Was 9/11 Commission “aggressive enough” in its study?

The Skyscraper Safety Campaign (SSC), a Project of Parents and Families of Firefighters & WTC Victims, is deeply concerned that the National Commission on Terrorist Attacks Upon the United States (The 9/11 Commission) failed to take an aggressive look at what happened to New York City (NYC) and its emergency personnel on 9/11/01.

Although we applaud the Commission for its investigative work on the terrorist attacks of 9/11 and the events leading up to this day, we believe the NYC-specific chapters of this report lack a comprehensive and critical analysis of the failures in emergency planning, coordination of command and control, and the wholesale communications failures of Fire Department of New York (FDNY) radios at the World Trade Center (WTC).

We also are troubled by the Commission’s conclusions regarding the issue of evacuation orders given by radio to the firefighters at the WTC, specifically those firefighters in the North Tower. We do not believe that the statement, “In view of these considerations, we conclude that the technical failure of FDNY radios, while a contributing factor, was not the primary cause of the many firefighter fatalities in the North Tower” (page 323) is accurate. Although the endnote cited for this conclusion (number 209) refers to 100 Commission interviews and the reviews of 500 transcripts, we do not agree that such a conclusion can be drawn.

Since it is impossible to ask these deceased firefighters whether or not they heard an official radio message to evacuate, we feel that it is inappropriate to conclude that they ignored a call for evacuation (for whatever reason) and stayed inside the building.

Numerous media articles and other published reports, including the post-9/11 FDNY McKinsey Report, directly contradict this assertion and reinforce the belief that no evacuation order was heard by the majority of FDNY firefighters in the North Tower. In addition, the overwhelming majority of firefighters and fire officers referred to the Commission through the SSC have stated emphatically that no order to evacuate was ever heard, yet the Commission cites “12 units” who gave such testimony.

Large numbers of relatives of firefighters have been given no information by the City of New York or FDNY regarding the deaths of their family members on 9/11. Consequently, the SSC calls for the full disclosure of the testimony and the identification of witnesses from these “12 units” who testified that evacuation orders were given, heard by all, and yet firefighters inexplicably decided to stay and die. This seems more like a replay of former NYC administration testimony statements of fact. Fire department families need to learn what happened to their loved ones. The Commission seems to have such information, and this must be made public.

New information provided in the book Radio Silence FDNY: The Betrayal of New York’s Bravest (www.RadioSilenceFDNY. com) provides further detailed accounts that say no evacuation orders were heard by the majority of firefighters in the North Tower on 9/11.

Regarding Commission recommendations, only a handful deal with the issues specifically concerning New York City’s preparedness and response protocols for future terrorist attacks in light of what transpired at the WTC in 1993 and 2001. The endnotes of Chapter Nine of the Commission’s report are quite detailed, but the recommendations themselves, in Chapter 12, are too broad in language and too few in number. We would have hoped for a more detailed, critical look at the city’s current emergency response readiness and the many specific recommendations that could have been made.

It is the opinion of the SSC that upcoming congressional hearings should examine seemingly contradictory evidence and questionable conclusions regarding the emergency response and FDNY radios on 9/11. Historical accuracy, public safety, and the deaths of hundreds of firefighters deserve nothing less than this.
Sally Regenhard
Chair

Monica Gabrielle
Co-Chair

Professor Glenn Corbett
Chief Technical Advisor

The Skyscraper Safety Campaign

Air management

I have 20 years of firefighting experience. I serve on the National Fire Protection Association’s (NFPA) committee for SCBAs. I have to say that David Bern-zweig’s article “Expanding Time to Exit for Firefighters” (July 2004) is right on. His ability to cover all the issues everyone on the NFPA committee is talking about was a breath of fresh air.
Brian H. Cox
Engineer
Clovis (CA) Fire Department


Although well written, I feel the article did not fully address the real issue when discussing SCBA air management and exit time. The key issue is not that air needs vary according to occupancy but that they vary based on the individual’s personal consumption.

Every firefighter must know his own air usage, which is dependent on many variables, such as physical fitness, tasks being performed, age, and experience. The air remaining in the cylinder or the threshold of the warning device does not determine the amount of time the firefighter has to exit. The individual firefighter should determine his personal air consumption rate while training. Bleeding the cylinder down to the low-air warning device threshold and then performing various arduous tasks while under stress would give the wearer some indication of his limited exit time. Our experience has shown the actual work and exit times are well below the 30- or 45-minute cylinder ratings. All firefighters should be aware that exit times of six and nine minutes, respectively, are unrealistic and unsafe.

Also, the recent addition of a heads-up display on the SCBA facepiece should indicate the time remaining for the wearer based on consumption rate, not the amount of air remaining in the cylinder. We know this technology is available and should be researched by NIOSH.
Nick Santangelo
Chief
Fire Department of New York
Fire Academy


We appreciate the article by David Bernzweig. We believe that any discussion that raises the awareness of air-management issues within the American fire service is a positive contribution. The author is to be commended for his extensive research into the rate of firefighter fatalities and the correlation to firefighters’ running out of air. These statistics drive home the positive message that air management is a critical skill for today’s firefighter and company officer.

Although we agree that air management is a serious consideration, we disagree with some of the assertions made in the article. The author cites the need for situational awareness, saying, “It is easy to see how situational awareness is so easily applicable to our job.” He then correlates this to air management, saying, “Air management is closely related to situational awareness.” However, later in the article, he asserts that the Rule of Air Management and our training techniques (outlined in our April 2003 Fire Engineering article) are “buzzword solutions that work well in the chief’s conference room or at some NFPA meeting, but they are just concepts.” Air management is not “just a concept” in the Seattle Fire Department. In fact, our line firefighters and officers have been training in air management for more than three years. We have had excellent results implementing the Rule of Air Management from the ground up in our department. Other fire departments in our area have been exposed to our air management training and are seriously considering adopting air-management policies. Finally, the Phoenix (AZ) Fire Department, one of the most progressive and forward-thinking fire departments in the United States, has implemented the tenets of the Rule of Air Management as a standardized practice.

Air management is an individual responsibility. Reliance on technology to solve this problem has already proved to be ineffective. In his article, Bernzweig recommends that a staff officer be assigned to air-management duties outside the hazard area. Although current technological advances may make this technically possible, the realities of today’s ever-shrinking staffing levels, as well as the practical application of his suggested technique, make it an unworkable solution. Also, Editor Bill Manning in his July 2004 issue editorial outlines the decrease in fire department staffing taking place nationwide. What fire department has an additional chief officer to expend on tracking the air use of firefighters on the fireground?

In addition, how can air management be accomplished outside the hazard area? Even if you knew each firefighter’s current air level, you would have to know the following to make an informed decision about the air status: distance from the opening, obstacles, work rate, environment, individual firefighter’s fitness levels, stress, assigned objectives, and a host of other variables that affect the individual’s air use. We would argue that air management couldn’t be accomplished by looking at a computer screen with the readouts of 15 to 40 firefighters operating in the hazard area.

The alternative is to implement the Rule of Air Management and its training components. Each firefighter and company officer is responsible for their air supply and the air supply of their team. Each team must exit the hazard area before the low-pressure bell rings. This will allow for an acceptable margin of error should there be a delay in getting out of the structure.

This training we are advocating is not just a suggestion. It is mandated by numbers 4 and 5 of NFPA 1404, Standard for Fire Service Respiratory Protection Training—2002 edition (plus appendices).

NFPA 1404 (5.1.7 plus appendices) states, “Training policies shall include, but shall not be limited to, the following:

(1) Identification of the various types of respiratory protection equipment.

(2) Responsibilities of members to obtain and maintain proper facepiece fit.

(3) Responsibilities of members for proper cleaning and maintenance.

(4) *Identification of the factors that affect the duration of the air supply.

(5) *Determination of the Point of No Return for each member.

(6) Responsibilities of members for using respiratory protection equipment in a hazardous atmosphere.

(7) Limitations of respiratory protection devices.”

One additional benefit of having your department operate under the Rule of Air Management is that the low-pressure warning bell is removed from the fireground except in case of an emergency. Think about how much more quickly we could respond to a firefighter in trouble if we did not have to wait until one called a Mayday or ended up unaccounted for at a roll call. There are just too many examples of dead firefighters who waited to make the call for help while their fellow firefighters were within earshot and action distance of them when their low-pressure bell began to ring.

The author’s stance that an increase in warning bell time will help solve the problem is counterintuitive to increasing firefighter safety. He then outlines that we have a false alarm problem on the fireground, stating, “The fire service has grown accustomed to the false alarm. Whether from the residential high-rise at 2 a.m. or our always-sounding PASS devices, the fire service has learned that these alarms are seldom warnings of ‘the real thing.’ ” Yet having more bells go off on the fireground—false alarms—is exactly what Bernzweig is advocating when he makes the case for increasing the warning bell time.

When speaking of the low-pressure warning bell, Bernzweig recognizes that “alarm misuse and abuse should be dealt with as a training and command issue at the local level” and that “all alarms sounding without crews’ exiting should be investigated.” Perhaps the author could train us in how to recognize the difference in the sound of the low-air warning bell of the firefighter in trouble vs. the firefighter exiting the building?

In one of our case studies, numerous crews working in a ship fire ignored the ringing bell of a Seattle firefighter. They assumed he was exiting the ship. These crews did not demonstrate enough situational awareness to recognize that this firefighter needed immediate help. The firefighter ended up out of air deep inside a smoke-filled environment. He pulled off his mask and, fortunately, was seen by a heads-up crew, who assisted him out of the ship. He is lucky to be alive today.

For us, one thing is certain: Firefighters don’t need a longer low-air warning bell time. Instead, let’s remove the low-air warning bells from the fireground. Have every firefighter out of the hazardous atmosphere before the low-air warning bell begins to ring. If there are no low-air warning bells on the fireground, then it becomes crystal clear when someone’s air supply is low—his bell begins to ring. No more guessing is needed. No false alarms. No dead firefighters.

The author notes recent studies conducted on the effectiveness of rapid intervention teams, citing articles published in Fire Engineering. To our knowledge, no firefighter has ever been removed, alive, by a RIT. The author states, “The reflex time associated with rapid intervention puts a downed firefighter at great risk of exhausting his air supply before the RIT arrives.”

History is an excellent teacher should we choose to heed the lesson. We need a better way. RITs are mandated, necessary, and absolutely indispensable on the fireground. We support their implementation, their use, and the training necessary to make them effective. We just look at the deployment of this resource from another angle. Imagine if, as soon as a low-pressure bell begins to sound, the firefighters in the immediate vicinity of that alarm bell take action. They move to the source of the bell, begin the activation of the RIT, locate the firefighter, and begin triaging the situation. The RIT activities become primarily support and extrication instead of locating and providing air. This means that for the firefighter in trouble, the rapid intervention comes from firefighters already inside the hazard area and that the RIT will come from outside to help. The situation will be resolved more quickly with fewer resources and less impact on the firefight.

We again commend Bernzweig for his contribution to the discussion of firefighter safety and air management. His well-researched article recognizes a problem and offers a solution that can be acted on. We disagree with his proposed solution and believe that an effective air management policy supported by training and implemented throughout an organization will solve the “time to exit” dilemma.
Phillip Jose
Captain
Steve Bernocco
Lieutenant
Casey Phillips
Captain
Mike Gagliano
Lieutenant
Seattle (WA) Fire Department


David Bernzweig responds: I do not believe that our solutions to this problem are that different. We both recognize that the flaw with the current required low-air alarm setting is that it may not warn users early enough, and we both advocate a solution to better manage the air we carry. The difference is that we represent two schools of thought. The writers believe that the key to effective air management is for firefighters to monitor their air supply and plan to exit the hazard zone before the low-air alarm begins to sound, thereby having a variable and subjective work period and exit time. I believe that the low-air alarm should be adjusted upward so that our work period is based on what is reasonable with regard to work and thermal stresses, depth of entry, and acceptable structural degradation; the remaining air is allocated for exit based on a reasonable exit time and a margin of error that gives firefighters a better chance of exit or rescue should everything not go just right. The difference here is that the work period is fixed based on what is acceptable and that neither period (work or exit) is as prone to human error.

The writers state that air management is an individual responsibility and that reliance on technological solutions has proved ineffective. I am curious as to why they believe that technological solutions have been proven ineffective in resolving this problem. Just what solutions have been proven ineffective? To the contrary, a multitude of firefighter injuries and fatalities have resulted from humans’ misjudging their environment or relying on the antiquated low-air alarm setting. The low-air alarm is arguably the most effective alarm with which the fire service deals; the only problem is that it is set too late. How is human management more effective and less error prone than a failsafe mechanical solution (the NFPA and NIOSH require at least two separately triggered and independent alarms)? Air management should be less prone to variation and should be based on realistic needs for uncommon situations.

The writers say assigning a staff officer to air-management duties is an unworkable solution because of staffing realities on the fireground. This is all the more reason to provide overtaxed firefighters operating in the hazard zone with an automatic reminder that it is time to exit. Furthermore, to argue that a solution is unworkable because of poor staffing is an unacceptable reason to dismiss it when the stakes are so high. The same was said about assigning RIC companies to the fireground, but we are willing to accept this as a real need for our safety.

Regarding how air management can be accomplished outside the hazard zone, the writers say a staff officer on the outside cannot possibly know the air needs inside because of a multitude of unknowns. This is true for both the staff officer on the outside and the firefighter on the inside. That is why most fire departments operate under some form of the incident command system and why the incident commander (IC) is located on the outside. Simply put, although there is important information that the IC needs from interior crews, the IC rarely bases decisions on this one-dimensional view. Often, information from the inside paints a very different picture from the view from the outside. Decisions are based on all incoming information, not just one perspective. There is no way to manage air effectively using the Rule of Air Management or situational awareness as a sole solution, since it is almost impossible to know the multitude of hazards hidden in a building (i.e., Seattle’s Mary Pang fire).

With regard to firefighters’ failing to alert those around them or the IC’s not knowing there is a problem until it is too late to effectively respond, the problem is that these firefighters never received proper training on when to call a Mayday. The problem is not that others operating in the vicinity failed to recognize their problem; it is that they failed to recognize it for themselves! The solution is to do a better job preparing firefighters for this potentiality. This is being done in most RIC programs today. The air-management solution does little to deal with these firefighters.

As for an earlier set point for the low-air alarm’s being “counterintuitive” to increasing firefighter safety, how so? As the writers’ case studies show, the low-air alarm as the primary exit indicator has been successfully indoctrinated into the firefighter psyche. If firefighters continue their current practice of exiting the hazard zone when the low-air alarm sounds (as I advocate), we have increased their safety. The only firefighters who need to respond to a low-air alarm are the firefighter whose alarm is going off and his crew. If a firefighter needs help, the PASS device and radio are the tools of choice.

The suggestion that firefighters respond to the sound of a low-air alarm before a Mayday is called simply because it is going off is troublesome. This would be redirecting resources from the task/tactical level (from inside the hazard zone) to respond to a low-air alarm. Isn’t this a bit excessive? Does Seattle really react in that way? Do Seattle firefighters respond to a low-air alarm as if a firefighter were in distress? Is the RIC automatically activated? Is there a call for an additional alarm? Are crews really expected to immediately abandon their assignment at the sound of a low-air alarm and move to the source? I assume Seattle operates under the incident command system. If so, wouldn’t this be freelancing? The fire service has been preaching mission discipline; this would be a clear and dangerous contradiction of that principle.

I commend the writers’ desire to eliminate all nonemergency alarms inside the hazard zone, but I disagree with much of their reasoning. Their recommendations are based on what they characterize as confusion created by a low-air alarm. The low-air alarm is more than just a personal alarm for the firefighter’s breathing air. It alerts others in the area that firefighters will be exiting (if the sound is not traveling away from them, they should ensure that everything is alright and act accordingly); it serves as a benchmark for the IC; and, most importantly, it alerts a company officer or other crew members that it is time to go, without the risks associated with human monitoring while doing heavy work. Simply put, the low-air alarm is not a crisis alarm; using it as such is subject to serious flaw.

Recognizing the difference in the sound of the low-air warning bell of the firefighter in trouble and the firefighter exiting the building, as I see it, is not difficult. The firefighter in trouble activates his PASS device or calls a Mayday to indicate he is in trouble.

As I mention in the article, air management is a necessary component for dealing with the exit-time problem. We must always maintain good situational awareness and air-management skills, but these tools are limited in their scope. They work well when operations are not complicated by unfortunate events (lost, trapped, disoriented firefighters, for example), but when things start going bad, we need a margin of error. The writers’ solution is to build the margin of error into the bottle through the use of human monitoring of the pressure gauge; I believe mechanical monitoring is a safer bet.

If one should choose to practice the ROAM solution, where is the margin of error if the interior crews misjudge their exit time? What if they fail to monitor appropriately because they are short staffed and engaged in heavy work? The answer is that they cut into their reserves.

If this solution works in Seattle, that is wonderful. But keep in mind that the writers are assuming that firefighters are dying solely because of poor air management, and this is just not the case. Firefighters are not dying because they are getting close to an exit and running out of air. In most cases, these firefighters are first becoming lost, trapped, or disoriented. No amount of air management is going to prevent this from happening; we work in a very hazardous environment. More air, allocated as a reserve, will give these firefighters a better chance of getting out with or without assistance. The issue here is not air management but air reserves.

The Rule of Air Management does not solve the exit-time problem; it merely offers part of a solution that is prone to human error (as the writers’ experience concludes).1 Furthermore, these solutions do not account for the unexpected or extraordinary events that tend to kill firefighters. Building the margin for error into the exit volume offers the most complete solution to this problem.

1. “Train in ‘The Rule of Air Management’ “, Fire Engineering, April 2003, 57.

Why not better restraining systems for fire apparatus?

Why is it that when I respond in my apparatus, I have the same seat belt as in my Jeep Cherokee? I’m in the truck loaded down with all kinds of equipment that has belt and self-fastening strips, and I have to turn around to grab an alarm bag or a thermal imaging camera and get stuck. When I get to the scene, I can’t find the buckle to unhook myself. Why can they build safe restraining systems for NASCAR and not us? I think it’s time to think outside the box and develop a restraining system that could act like the restraints on a roller coaster while we can move a bit with all that gear on. We would appreciate manufacturers’ paying attention to this issue when designing apparatus cabs.
Richard Lockhart
Battalion Chief
Norristown (PA) Fire Department

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