Hazmat/CBRN Incident: London’s King’s Cross Underground Station

Author’s note: This article is compiled from first-hand interviews with firefighters from the London Fire Brigade (LFB) who participated in the events of July 7, 2005. They included those in incident command, responders on first-due apparatus, and senior scientific advisors to the LFB responsible for hazmat/chemical, biological, radiological, or nuclear (CBRN) incidents. I also made extensive use of relevant documents from the LFB and British government agencies concerning doctrine and procedures the LFB uses when responding to a hazmat/CBRN incident. I likewise used open-source media reports but only in the context of drawing on first-hand accounts provided by identified personnel with first-hand involvement in the events described.

I am solely responsible for the information contained in this article; it does not reflect the official position of the LFB or any of its officers or firefighters.

This article discusses the events of 7/7 from the perspective of the LFB. Although the terror attacks and subsequent LFB response are addressed in their totality, this article focuses on the terror attack on the King’s Cross underground station. The King’s Cross attack was the deadliest event of that day and presented LFB with the greatest challenges, given its depth underground (more than 100 feet) and remote location (more than one-quarter mile down the tunnel from the station platform). This article is not meant to be critical of the LFB’s heroism, dedication, and professionalism. Rather, it is designed to elicit lessons learned from these terrorist attacks that might enable firefighters and first responders in London and elsewhere to more effectively respond to hazmat/CBRN incidents in the future.

BY SCOTT RITTER

On July 7, 2005 (7/7), terrorist bombers struck four targets in London—three underground (subway) trains, and one passenger bus. Fifty-six people, including four terrorist bombers, were killed in these attacks, and more than 700 were wounded. There were no casualties among the firefighters, police, and emergency medical service (EMS) personnel responding. London’s emergency services response to these attacks has been widely hailed as a success. Not only were their courage and professionalism highlighted but also the planning and preparation undertaken by those responsible for London’s security since the September 11, 2001 (9/11) terrorist attacks on the United States.

However, a more detailed examination of the events of 7/7 show that there were significant shortcomings regarding almost every aspect of the response of the emergency services to the terrorist bombings, especially from the standpoint of a potential hazardous materials (hazmat) or chemical, biological, radiological, or nuclear (CBRN) attack.

BACKGROUND

Despite the tragic results of the 7/7 bombings in London, the situation could have been far worse. Had the terrorists used two devices [one with explosives, the other with homemade sarin (GB) nerve agent designed to be dispersed by the primary explosive package], the consequences of the attack would have been far more dreadful for the public and the first responders (firefighters, police, and EMS).

Such a scenario is not plucked from the imagination. British officials had conducted several exercises in downtown London, including underground facilities, using this very same scenario. The OSIRIS 2 exercise that took place on September 7, 2003, tested the response of London’s emergency services to a chemical attack on the London Underground at Bank Station and University College Hospital, London. It was an opportunity for a large-scale test of mass decontamination equipment procured under the “New Dimensions” program under realistic surroundings, as well as the recently published Strategic Guidance on Decontamination. (The New Dimensions Group was established after 9/11 to evaluate fire service capabilities and to make recommendations to ensure that the service was sufficiently trained and equipped to deal with catastrophic, CBRN, and conventional terrorist incidents.)

Although London authorities deemed the exercise a great success relative to procedures, equipment, and staffing, the LFB had noted some issues of concern, including the following:

  • Rescue crews were sent underground before the threat they faced had been properly established. A similar mistake after the 1995 sarin attack on the Tokyo subway resulted in some of the first responding crews becoming exposed to sarin.
  • The decontamination tents may have been incorrectly situated, because insufficient attention was paid to the direction of the wind.
  • At least one of the showers that should have been used to decontaminate firefighters was faulty.
  • Emergency crews without proper equipment wandered into the exclusion zone.

There was clearly disagreement between higher authorities and those on the ground concerning the results of the exercise. The LFB’s concerns were based on the training and organization for such events that the LFB had received (see “Preparedness”).

It may be easier to understand what happened in London on 7/7 if the London attacks and the response of the LFB are viewed in a historical perspective (see “The London Brigade: Historical Perspective”).

On March 20, 1995, the Tokyo Subway sarin attacks occurred, the first terrorist attack of its kind in modern history. Twelve people died, and more than 5,000 were injured. The first responders did not contain the incident scene. As a result, there was massive cross-contamination, including staff/facility contamination at the various hospitals involved because of “walk-ins.”

A London health official wrote of the Tokyo attack:
If a similar incident occurred in the London Underground system, it would be catastrophic. Underground staff, police, firefighters, ambulance staff, and the general public could all be contaminated before the chemical was identified. There could be mass casualties, including personnel in the emergency services. How would London accident and emergency departments cope, faced with a chemical disaster such as this?

This is a sound question, worthy of further exploration, especially from the point of view of the fire service.

THE INCIDENT

At approximately 8:50 a.m., simultaneous explosions occurred belowground on three subway trains. The first occurred some 100 meters from the station platform at Edgware Road, killing seven persons at the scene. Eighty were injured, of whom 38 were eventually transported to a hospital. Of these, 24 were in critical or serious condition.

The second device exploded on the floor of the third car of a train, 200 meters from the Aldgate station platform. More than 100 persons were wounded, 16 of them severely; seven died at the scene.

A third device exploded in the front car of a subway train between the King’s Cross and Russell Square stations. Approximately 236 persons (36 of them severely injured) were injured enough to require evacuation to hospitals. Twenty-five people died at the scene.


Figure 1.
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At 9:47 a.m., at Tavistock Square, a device exploded aboard a double-decker bus. Fourteen doctors, many from the nearby British Medical Association, provided immediate care. Thirteen persons died at the scene. All told, four suicide bombers had left approximately 700 persons injured and 56 dead. Most who died did so at the scene.

If the terrorists had employed a sarin nerve agent device in parallel with these explosive attacks, the results most likely would not have mirrored those found in most computer simulations, because of a variety of factors. First of all, the heat and energy of the explosion itself will have a different effect on the spread of the sarin agent, depending on the conditions at the time of the blast (pressure, temperature, humidity, etc.). Second, homemade sarin most probably will not be able to attain the purity, and as such lethality, of sarin manufactured under laboratory conditions. This means that the symptoms usually associated with the military use of sarin nerve agent (i.e., death within 15 minutes of exposure) may not be as acute during a terrorist attack. The margin between sarin doses that are life threatening is only slightly more than those producing lesser effects. As such, it may not be immediately obvious to first responders that a sarin attack occurred.

In a terrorist attack such as the one postulated here, the exposure of victims to sarin most likely will not be uniform. Some victims will be exposed to inhalation (breathing vapors) contact and some to absorption (liquid on the skin) contact. Others may have their clothing contaminated but not be directly exposed through inhalation or absorption. If not properly decontaminated, contaminated victims could easily expose additional victims to the nerve agent, as well as contaminate emergency equipment, vehicles, and facilities.

The earliest detectable symptom following minimal exposure to sarin is pinpointed pupils. Within a few minutes of exposure, redness of the eyes may occur. The earliest effects on the respiratory tract are a watery nasal discharge, tightness in the chest, and a prolonged wheezing. With the exception of pinpointed pupils, all other symptoms are similar to those that would be found in victims escaping from a bombing attack that resulted in shock and smoke inhalation. Likewise, moderate exposure to sarin can result in pain in the eyes, a headache, and even nausea and vomiting. Again, victims from a conventional bombing producing significant smoke may likewise exhibit such symptoms.

The difficulty in ascertaining a sarin-based attack should be kept in mind as the events subsequent to the actual bombing unfold. The first indication that something was amiss came from fragmentary reporting received from the London Underground.

8.51 a.m.: Aldgate Station was reporting that an explosion had been heard. The London Underground’s Power Control Center reported that traction current had failed. The Central Line control center reported a loud bang heard near Liverpool Street. The Metropolitan Line reported hearing an explosion near Aldgate, on train 204 (the train that had been attacked).

8.52 a.m.: The London Underground staff began evacuating passengers from the Edgware Train attack.

8:53 a.m.: The Piccadilly Line reported a tunnel telephone line being activated and an indication of power failure.

8:56 a.m.:The managing director of the London Underground received a text message on his mobile phone, informing him that there was a power failure on the north side of the Circle Line.

8:59 a.m.:London Underground staff at Edgware Road reported that there was the possibility that a person was under a train, a train was derailed, or a train hit a tunnel wall. There was no mention of the possibility of a terrorist bomb attack.

• At the same time, the London Underground Network Control Center (NCC) reported two possible derailments, but the Piccadilly Line (i.e., King’s Cross) was reporting only that tunnel telephone wires, used to cut out the power in an emergency, had been activated. The National Control Center made its first call to the London Fire Brigade (LFB) and the London Ambulance Service (LAS), requesting responses to multiple sites, including Euston Station, Edgware, and Aldgate.

• The LAS received reports of an incident at Liverpool Street station. By 9:03 a.m., the LAS reported that ambulances were en route.

• The Battersea Fire Station’s Fire Rescue Unit (FRU) was called out to Edgware Road Station, responding to the possibility that a train had derailed. FRUs are specially trained to deal with train derailments on the London Underground. They are also trained and equipped to deal with hazmat/CBRN incidents. Three pump-ladder apparatus were also mobilized to Edgware Road. None were informed of the possibility of a terrorist attack.

9:01 a.m.:The LFB Central Dispatch mobilized a three-pumper response to Euston station, a combined London Underground Station/Train Terminal. The report had come in as observed smoke coming from Euston station. This normally generates an automatic three-pumper mobilization per standing operating procedures. Two pumpers were mobilized to Euston station from the Euston fire station. Per standard operating procedures, a third pumper, this one mobilized from the Soho fire station at 9.04 a.m., responded to the next underground station up the line, King’s Cross, to check for fire spread.

• Central Dispatch was responding to the call from the London Underground, indicating a single incident at Euston station. An automated voice announced the call in each station, mobilizing the fire crew to don conventional personal protective equipment (PPE) and mount the designated vehicles, while a teletype printed out a formal order, which was handed to the pumper officer before boarding the apparatus. Once onboard, the officer had single-channel VHF radio communications with Central Dispatch. He had no means of monitoring other ongoing activity taking place within the LFB. As such, the responding units had very limited situational awareness and arrived on-scene expecting a conventional incident. They had no reason to suspect that there had been a terrorist incident.

• The Euston fire station, the closest to King’s Cross (approximately one-third of a mile from King’s Cross Station), received the call right in the middle of shift change from Red (overnight) to Blue (daytime). Two pumpers were dispatched to Euston Square station to cover the report of smoke. No smoke was found. The Euston station pumpers returned to their station, unaware that the Soho pumper was at King’s Cross and had initiated a “Major Incident Procedure” (MIP).

Seven London police were among the first to arrive at King’s Cross Station. They were not aware that there had been a bombing attack. They were greeted by people, blank-faced and blackened with soot, fleeing the station. The officers attempted to form a filter corridor to channel the evacuees toward ambulances, which were starting to arrive, but they were overwhelmed by the crowd, who told the officers that there were more people still down in the station.

The officers started attending to the casualties. It is not known what reports, if any, the police sent to their higher headquarters. However, no information from the police was ever relayed to LFB first responders during this critical period.

9:11 a.m.:The Battersea FSU arrived at Edgware station; it was the first-in unit. The crew of five firefighters was immediately confronted by walking wounded. Their electronic personal dosimeters were not going off, making them believe that the incident did not involve any sort of radiological release. The firefighters approached the incident site without donning either breathing apparatus (BA) or extended-duration breathing apparatus (the equivalent of the U.S. 60-minute bottle).

9:13 a.m.: The initial responding unit arriving at King’s Cross, consisting of the single pumper unit deployed out of the Soho fire station, arrived with four personnel (a driver, an officer, and two firefighters). They immediately came in contact with victims streaming from the station. There was no coordination between the firefighters and the police already on-scene; no information was exchanged.

• The fire officer rapidly evaluated the situation based on statements made by the victims and determined that there had been an incident on the westbound Piccadilly Line. The officer initially planned to deploy two firefighters wearing BA and gas-tight chemical protective suits to the incident scene. However, as the Soho engine crew made its way down from the main entrance to the main concourse located some 70 feet underground, down an escalator, they ran into a growing stream of victims, some of whom were displaying, in the firefighter’s own words, “classic collision injuries.” The officer was certain that he was facing a major accident of some sort but still had no reason to suspect an act of terror.

• The large number of injured personnel coming out of the station, including several with serious injuries, combined with the fact that the electronic personal dosimeters (EPDs) carried by each firefighter showed a negative reading for radiation, prompted a quick change of plan. The firefighters began initial rescue work, tending to the injured. A triage was established on the concourse, with the firefighters sending up to the top those with minor or no injury and holding those with more serious injuries for the arrival of the LAS. All firefighters wore Level 1 respiration protection consisting of basic cloth filter masks. The firefighters were quickly overwhelmed by the magnitude of the incident, having been immediately confronted by some 200 victims seeking assistance.

9:15 a.m.: The first responding officer contacted Central Dispatch on his VHF radio and announced an MIP for King’s Cross Station. The MIP activation automatically dispatches to the scene eight FPUs (the immediate dispatch of seven in addition to the one already on-scene); one FRU; a hose laying unit (to provide additional water supply); one damage control tender (responsible for lighting), and one major incident unit (MIU), which provided increased command and control capabilities. Along with the MIU, a senior LFB officer was dispatched to assume command of the incident, which was still identified as an unspecified accident as opposed to a terrorist bombing attack. At this time, no hazmat officers were dispatched, nor were any hazmat scientific advisors called out. The Multi-Agency Incident Assessment Team (MAIAT) was not mobilized, nor were any of the LFB’s decontamination units (incident response units).

• Shortly after declaring the MIP, VHF communications between the first-responding officer at King’s Cross and the LFB Central Dispatch were cut. VHF communications remained a problem throughout the incident.

• Confusion reigned. The two pumper units dispatched to Euston station returned to the Euston fire station, having found no evidence of smoke. They were not in communications with the third-responding pumper, the Soho pumper unit operating on its own at King’s Cross. On their return to the Euston fire station, the two pumpers were redispatched in accordance with the declared MIP. However, because the original dispatch had been for the Euston station and the Soho pumper that had responded to King’s Cross was part of the original Euston station response, the MIP mobilization was sent to Euston station instead of King’s Cross, responding to a report of fire that originated from the fragmented initial reports of the officer of the Soho pumper. In fact, initially all of the additional units dispatched as a result of the MIP mobilization were sent to Euston station instead of King’s Cross. There was no means for any units responding to the MIP mobilization to contact the Soho pumper officer and ascertain the true situation on-scene.

9:25 a.m.: The senior fire officer mobilized under the MIP arrived at King’s Cross and immediately attempted to restore some order. Hazmat/CBRN concerns were raised while conducting the initial assessment. The ambulatory casualties were speaking of an explosion device accident, so it was starting to register that there had been some sort of terrorist attack. However, like the initial responding officer, the senior fire officer (who was also trained as a hazmat officer) noted that the failure of the EPD to register any radiation eliminated a dirty bomb hazard. Also, the large number of casualties encountered indicated that if there had been a bomb, it was likely a large bomb, thereby reducing the chances of there having been any meaningful release of chemical or biological agent. This assessment was based on the mistaken assumption that conventional explosives had been used in the attack. However, the terrorists had instead used TATP, a hydrogen peroxide-based explosive that acts in an endothermic, instead of exothermic, fashion. This means that the bomb behaved like a large air bag, creating a rapidly expanding shock wave void of the heat of a conventional bomb. A TATP explosive is actually a very viable means of disseminating a CBRN agent.

London firefighters were trained on the 1-2-3 principle: If one casualty was observed down for no obvious cause, proceed on. If two people were down with no obvious cause, proceed with caution. If three or more were observed down for no obvious reason, pull back and regroup while awaiting personnel equipped with the proper detection equipment and protective gear. The King’s Cross incident did not violate the 1-2-3 principle. However, the 1-2-3 principle allows for the creation of a false sense of security. Firefighters should always assume contamination until proven otherwise. This is especially true when it comes to matters pertaining to airway exposure. BA should always be worn. However, in this instance the decision was made to press forward without donning BA or gas-tight chemical protective suits.

• As more firefighting resources arrived, the senior fire officer set about bringing structure to the emergency response. By 9.30 a.m., communications were finally established between King’s Cross Station and Central Dispatch via commercial landline telephone. At about the same time, the police bomb squad showed up with dog teams and did a quick sweep of the station (but not the actual incident site) for explosives and secondary devices.

9:36 a.m.: All London hospitals had been asked to stand by to receive casualties according to their major incident plans. The LAS thought there were 12 incidents, and there was confusion as to where they were. The central London hospitals, namely the Royal London Hospital, University College Hospital, Royal Free Hospital, St. Mary’s Hospital, St. Thomas’ Hospital, and Charing Cross Hospital, were activated to major incident declared status (casualties to be sent). However, no indication of a terrorist attack was transmitted at this time.

9:45 a.m.: The senior police officer on-scene called for a Silver Command meeting (see “Gold-Silver-Bronze Incident Command Framework”) formally establishing the senior fire officer as LFB Silver Command for the King’s Cross incident. At the Silver meeting, the LFB was given primary responsibility for the rescue operation. The LAS Silver established two triage points—one on the concourse near the ticket office, where the Soho pumper crew had started processing victims, and another down on the Piccadilly westbound platform.

• LFB Silver Command broke the fire brigade’s operation down into three sectors. Sector One was at the street level outside the station, where command was established, as well as the staging of initially arriving resources. Sector Two, also referred to as Forward Control Point, was located one lobby down, in the giant concourse area. This is where personnel and equipment would be staged for the rescue operation. Sector Three represented the rescue effort, staging on the Piccadilly westbound platform, and continuing on into the tunnel to the incident site. Reports were coming in of victims coming from Russell Station, so the LFB Silver dispatched a single pumper to that scene to assess the situation and help determine if Russell Square would be Sector Four of this incident or a separate incident all of its own. Also by this time, a hazmat officer arrived at the scene. However, he was not assigned to any hazmat responsibilities and was used in a support/liaison capacity.

• The firefighters who had been staging at Euston station recognized their mistake and began making their way on foot to the King’s Cross Station. Each arriving crew was given a task in accordance with the sector division of labor the LFB Silver Command established.

10:00 a.m.: With a fresh crew freeing up the Soho pumper crew from treating casualties, the Soho pumper officer gathered his crew to make the first push down the tracks to the actual scene of the incident. Up until now, no rescue personnel had been to the actual incident scene. The Soho crew wore only PPE, with breathing apparatus worn but not donned.

10:15 a.m.:The Soho crew members made the scene of the incident. They were able to determine that the attack had involved some sort of explosive device and that it most probably was an act of terror. Dead bodies and parts of bodies filled the car. Despite the fact that the bomb had blown up nearly 85 minutes prior, this direct observation was the first positive confirmation that the King’s Cross incident was more than likely an act of terror.

• The Soho crew began searching for survivors and orchestrating their removal from the wreckage. Six seriously injured victims were discovered, some with missing limbs and all with severe injuries, during this search. Almost two dozen dead bodies were discovered. Fire brigade personnel carried the survivors from the scene, down the tunnel to the triage center the LAS had established near the main station.

Reports coming to command from the incident scene allowed the LFB Silver Command at King’s Cross to determine that the bomb was smaller than had originally been thought. This determination was based on the damage observed and the nature of the casualties, which included a large number of people who had had their legs blown off, indicating a bomb exploded at leg-level, such as one carried in a backpack. The temperature at the scene was more than 130°F, and the carnage at the scene meant that all involved in dealing with casualties were covered in blood, creating a potential bloodborne pathogen risk. Also, while it became clear that the tunnel itself was in no danger of collapsing, thus alleviating the need to mobilize a specialized US&R team for shoring duty, there was a concern that damage to the tunnel had caused a release of asbestos into the environment.

• Better respiratory protection was required, and the LFB Silver Command requested a US&R vehicle to come to the scene. The US&R vehicle was equipped with Level 3 respirators (half-masks). Once the masks were offloaded and distributed, the US&R vehicle was returned to service. Also, one of the pumper crews set up at Sector Three a bleach dam, using ladders and tarps, so that crews leaving the area could step in, wash their boots and hands, and prevent the spread of any potential bloodborne pathogens. However, the half-masks did not have any associated communications devices to interface with the radios in use, so if someone needed to talk on the radio, the mask would have to be removed, negating the impact of wearing the mask.

• The arrival of a fire command unit, together with a fire brigade communications officer, enabled communications between command and each of the sectors. Using a hard-wire phone, wire was laid between Command, Forward Control, and the Piccadilly westbound platform; sector officers, or Bronze Command, were established for each. The importance of the hard-wire communications was underscored by the difficulties the firefighters experienced in communicating on their UHF radio sets. The London Underground was equipped with built-in repeater systems (i.e., “Leaky Feeder”), ostensibly allowing those operating radios underground to communicate with those above ground, but the radio frequencies were saturated, and the most reliable means of communication became the hard-wire sets. However, no set was run to the incident scene itself, where the Soho pumper crew was working with police and LAS crews to evacuate the most seriously injured. This led to a situation where the Soho crew was operating in isolation for more than an hour without relief of any sort.

Given the fact that the bomb blast had literally ripped the bodies of its victims apart, there was no need for special extrication tools or the FRU crews that staffed them. Once the damage control tender arrived, the FRU crews were tasked with setting up adequate illumination of the scene. Ventilation was an issue—the trapped heat and smoke made work conditions very difficult. The LFB lacked any ventilation equipment, but the London Underground and the nearby Channel Tunnel Railway had large smoke extraction equipment that had been put at the disposal of the firefighters. However, no formal environmental testing was done. Even though the EPDs were not being set off, the LFB Silver Command believed that no ventilation should be conducted, thereby expelling the bad air out of the subway passage, cooling down the scene and improving visibility, until such a survey had been accomplished.

• The explosion had taken place inside the first car of the train. The LFB Silver at King’s Cross was concerned that some of the passengers who had been in the first car might have disembarked and proceeded down the tracks to the front of the car, toward Russell Square Station, instead of making their way through the damaged car and out the back, as the other passengers had done. A single pumper unit was dispatched to Russell station to carry out an evaluation and to look for victims. None were found.

• However, there still was a concern that viable victims might be trapped in the front car. The LFB Silver at King’s Cross dispatched a single FRU from Euston station to Russell Square, where they brought into service a rescue and recovery (RAR) trolley, a battery-operated unit that allows firefighters to move safely down rail tracks, even if power is cut off. It so happened that this FRU had onboard one of the LFB’s scientific advisors who had been present at an earlier hazmat incident with the FRU. The scientific advisor conducted basic radiological surveys at Russell station but not at the incident scene itself. A team of firefighters made entry with the RAR at 11 a.m. and determined that the front car had been fully evacuated and that no viable casualties remained. Police used the FSU-staffed RAR during the next two weeks to assist in transporting police investigators to and from the incident site.

Around 10:30 a.m.: The MAIAT was finally mobilized. This specialized team was developed to carry out detailed environmental testing of potential terrorist incident sites prior to rescue workers’ carrying out their tasks. Because of the confusion attending the attacks on 7/7, the MAIAT did not arrive on-scene until well after the rescue operation was complete, thereby negating its reason for existing (i.e., to conduct adequate environmental surveys prior to the initiation of rescue work to protect rescue workers from dangers associated with hazmat/CBRN releases). The MAIAT arrived at Edgware station, where it began to conduct an environmental assessment of the area around the entrance to the station. Nothing of note was detected in the way of a hazmat/CBRN hazard. No effort was made to conduct a similar survey at the scene of the incident itself. By this time, it was clear that multiple incidents had taken place in London.

The MAIAT was split into four groups of two personnel each; they were dispatched to each of the remaining incidents to carry out additional surveys. With this reduced capability, arriving well after rescue workers had already accessed the incident scenes and evacuated the casualties, the MAIAT team conducted environmental surveys, still limiting itself to monitoring the environment at the entrance to the incidents and not the incident scenes themselves.

11:30 a.m.-12:30 p.m.: The firefighters and LAS had determined that all live victims had been removed from the incident scene. However, to be certain, and because the bodies of dead and living alike had been so horribly mangled, it was decided that a team of doctors should carry out a final survey of the scene. This was done by 12:30 p.m.

• Shortly thereafter, the LFB Silver Command terminated the rescue operation. King’s Cross had become a crime scene, which was run by the Transit Police (below ground) and Metropolitan Police (above ground). LAS and LFB crews were on standby to assist the police as required. Neither the LAS nor the LFB were involved in any aspect of evidence collection. Specially trained police teams collected all evidence. The LFB’s specially trained fire investigators photographed the scene for the police.

More than 100 ambulances and more than 250 ambulance staff attended the incident scenes, with the added support of the staff in the control room. As part of the coordinated plan, the LAS worked with the other London emergency services, ambulance services from adjacent areas outside of London, and voluntary agencies such as St. John Ambulance and the British Red Cross.

Of the eight major emergency hospitals in the region, only two were placed on full emergency status under the coordination of University College Hospital. The Royal London Hospital in East London took the casualties from the Aldgate and King’s Cross Underground bombs and the bus incident. This hospital also serves as the base for the London Air Ambulance service, whose main role during the emergency was to ferry in additional medical staff from outside London. The air ambulance was also able to fly in 31 doctors and paramedics to the four bomb sites. The other hospital was St. Mary’s near Paddington, which was a short walk from the Edgware Road Underground blast. The walking wounded were initially treated on the scene at the Hilton Metropole Hotel across the road from the Underground Station, since the station and the train lines are at surface level. Buses then transported them to the hospital.

Subsequently, patients were transferred to special units at eight hospitals; they included intensive care, operating room, and the burn unit. An additional 22 hospitals in the London region were placed on standby for any further eventuality. No hazmat/CBRN detection or decontamination services were provided for any of the victims.

King’s Cross, Russell Square, and Edgware Road were all clear of serious casualties; only walking wounded remained.

1:00 p.m.:The LAS Gold Control made the decision to stand down all the peripheral London hospitals, leaving the remainder active until all the casualties were cleared.

At this late stage in the incident, for reasons yet to be made clear, the LFB’s scientific advisors office was formally informed that there was a terrorist attack and that they were to go to each of the incident scenes to conduct environmental surveys. By this time, all incident scenes had been turned over to the Metropolitan Police and were being treated as crime scenes. The police were hesitant about allowing the scientific advisors access into the crime scene perimeter. The scientific advisors deploy without any PPE; they use gas-tight chemical protective equipment and breathing apparatus provided by the LFB. By this time, the LFB had largely withdrawn from the various scenes, and the scientific advisors had to make use of white police suits and standard respirators (not breathing apparatus). Also, since the MAIAT had already conducted a chemical/biohazard monitoring search, the scientific advisors decided that their role would be to inspect each incident scene for the presence of any radiological material.

1:30-2:30 p.m.: The environmental surveys were initiated and completed by 2:30 p.m. Nothing was found.

2:30 p.m.: LAS Gold Control sent a “scene evacuation complete” message.

2:45-4:00 p.m.: The Royal Free Hospital stood down at 2:45 p.m., and St Mary’s at 4:00 p.m.

• The incident scenes were completely under the control of the Metropolitan Police. The LFB’s role was purely scene support. No more hazmat/CBRN detection/response activity was undertaken.

POST-INCIDENT ANALYSIS

• The LFB is a highly trained, extremely motivated, and tremendously capable organization. Yet, on 7/7, it operated in a manner which, had the terrorists made use of a nerve agent such as sarin, it most probably would have failed to provide adequate protection to its members, fellow rescue workers, and the community. Doctrine and experience dictate that every terrorist incident must be treated as a CBRN event until proven otherwise. The failure of the LFB—and for that matter, the entire London Emergency Services Coordinating Authority—to implement anything remotely resembling a unified, coherent, and coordinated CBRN response plan placed the lives of the first responders and citizens at risk.

This, of course, is a criticism that also could very well be leveled at any fire department and emergency response organization in the United States, which is why the events of 7/7 need to be studied in detail. The amount of money, time, and resources expended by the American fire service in preparing for a future terrorist attack provides no assurance of an adequate response if first responder training and associated civil preparedness are conducted in a vacuum.

• Materially, the LFB appears to have had sufficient resources available to operate safely in a CBRN environment, in terms of carrying out required monitoring functions, conducting rescue operations, and supporting decontamination efforts. You can make the same claim for most major American fire departments, especially following the events of 9/11 and the availability of funding for hazmat/CBRN preparedness.

Doctrinally, adequate procedures were in place for implementing each of these tasks in isolation. Despite reported shortfalls, training evolutions conducted prior to 7/7 showed that the LFB was capable of doing the technical tasks assigned to it for operations in a CBRN environment.

• The major failures responsible for the lack of performance on 7/7 appear to be threefold:

Poor initial size-up on the part of the initial responders regarding the potential of a CBRN threat (i.e., inadequate PPE/respiratory protection and assumptions about the possibility of a CBRN threat leading to implementing courses of action that would not be acceptable in a CBRN environment). It may be tempting to say that the initial responders got the initial size-up correct, since there wasn’t any CBRN release. However, this is not sound thinking when dealing with a terrorist event. The assumption must be that CBRN could have been used; then collect data that confirm or refute this assumption.

Inadequate communications throughout the incident. Although the Gold-Silver-Bronze incident command system functioned, it did so devoid of almost any viable and real-time information about the incidents.Communications overload, combined with limited communications options and the nearly complete inability of multiple agencies to communicate with one another, meant that no information of intelligence value was being communicated in a timely fashion. There was no effective vertical communication (i.e., from the incident to Command or from Command to incident) or horizontally (among the various elements operating at each incident or between incidents). This led not only to confusion but also to a potentially fatal delay in recognizing that a terrorist incident had occurred, thereby delaying the implementation of an appropriate response, especially in regard to a potential CBRN incident.


Figure 2.
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Overemphasis on a top-down approach toward mitigating a CBRN incident. Front-line units were inadequately trained and equipped to carry out initial scene assessments on their own, resulting in a critical delay as requests for support were made, validated, and appropriate resources dispatched. Firefighters were provided with only one PPE option regarding operating in a potential CBRN environment (i.e., full Level A protection) other than their normal structural firefighter PPE. Formal decontamination was centralized and nonresponsive. The same was true about hazmat/CBRN monitoring and detection. There was a significant delay in bringing adequate resources to the incident, as the chronology of the events of 7/7 illustrate, which could have been potentially fatal if there had been a CBRN release.

LESSONS LEARNED FOR THE U.S. FIRE SERVICE

The issues raised here are problems faced not only in London. Every fire service involved in responding to a potential terrorist/hazmat/CBRN incident has issues that parallel those raised here. Specific solutions to these issues will differ by jurisdiction, but the following points should be addressed:

Increased training for first responders not only in terror/CBRN recognition, but also in procedures, including appropriate PPE, required to safely operate in a CBRN environment. Firefighters must be given immediate access to the tools and PPE they need to accomplish their rescue tasks in a CBRN environment. This means increased training on the need for the full PPE envelope, including breathing apparatus, at all times; the risks/benefits of treating conventional firefighting PPE in a hazmat/CBRN environment; and options for field-expedient mass decontamination using available resources (i.e., on-hand pumpers/engines). Incorporating automatic full PPE protection in every first response scenario will reduce the tendency of firefighters to become complacent about when to wear the appropriate level of protection. The new NFPA 472, Standard for Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents (2008 ed.), addresses many of these issues from a standards perspective, providing for mission-specific tasking of operations-level first responders (the majority of firefighters fall into this category). Recognizing the need to adapt this new standard and to train accordingly is the responsibility of every fire department.

Improved point-to-point communications within the fire service, up and down the chain of command and laterally between operational units.Develop redundant capabilities, and ensure that the fire service can communicate with police and EMS. There can be no effective command, control, and communications in a CBRN incident without the ability to develop and transmit usable, real-time intelligence. Data must be able to be passed among involved units and organizations. There must be a venue for someone operating outside the immediate scene of the incident to compile and assess information from a variety of sources and the means to pass all information of relevance to the concerned parties.

If critical capabilities, such as detection, monitoring, and decontamination, are going to be centrally controlled, then automatic early dispatch to any scene of a potential incident must become the rule.To have detection/monitoring capability arrive on-scene hours after an incident has occurred, well after rescue workers and civilians could have been exposed to CBRN contamination, is unacceptable. To have mass-decontamination units remain in quarters when there were potentially hundreds, if not thousands, of contaminated victims, both civilians and rescuers, is likewise unacceptable. Either decentralize these capabilities, and push them down to the first responder level, or make sure that these capabilities are mobilized and dispatched as soon as possible, even if this means that there will be an increase in false alarms.

•••

The courage, dedication, and professionalism displayed by the members of the LFB, the LAS, the various law enforcement agencies, and other emergency response personnel in dealing with the horrible events of 7/7 cannot be overemphasized. Any critique of their performance on that day is not meant as an insult to their service. Every professional understands the importance of a structured post-mortem in preparing for the future. The LFB has made several changes in the way it approaches potential terrorist acts, as well as hazmat/CBRN incidents. Other issues of concern will undoubtedly be noted as the events surrounding the terrorist bombings of 7/7 and the associated hazmat/CBRN response undertaken as a result are reviewed by interested parties.

The London Brigade: Historical Perspective

The London Fire Brigade, the third largest firefighting organization in the world, serves the Greater London metropolitan region, which has a population of some 7.6 million people. It is comprised of 5,700 operational firefighters and officers staffed in 112 stations. It is run by the London Fire and Emergency Planning Authority (LFEPA), which consists of 17 LFEPA members—nine from the Greater London Assembly and eight nominated by the London boroughs through the Association of London Government. The LFEPA, like the rest of the fire service in the United Kingdom, takes its guidance from the Office of the Deputy Prime Minister (ODPM), which oversees national fire-related issues.

The LFEPA coordinates with other emergency service agencies in the Greater London region [i.e., the London Ambulance Service (LAS), Metropolitan Police (MP), British Transit Police (BTP), etc.] through the London Emergency Services Liaison Panel (LESLP). The LESLP publishes the Major Incident Procedures Manual, which governs emergency response actions, including those of the LFB during identified major incidents, including those involving acts of terrorism, hazmat, and CBRN attacks. The LESLP Manual also provides for a system of incident command to coordinate the responses of all involved agencies during an identified major incident. The Sixth Edition of the Manual, dated July 2004, was in effect at the time of the 7/7 London Underground attacks.

Before 9/11, there was no specific operational entity within the LFB focused on hazmat/CBRN terrorism. After the attacks of 9/11, the ODPM allocated more than $1,670,000 on two main research projects. The first looked at the decontamination of people in collaboration with the Department of Health and the police and ambulance service. The second, in conjunction with the police, developed protective equipment designed to protect the first responders’ airways and skin through impermeable clothing. The ODPM’s Fire Research Division has a small research group of 15 professionally qualified staff who, before 9/11, spent about $980,000 annually on a variety of issues in support of the fire service. This work expanded significantly after 9/11, to include research on responding to hazmat/CBRN incidents.

Following 9/11, the ODPM requested the chief inspector of fire services for England and Wales to examine the fire service’s ability to respond to similar catastrophes. A “New Dimension Group” was established to evaluate fire service capabilities and to make recommendations to ensure that it is sufficiently trained and equipped to deal with catastrophic, CBRN, and conventional terrorist incidents. Before 9/11, individual fire authorities procured their own equipment. A decision was subsequently made that central government would buy the key items of equipment such as radios and mass-decontamination equipment.

• The ODPM procured 80 incident response units for carrying mass-decontamination equipment and 190 purpose-built decontamination units. Each vehicle carries decontamination units, each capable of decontaminating large numbers of people (200 people per hour) and ancillary equipment, including temporary clothing for affected members of the public. This equipment was deployed on the basis of a comprehensive analysis of risk, to meet the needs of all fire authorities. The LFB received 10 of these new incident response units.

In February 2003, the Home Office of the British Government published the strategic national guidance for “The Decontamination of People Exposed to Chemical, Biological, Radiological, or Nuclear (CBRN) Substances or Material.” The London Ambulance Service was given the lead for decontamination; the fire service was to assist.

Preparedness

Central London, where the 7/7 bombings occurred, is classified as a Risk Category A area, the highest level of classification. The national response standard for a Category A area in July 2005 was three pumpers (engines), the first two arriving within five minutes and the third within eight minutes. If required, specialized fire rescue units are able to respond within 15 minutes of notification.

When responding to incidents involving the London Underground, most London firefighters are influenced by the events of November 18, 1987, the so-called “King’s Cross Fire,” which resulted in 31 deaths (including one firefighter) and some 60 injuries. Largely because of this fire, the LFB rethought the way it fights subway fires. Most London Underground incidents the LFB encounters deal with power outages, small fires, and personnel on the tracks (i.e., suicides). There are some incidents involving derailments, but they are few and far between. Prior to 7/7, the most significant incident involving the London Underground was the power outages of August 28, 2003, which disrupted trains for 40 minutes and affected more than 200,000 commuters.

The influence of these two incidents on LFB’s operational procedures cannot be overlooked or minimized. According to the LFB’s philosophy, as set forth in the 1999 Fire Service Inspectorate regulations, all tactical and operational assignments must be based on a risk assessment. All activities should be conducted so as to minimize the risks to operational personnel and the public. Where a significant risk (e.g., a chemical hazard or a dangerous structure) is identified, steps must be taken to manage that risk through the application of preplanned standard operating procedures. Fire officers are taught to employ a process of dynamic risk assessment, whereby the risks they encounter must be continually assessed as the incident progresses.

The process requires officers to do the following:

  • Evaluate the situation, tasks, and persons at risk. This is similar to the American concept of size-up, wherein the duty of the officer in command is described in terms of sizing up the situation and issuing the necessary orders.
  • Select systems of work. The strength of this assessment is that it acknowledges that the safety of a particular way of working depends on the current environmental context. This encourages experienced fire officers to take a flexible approach to procedures depending on circumstances and to use their professional experience to assess the situation, possible ways of working, and standard procedures to make decisions about risk taking. The experience of the decision maker is critical. In the U.K. fire service, all officers enter the service at firefighter rank and, although there may be drawbacks to this single-tier entry system, its strength is that all officers have gained considerable experience before they are expected to command incidents.
  • Assess the chosen systems of work. This introduces a control on firefighters who may in the heat of the moment become inclined to place themselves at risk needlessly. It is acknowledged that it may be necessary to take some risks if lives are in danger. The LFB uses the following heuristic as a structure for this assessment: “Firefighters will take some risk to save savable lives. Firefighters will take a little risk to save savable property. Firefighters will not take any risk at all to try to save lives or properties that are already lost.”
    The fire officers’ decisions are made on the basis of expertise rather than the application of formal written procedures. The precise level of risk that can be taken remains a matter of the judgment of the individual incident commander (IC).
  • Reassess systems of work and additional control measures. This is a checking loop where any possible additional safety systems can be introduced. This is not strictly control of risk, as it would tend to be the addition of protective equipment or personnel with a view to protecting the safety of personnel rather than preventing the risky occurrence.
    The risk assessment model the LFB uses offers a structure by which the quality of dynamic risk assessment can be evaluated. However, with the time frames available, especially in the early stages of incidents, it seems unlikely that there would be sufficient time to carry out a deliberate risk assessment. This model, therefore, has its limitations; unfortunately, the emphasis placed on the experience and ”instinct” of the IC and the lack of emphasis placed on firmly established procedure means that undue influence can be exerted on a real-time risk assessment by historical incidents of high profile such as the King’s Cross fire and the London Underground power outage.

Gold-Silver-Bronze Incident Command Framework

The London Fire Brigade operates under a national multiagency incident command framework known as “Gold-Silver-Bronze.” This framework works as follows:

  • Gold (Strategic) is the commander in overall charge of each service, responsible for formulating the strategy for the incident. Each Gold has overall command of the resources of his own organization, but delegates tactical decisions to his respective Silver command.
  • Silver (Operational) takes charge of the scene and is responsible for formulating the tactics to achieve the strategy set by Gold. Silver should remain detached and not become personally involved with activities close to the incident.
  • Bronze (Tactical) controls and deploys the service’s resources within a geographical sector or specific role and implements the tactics assigned by Silver.

The LFB system is similar to the concept of unified command in the American incident command system. From the fire perspective, “Gold” functions as an American chief of department, so to speak; “Silver” serves more like the traditional American IC; “Bronze” functions in a manner similar to an American Operations position or company officer.

The Command Support Centre provides an essential and integral element of operational practices for the LFB and, in accordance with the LESLP Major Incident Procedure Manual, serves as the LFB’s Gold control.

The Special Operations Room (SOR) at New Scotland Yard monitors all major disasters that occur in London. Its sole function is to monitor disasters, terrorist incidents, disorders, and demonstrations. The room has consoles set aside for the LFB, LAS, British Transport Police, City of London Police, and additional agencies (for example, the armed forces). The various service liaison officers work from here. They have access to all the radio and CAD communications channeled through the room and can, for example, relay requests for assistance to their own control rooms (i.e., to the LFB’s Gold control at the Command Support Centre).

The SOR does not control the incident. Its function is to provide a support structure to Gold and those at the scene and to assist in the management of the incident. Within Central Command Complex at New Scotland Yard, there are also facilities for communicating with all other police forces in the United Kingdom, members of Interpol, and central government.

There is an interagency command channel. The command vehicles from each agency at the scene are equipped with a number of handheld multichannel UHF radios. They operate on the interagency command channel and are intended for command use only by the respective service “Silvers” for liaison purposes—not for general interservice use. Police are responsible for issuing the radios to the other services at the scene.

Overall Gold Command for London is under the command of the commissioner of the Metropolitan Police and reports to the Cabinet Official Briefing Room A (COBRA) Committee, chaired by the Prime Minister; it includes the Security Services (MI5). The emergency committee meets in COBRA.

SCOTT RITTER is a lieutenant with the Delmar (NY) Fire Department. He is a nationally certified fire service instructor II. In addition to his duties with the Delmar Fire Department, he serves as a hazmat specialist with the New York Task Force 2 Urban Technical Search and Rescue Team and has instructed at the IAFC HAZMAT Conference. In July 2005, Ritter was in London on personal business. He was less than 200 yards from Tavistock Square when a terrorist bomb destroyed the London City Bus.

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