One Year Later: Lessons from the Boston Marathon Bombings

BY JAY FLEMING

Patriots’ Day is a great day of celebration in Boston, a day when businesses and schools are closed and families take in the New England sunshine, a traditional late morning Red Sox game, and then the celebrations that surround the 26.2-mile Boston Marathon. For more than a century, Patriots’ Day has commemorated the opening battles of the Revolutionary War on nearby Lexington Green. So it was on April 15, 2013, a spring day in New England when weekend-long festivities were culminating in the 117th running of the Boston Marathon, one of the world’s premier foot races. But from this day forward, it will also be a day of remembrance for the victims and survivors of the two bombings that shattered that peaceful day and brought the region to a standstill for four days.

Through a combination of extensive planning, preparation, and meritorious service by responders, every single person who could have been saved lived, a remarkable effort of the Boston Fire Department (BFD); Boston Emergency Medical Services (BEMS); Boston Police Department (BPD); numerous volunteer medical staff members supporting the Marathon; the nurses, physicians, and surgical staff in many Boston area hospitals; and countless volunteers who risked their lives to help out in any way they could.

(1) Firefighters respond with first-aid equipment. (Photos courtesy of Jay Connor and the Boston Athletic Association unless otherwise noted.)

The BFD looks back one year later at the many lessons learned or reinforced during those bombings. Those lessons include maintaining an aggressive deployment profile for the special event; having a thorough and detailed plan for the Marathon; conducting detailed briefings based on up-to-date threat intelligence and the hazard profile for the response area; providing adequate equipment to deployed personnel; ensuring command and communications support for incidents; reemphasizing the importance of interagency operations; using critical incident stress debriefing (CISD); and recognizing the calculated risks taken by firefighters who rushed in despite the dangers of possible secondary devices and played their part in saving lives that day.

MARATHON PLAN

The BFD Marathon Plan is the product of the department’s Office of Field Services (OFS). Led by District Chief Paul Burke, OFS staff developed the plan in coordination with operations personnel and the BFD Fire Alarm Office, which is responsible for dispatching the BFD to more than 73,000 emergency runs per year and maintaining the fire department’s communications systems. The BFD Marathon Plan has evolved with the experience of each Marathon. As race conditions dictate changes, so does the BFD Plan. Most notably, this occurred after the 2012 Marathon. During the 2012 race, more than 3,000 Marathon runners were overcome with heat-related injuries after crossing the finish line. As a result, the Boston Athletic Association’s (BAA) Medical 2013 deployment plan was updated to include additional medical resources. The BFD plan is a component of a citywide plan created in consultation with and with input from each city agency, in particular BEMS and the BPD.

The BFD plan included 267 on-duty personnel as part of the department’s daily staffing, supplemented by 57 personnel on a special detail to cover the Marathon area near the finish line. Those personnel included a lieutenant to coordinate with BEMS and a command staff including two deputy fire chiefs and four district fire chiefs reporting to them. One deputy chief was assigned to the BFD’s Mobile Field Command Unit and served as the Marathon operations chief for the Marathon finish line event area. The second deputy chief served as a liaison to the BPD’s Unified Coordination Center, a multiagency coordination center, located at BPD Headquarters, with representatives from various agencies involved in protecting the Marathon.

The four district fire chiefs commanded either functional groups or geographic areas. Marathon Division supervisors were assigned to cover the North and South Divisions (covering the areas on each side of the final few blocks), the Kenmore Division (covering Kenmore Square and using a Rapid Response Group for investigating alarm activations and controlling BFD responses near the event), and the Hazmat Group. The Hazmat Group consisted of a prestaged decontamination engine company with seven personnel and a multiagency Special Emergency Response Team (SERT) of six personnel from BFD, BPD, and the Massachusetts National Guard Civil Support Team (CST).

Figure 1. Table of Organization for BFD Marathon Operations

Additional personnel included supplemental staff for communications; liaison staff to other coordination centers; and planning, finance, and logistics sections. Since the Marathon crowds would cause significant response delays in the finish line area, five officers and 20 firefighters were assigned as an Incident Response Strike Team (IRST). Their main purpose was to patrol the area and respond to miscellaneous hazards, limited medical calls, fire alarm activations, and potential fire incidents. IRST members were equipped with bunker coats, station work uniforms, a self-contained breathing apparatus face mask with an air-purification respiration canister, a portable radio, a BFD reflective vest, street area maps, and a medical bag.

To provide a unified approach to the Marathon, the BFD employed a detailed incident action plan (IAP) with two overarching goals: first, “to provide to the members of the BFD operational guidelines for the effective management and coordination with all public safety agencies that may be involved in a response to any event that may occur during the 117th Boston Marathon”; and second, to “provide for the safety of the citizens who live in the city, employees who work in the city, race participants, spectators, and first responders.” The IAP included command structure, assignments, racecourse response protocols for apparatus, communications procedures, Copley Square fire alarm investigation and communications procedures, hazmat response procedures, and (notably) duties in the event of an explosion.

Figure 2. Finish Line Area Indicating Key Items/Locations

The IAP went further in detailing a specific set of strategic objectives for on-duty personnel:

• Ensure the maximum protection for and mitigation of a potential weapon of mass destruction/chemical, biological, radiation, nuclear, explosive incident at the Boston Marathon.
• Provide for active environmental monitoring and prestaged decontamination assets in close proximity to the finish line.
• Maintain response time of emergency vehicles and personnel into the event-affected areas.
• Maintain racecourse integrity and control of the event.
• Monitor the multijurisdictional course progress to ensure situational awareness of any event that may cause disruption to race participants.
• Establish protocols for responding apparatus.
• Stage sufficient apparatus on each side of the race for response to a full-alarm assignment without crossing the racecourse.
• Develop a mutual-aid response plan with adjacent jurisdictions.

(2) The “Chute” area near the finish line. Note the barriers along the sidewalk.

THE BOMBING

The day was going according to plan, which meant a 3-2 Red Sox victory in the bottom of the 9th inning over the visiting Tampa Bay Rays at historic Fenway Park, followed by a smooth beginning to the Marathon. The race started at 9 a.m. The wheelchair, hand cycle, and elite men’s and women’s racers had crossed the finish line by noon, and the remaining runners continued, turning onto Boylston Street just next to the historic firehouse of BFD Engine 33 and Ladder 15, and then down another 3½ blocks to the traditional finish line between Exeter and Dartmouth Streets. These final blocks are a straight line through a typical downtown street. Thousands of spectators lined the sidewalks, cheering the runners through the final push to the finish. To prevent the crowds from surging forward and interfering with the racers, metal bike racks were lined along the route.

(3) The Copley Square Medical Area. Public Safety command vehicles were located here.

Near the finish line, a double fence with snow fencing served as a barrier, keeping the crowds to the sidewalk and leaving the runners to funnel through a narrow chute a few yards away from the finish line and VIP stands. Immediately after the finish line, a large public safety compound was established in Copley Square, where the BFD Mobile Field Command Unit and other public safety command vehicles were located; also located in this compound was a large medical treatment tent staffed by BEMS, BAA, doctors and nurses and numerous volunteers from area medical centers, and additional support for the runners.

At 2:49 p.m., the first explosion occurred in front of 673 Boylston Street. Spectators, responders, medical staff, and fellow racers overcame initial shock and began to triage and treat the severely injured. The second explosion went off 13 seconds later about 600 feet west of the first explosion, again on Boylston Street.

(4) The finish line before the blast.

At 2:49, BFD radios cracked with the first report: “We have an explosion down on Boylston Street. We have an explosion. Strike the Box for 671 Boylston Street-multiple people down.” Fire Alarm transmitted box 1572.

Lieutenant Douglas Menard, the closest BFD member to the first bomb site at the time of the bombing, recounted the following: “The blast pressure was enough to feel like it kicked out the back of my knees. I turned immediately and saw a rush of wounded coming toward me through the smoke. I seemed to be the closest person who did not have a scratch on him. Just then, a second explosion occurred. I went through the wounded and did a quick triage while getting on the radio and reporting that there were multiple wounded, secondary devices, watch out.”

Because the first bomb site was near the finish line, many of the medical staff responding from the medical tent stopped at the first bomb site without even realizing that there was a second bomb site 600 feet away. Fortunately, this second bomb site was the location to which the BFD EMS Liaison Lieutenant Edward Lorenz responded. Initially, Lorenz and the other members of the BFD who had been prepositioned nearby responded within a minute or two. The site was also within a couple of hundred feet of four fire companies: Engine (E) 7 and Ladder (L) 17 were two blocks away at another incident, and E-33 and L-15 responded from their firehouse on Boylston Street and arrived within three minutes. Following Lorenz’s leadership, the BFD members at this site, working with some BEMS staff and numerous volunteers, were able to triage the victims at this site and treat and transport quickly. At the second blast site, because of a delay in getting ambulances to this location, two victims were transported to the Massachusetts General Hospital by a BPD vehicle with Boston firefighters holding tourniquets. (Both victims survived.)

(5) Boylston Street moments after the blast. (Photo courtesy of Al Ghilardi and the Boston Athletic Association.)

Firefighters assigned to the IRST ran to each site from their positions around the race area, providing cravats as tourniquets and bandages to stop bleeding. The BFD estimates that within three minutes, more than 30 firefighters were on scene treating victims. Within 10 minutes, an additional 30 firefighters arrived.

Near the first site, Deputy Chief Robert Dunderdale shifted his position at the Field Command Unit to site number one and began directing emergency operations. As Box 1572 was struck, Dunderdale provided a report to the BFD Fire Alarm, which provided immediate situational awareness to responding companies, “Marathon Operations, multiple explosions, mass casualty, damage to building, no fire. Have companies come in with medical and first-aid equipment.” Moments later, Dunderdale notified all members to be aware of the potential for secondary explosions and treat the area as a crime scene.

Figure 3. 2013 Boston Marathon Finish Line Area

In addition to the activities on Boylston Street, just seven minutes into the incident, companies were dispatched to the John F. Kennedy (JFK) Presidential Library, a federal facility, for a building fire. Members were told that this might be a second bombing. Companies responding to the JFK Library reported heavy fire showing. At the time it happened, this appeared to the members involved to be a possible game changer. In the back of everyone’s mind, an additional terrorist attack had occurred. Emergency responders on Boylston Street assumed that another bomb was likely on Boylston Street. Firefighters at the JFK Library assumed that a second device was waiting for them as they evacuated occupants. In both cases, the incident commanders knew that lives would be lost if time was spent looking for secondary devices before treating victims. Although aware of the potential danger, firefighters were committed to rescue operations at both sites. It was eventually determined that this second explosion/fire was not terrorist related but a complete coincidence.

Deputy Chief Stephen Dunbar, Division 1, arrived on scene approximately 10 minutes after the bombing. He assumed command in accordance with the IAP. Simultaneous with the treatment of victims, other Boston firefighters started to set up decontamination areas in case decontamination was needed. In addition, members working on the SERT, consisting of hazmat personnel from the fire department and CST personnel from the National Guard, immediately conducted a hazmat assessment, ruling out the presence of chemical or radiological contamination in the explosion.

After patients were transported by BEMS, private ambulance, and several police vehicles, attention turned to other hazards. Concern over secondary devices was constant from the beginning. The number of athletic bags left near the bomb sites led to emergency responders receiving potential secondary device reports every few seconds.

Fortunately, Burke, who authored the IAP, also responded to the scene from his assignment on the BFD Command Unit and connected with his counterparts on the BPD and BEMS to ensure a coordinated response. BFD members were repeatedly informed by radio to be alert for secondary devices and to be aware that this was a crime scene. The BPD waited until all victims were removed before taping off the area. It then coordinated access to the building with the BFD.

(6) The first bomb site.

Limited primary searches were conducted in the buildings near the bombing site as the police began to cordon off the area and declare it a crime scene. Additional arriving BFD units assisted in the evacuation of people from buildings along the blast site. Occupants were unable to leave their buildings and had to be sheltered in place. Many were evacuated from rear fire balconies and led to safety through public alleys and away from the front of the buildings. The building damage appeared moderate. Because of limited ability to cross the crime scene and conduct closer structural examinations, building integrity was determined by a visual assessment. Interior hazards included damaged building services. Overhead hazards included glass shards from broken plate-glass windows dropping to the street. Accordingly, sidewalks within blast zones were also considered within collapse zones.

As soon as the last patients were transported, the BFD began a personnel accountability report (PAR) for Marathon staff, quickly verifying the safety and location of all BFD personnel.

Approximately one hour into the incident, BFD Chief of Operations John F. Hasson assumed command, Dunbar took over the Operations section, and Dunderdale became the first BFD representative at an ad-hoc interagency emergency operations center (EOC) that had been set up in the nearby Westin hotel. Hasson, now serving as acting commissioner, continued the close coordination with the BPD and began to demobilize the BFD response while continuing to maintain a presence in the area. Dozens of more potential “secondary devices” would be discovered for several hours; each required a coordinated response of the BFD and BPD.

(7) Note that the barriers have been torn down.

Each scene had dozens of traumatically injured patients. At the site of the first bombing, approximately 60 feet from the finish line, one victim had died. Two more had died at the second bombing scene. More than 177 victims were treated at 10 area hospitals; 23 were critically injured. Of the 23 critically injured, 17 suffered single amputations and two suffered double amputations. Others victims bled from penetrating wounds or were injured by the pressure wave from the blast. In total, more than 285 victims received medical treatment as a result of the explosions.

The Federal Bureau of Investigation (FBI) later determined that the bombs were homemade devices consisting of pressure cookers, explosives, and projectiles.

POST-INCIDENT AND MANHUNT PHASE

As the situation shifted from a lifesaving response to a law enforcement investigation, three engine companies remained on the scene to assist law enforcement and stand by for other hazards.

Over the next few days, BFD personnel began to assist law enforcement and the FBI with clearing out window sashes and collecting evidence using fire department ladders.

For the week following the bombings, Dennis Keeley, the District 4 chief who responded to the Marathon, acted as the initial BFD liaison with the FBI/BPD and, supported by field companies, assisted law enforcement agencies conducting evidence recovery operations. Investigators scrubbed building facades for bomb fragments from the safety of tower ladder baskets. BFD’s liaison support group helped investigators recover hundreds of pieces of evidence while keeping everyone safe.

Because of the nature and size of the BFD incident, critical incident stress management (CISM) teams were activated. BFD CISM teams conducted initial debriefings; regional teams were called in to assist with later debriefings. Over many years, the fire service had developed a fire service CISM program. Members of this group were called in and met with the BFD staff. It was the first of many meetings to help with the mental welfare of BFD members.

The next days were occupied with the law enforcement manhunt that captivated the nation. The BFD placed additional staff on engine and ladder companies, increasing staffing from four to five personnel on engines and from five to six on ladder companies. During the course of the manhunt, the BFD responded to calls for suspicious packages. The citizens of Boston were on a heightened alert because of the ongoing events and abandoned bags that would have been ignored just a few days ago, which now were viewed as potential bombs. Note: The vast majority of the suspicious package calls were on the 15th.

LESSONS LEARNED AND REINFORCED

Even though the bombings claimed three lives (and later a fourth as a Massachusetts Institute of Technology police officer was killed by the bombers during their attempted escape from Boston), it couldn’t permanently scar the resilience of the Bostonians. The Red Sox would go on to win the World Series. The victims of the Marathon Bombing would inspire everyone with their courage and resilience as they struggled to recover. The BFD began another year-long planning cycle for the 2014 Marathon, a planning cycle that would employ additional changes based on the lessons learned that day. Among those key lessons learned or reinforced are the following.

• Special events require an aggressive deployment posture. The BFD deployment posture included the staff from Operations, Field Support, and Fire Alarm. The BFD assigned chiefs to oversee the Marathon area and to serve as liaisons with other emergency services organizations. Firefighters were specially assigned to serve on the IRST to investigate fire alarm activations, go on medical calls, and patrol for hazards. The Special Operations Division’s hazmat decon unit was prestaged at a strategic location near the finish line. If your community holds a special event, consider taking an aggressive and proactive deployment profile so that your resources will be in the right place should something bad happen. In this case, the aggressive deployment of Boston’s emergency resources helped minimize the death toll.
• A detailed planning process involving stakeholders is imperative. The BFD Marathon IAP was the result of a process of a year-long series of planning meetings involving many stakeholders. The BFD process brought in subject matter experts to ensure the department was ready for the various threats and hazards that might present themselves, including a bombing or mass-casualty incident. The process resulted in a model IAP that detailed the roles and responsibilities and communications plan for all personnel. Conduct a preincident planning process that results in a thorough IAP for all special events in your community.
• Conduct serious briefings based on up-to-date intelligence and the hazards in the area. The BFD conducted serious and detailed briefings for all personnel at the Marathon site. It wasn’t treated as just an “easy overtime” assignment. The BFD briefing included the latest law enforcement intelligence and a focus on the known hazards in the area. Although there was no specific threat to the Marathon in 2013, the use of intelligence information set the right tone for personnel during the assignment. The BFD’s preincident briefing included a review of improvised explosive devices. Take briefings and intelligence reports seriously, and convey that information to personnel on the line.
• Provide equipment for everyone. BFD personnel on the detail were all provided equipment that included a BFD identification vest, a department radio, and basic medical gear. The vests were used for the first time at this Marathon, and although they were received with some skepticism, as soon as the bombings occurred, their utility became evident. BFD on-duty staff members assigned to the Marathon detail were easily identified and able to make their presence known without having to fumble for identification or stop to retrieve bunker gear. All personnel were provided with basic EMS equipment, which they could use in the chaotic environment just after the explosions. One lesson the BFD has learned is to supply tourniquet kits as well as traditional cravats to all personnel. Coincidentally, all BFD staff had received in-service training on the use of tourniquets in the months prior to the Marathon. During special events, provide the correct type and amount of medical equipment and training for the type of expected potential hazard.
• Commanders need command capacity to operate during special events, just as on the fireground. The BFD, BPD, and BEMS radio channels were quickly overwhelmed with radio reports during the first minutes of the attack. Maintaining effective radio discipline is imperative when these incidents happen. Although the radio system technology could handle the transmissions, numerous reports crowded the radio space.
  The BFD IAP used three separate channels for this event. Even with separate operational channels, BFD commanders found it difficult to transmit instructions to other commanders and command posts. The BFD recognizes that as an actionable item and would implement a separate command and control for the 2014 Boston Marathon. In addition, each command position would be assigned an incident command technician to assist with communications. Additional Fire Alarm staff would be assigned to the Field Communications Unit. Ensure your command teams at special events have the staff assigned to handle a working incident.
• Interagency relationships are as important as ever. Good interagency relations help to drive effective interoperability. Understanding cooperating agencies’ missions, procedures, and information needs required to successfully deliver its services and keep its people safe is vital. When agencies communicate effectively and exercise municipalitywide protocols, multiagency response becomes less fragmented and more cohesive. Agencies knowing cooperating agencies’ priorities, strategies, and tactics can adapt their own procedures to foster mutual success. The BFD enjoys a close working relationship with all the other partners who were involved in the planning for the 2013 Marathon. More importantly, interagency relationships help build trust and respect; this relationship will help you get your plan back on track when something goes terribly wrong.
  Although Boston has used a Unified Command Center for coordination, it can’t substitute for a unified command post at an incident site or for the exchange of liaisons among agencies. Although it is common for chiefs to have aides (incident command technicians) on the fireground, it seems less common in other public safety agencies. This is probably because excessive radio traffic, accountability, and span of control are less prominent issues. However, if all agencies provided “incident command technicians” to their senior officers, then these senior officers could all operate on a command channel while their incident command technician monitored that agency’s operational channel. In that manner, these senior officials could monitor their own agencies’ activities while simultaneously communicating with senior officials from other agencies.
• CISD is an important part of fire service readiness. BFD personnel received access to CISD after the incident. CISD is an accepted tool in the fire service. Each department must explore its own ability to provide for the mental health and welfare of its members and their families. Make sure you have plans for the mental health and welfare of your personnel and their families. If your department is too small to have an adequate program, make prior arrangements with a nearby larger community. The BFD CISD team has responded all over New England when needed.

BFD personnel detailed to the 2013 Boston Marathon were not only first responders but also targets and victims of the terrorists’ attacks. Fortunately, no BFD members were killed or severely injured. Yet, even as potential victims of a secondary device, BFD personnel did what they were trained to do and what they planned to do in the event of such an attack. Their efforts and the efforts of BFD units responding to Box 1572, along with their fellow first responders from the BPD, BEMS, National Guard, other agencies, and volunteers, saved lives. The most seriously injured victims of the attacks were attended to at the scene, removed to waiting ambulances, and transported to trauma centers across the city within 20 minutes.

What is memorable about the role the BFD played at the 2013 Marathon is that its actions were by design. The BFD’s accomplishments that day were the outcome of years of planning and training; proactive senior leadership; fielding the right numbers of personnel and equipping them with medical bags, radios, a communications plan, and clearly written procedures for each position; staging the right numbers of capabilities; accurately interpreting up-to-date threat intelligence and preparing its people to face the threats; and synthesizing all of its preparedness measures into effective action.

Even a well-developed plan, proper training, and sufficient resources are not always enough to stop a tragedy; however, those components will allow you to respond in a manner that will reduce the loss of life.

Boston Strong arose on April 15, 2013, just as the BFD had planned.

Note: Many members of the BFD contributed to this article, particularly those who responded that day. At the time this article was prepared, the BFD was awaiting the completion of the BFD Marathon After-Action Report, which will be posted on the BFD Web site, http://www.cityofboston.gov/fire/.

The Boston newspapers, the Boston Globe and Boston Herald, have created special Web sites for the Marathon bombing. They contain additional images and stories. Their links follow:

• https://www.bostonglobe.com/metro/specials/boston-marathon-explosions.
• http://bostonherald.com/topic/boston_marathon_ bombing.

Boston Fire Department Profile

The Boston Fire Department (BFD) has protected Boston since 1678. It is one of the original colonial fire departments that predates the founding of the United States. Today, the department serves more than 630,000 residents of the 47-square-mile city with more than 1,400 personnel deployed across 34 fire stations, with 35 engine companies, 23 ladder companies, two heavy rescue companies, five hazardous materials units, and marine units. The fire department provides basic life support as a first responder; advanced life support and patient transport are provided by Boston EMS.

JAY FLEMING has worked for the Boston (MA) Fire Department for more than 35 years. He worked his way up through the ranks from firefighter to deputy chief. Eight of his years of service as a deputy chief were in the role/capacity of fire marshal (for the city of Boston). As fire marshal, he supervised the Fire Prevention Division, which includes the Fire Investigative Unit (arson squad) and the Fire Education Units. He is assigned to Division 2 and is the incident commander for all multiple-alarm fires and other major incidents. Division 2 includes six fire districts, 28 companies, and approximately 300,000 people.