliani, Governor Pataki, or even President Bush. After all, as the Bosses, they bore the ultimate responsibility. But they too were confused by the mixed signals from their own experts. No one expected them to come to our safety meetings. In a disaster, you can’t expect the Boss to find the problem; you have to bring the problem (and the solution) to the Boss. This is the job of the Great Machine.

The Great Machine connects everything at all levels of the response. First, it connects agencies together in the EOC. Then these same agencies connect down to the boots on the ground and up to the Bosses.

This last part is critical because in the parallel universe, everything that can go wrong will go wrong all at the same time. We need the Bosses to quickly make the decisions that only they can make and to resolve the issues that only they can resolve; otherwise, we cannot act in the moment.

The local government did its job. OEM activated the ICS organization, the Great Machine, for everyone to plug into. But because everybody didn’t plug into it, the failed policy couldn’t get fixed. The WTC Health and Safety Task Force was a team within the Great Machine. All the issues of worker safety bubbled up into the Task Force, and we solved most at that level. But we couldn’t solve the problem of the failed enforcement policy. So, we bubbled it up through the Great Machine to the Bosses. In this case, the mayor could have demanded an explanation from the EPA, the New York State Department of Labor, and OSHA—except that the EPA administrator, state labor commissioner, and secretary of labor were nowhere to be found. They wanted to be involved with the World Trade Center response but would not commit.

bringing chaos to the chaos

Mistakes and blunders are pervasive in the parallel universe. Fortunately, we have an organizing system. ICS is the toolbox that disaster professionals bring into the parallel universe, and the Great Machine is the most important tool in that toolbox.

As a nation, we have not succeeded in bringing our toolbox to bear to minimize the blunders and to bring order to the chaos. The biggest obstacle to this is the federal government itself. Although it preaches[xvi] ICS, it doesn’t follow it in practice.

September 11 is the good example of this. In the aftermath of the attacks in New York, FEMA, New York State, and New York City set up in separate locations. FEMA set up a Joint Field Office in another passenger ship pier south of Pier 92 on the Hudson River. New York State stayed in the State Operations Center 150 miles north in Albany. So instead of one disaster response, we had three. This dysfunctional environment enabled a failed policy that resulted in needless suffering.

This pattern—multiple agencies with different missions working separately with no accountability—is repeated in every disaster zone. Some might say, “That’s not fair; 9/11 was almost twenty years ago. We have made progress since then.”

And to that I would say that, with respect to ICS, nothing has changed.

Those who think we have made progress in our ability to come together as a nation during disasters are mistaken. We know this because we continue to see the same patterns of dysfunction in every disaster. Young staffers new to the EOC are often startled when they encounter it. In addition to setting up in locations far removed from the epicenter of the response, the federal government during catastrophes mirrors the daily workings of the bureaucracy itself, bringing forth an invasion of undisciplined and politicized agencies, headed by powerful secretaries that stride the earth like giants, accountable to no one.

From the local perspective, there seems to be little accountability anywhere. The middle-management layer on the federal org chart has been conditioned to distrust state and local governments with a strong “don’t go native” culture. Therefore, federal agencies don’t plug into anybody’s Great Machine.

The result of this dysfunctional culture is a massive missed opportunity. Our federal government has enormous assets and talent. It has the potential to convene the greatest of Great Machines.

If we go back in time, nearly fifty years, to that disastrous wildfire season in California, we can review the problems that were brought to light: issues like lack of accountability, poor communication, lack of interagency integration, and freelancing. It is these problems, the very ones that prompted FIRESCOPE to develop ICS in the first place, that federal agencies continue to bring into the field and will bring to the next catastrophe in this country. Dozens of high-level federal officials will deploy without authority and they will freelance, bringing chaos to the chaos.

Excerpted from Moment of Truth: The Nature of Catastrophes and How to Prepare for Them

[i] The Faulkner Reader: Selections from the Works of William Faulkner. Modern Library, 1971

[iii] Daryl Osby, Ken Kehmna, Firefighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE), accessed at https://www.firescope.org/index.php

[iv] Amanda Griscom, “Man Behind the Mayor,” New York Magazine, 15 October 2001, accessed at https://nymag.com/nymetro/news/sept11/features/5270/

[v] Brian Michael Jenkins; Frances Edwards-Winslow, Ph.D., CEM, “Saving City Lifelines: Lessons Learned in the 9-11 Terrorist Attacks,” MTI Report 02-06, September 2003, accessed at https://transweb.sjsu.edu/MTIportal/research/publications/documents/Sept11.book.htm

[vi] The CDC’s Strategic National Stockpile is a supply of pharmaceuticals and medical supplies for use in a public health emergency. The Push Package is its first tranche, a fifty-ton cache that can be delivered to anywhere in the US within twelve hours.

[vii] One of the three bulk samples showed a one percent level of asbestos; the other two samples were negative. The lab used phase contrast microscopy (PCM) to analyze the air samples and found that there was a fiber count elevation in the air consistent with asbestos. The fiber count from the air sample was approximately 0.06 fibers per cubic centimeter. This is lower than the permissible exposure limit, or PEL, set by OSHA, which is 0.1 fibers per cubic centimeter. When asbestos reaches a concentration of 0.1 fibers per cubic centimeter, OSHA regulations force employers to remove the asbestos or put people into respirators, whichever is more practical.

[viii] White polyethylene coveralls, the so-called “moon suits.”

[ix] In everyday life, New York City's Department of Citywide Administrative Services (or DCAS) can take months to approve a new purchase, but red tape melts in the parallel universe.

[x] Any criticism of the EPA cannot extend to its people. EPA field staff were all-in on this with us. They worked as hard as we did, maybe harder, and they cared. New York City owes EPA on-scene coordinators, such as Steve Touw, Mike Soletsky and Jim DaLoia, a debt of gratitude.

[xi] The health and safety professionals who went above and beyond the call of duty, working around the clock, on the mission of the WTC Health and Safety Task Force are too numerous to list here. I will name just a few of them: Bob Adams (DDC), Ray Master (Bovis), Bruce Rottner (DDC), Stewart Burkhammer (Bechtel), Dan Hewett, Ken Martinez (CDC/ NIOSH), Gil Gillen, Rich Mendelson, Pat Clark (OSHA), Robert Avaltroni, Michael Gilsenan (NYC DEP), Steve Touw, Michael Soletsky, Andrew Confortini (EPA), Michael Mucci (DSNY), Michael Nardone (FBI), Ralph Pascarella (Operating Engineers), Maureen Cox (PESH), Sylvia Pryce (COSH), Tom Mignone (USPHS), Phil Taylor, Mary Plaskon (Port Authority), Ronald Spadafora, David Prezant MD (FDNY), John Scrivani (NYPD).

[xii] On September 20, 2001, at the city’s request, OSHA assumed full responsibility for respirator distribution, fit-testing, and training at the WTC site. On September 13, 2001, another comprehensive respirator fit-testing program was established by the New York State Department of Labor Division of Safety and Health. The following day, OSHA also began conducting fit-testing and distributing respirators.

[xiii] Especially Ralph Pascarella.

[xiv] Despite the fact that the World Trade Center site was, in the words of OSHA administrator John Henshaw, “the most dangerous workplace in the United States,” in the end there were few serious injuries and no work-related deaths there during the recovery phase.

[xv] United States Department of Labor, Occupational Health and Safety Administration, “A Dangerous Worksite: The World Trade Center,” accessed at https://www.osha.gov/Publications/WTC/dangerous_worksite.htm

[xvi] Robert Neamy, “From Firescope to NIMS” Fire Rescue Magazine, 1 August 2011, accessed at https://www.firerescuemagazine.com/articles/print/volume-6/issue-8/command-and-leadership/from-firescope-to-nims.html

---