Lessons Learned: World Trade Center and the Pentagon (September 11, 2001)

The first panel focused on lessons learned from the WTC and Pentagon events about the training of workers for major disasters. Several reports have already examined various aspects of these disasters, including a report by the Worker Education and Training Program of the National Institute for Environmental Health Sciences (NIEHS)² and a report by the RAND Corporation³ on the adequacy of PPE. Members of the panel emphasized the need for training on incident command, as well as for cross-functional training (Figure 3).

Other findings from the analysis of the WTC and Pentagon events included both the identification of the problem areas and the opportunities for improved emergency response training. One of the central issues identified by the panel concerned the challenges of transitioning from the emergency response to the post-emergency response clean-up operations, which involved decontamination and remediation. The HAZWOPER standard

distinguishes between operations during and immediately after the emergency, and the post emergency response operations which take place some time after the initial response. In particular, there are detailed training requirements for emergency responders and for workers involved in post-emergency response clean-up operations, but the requirements for training of skilled support personnel during emergency response are far less stringent. Skilled support personnel are required to have only an “initial briefing at the site prior to their participation in any emergency response. The initial briefing shall include instruction in the wearing of appropriate personal protective equipment (PPE), what chemical hazards are involved, and what duties are to be performed.”⁴ Because the transition to post-emergency response was not clearly delineated, training requirements for skilled support personnel under HAZWOPER were not as clearly defined as they might have been. Other problem areas included the following:

• There was a need for critical incident stress debriefing during and after the event.
  
  
• First responders were overwhelmed by the enormity of the event.
  
  
• No one was “in-charge of or clearly responsible for enforcing” safety and health guidelines.
  
  
• Data collection did not always get transmitted to the field. There was very good collection of injury and illness data, but it was not always utilized effectively. Similarly, monitoring of personal exposures, even where it occurred, did not always get transmitted or used effectively.
  
  
• A presumptive protection standard (e.g., the HAZWOPER standard) was not used.
  
  
• Site-specific safety and health training did not begin until nearly three months into the response.
  
  
• Workers who are not traditionally seen as first responders, such as utility workers, sanitation workers, and skilled support personnel, also had significant and unforeseen exposures.
  
  
• There were multiple threats present at the site, particularly for those workers associated with demolition (e.g., risk of structural collapse and falls).
  
  
• There was concern about the unknown potential for secondary CBRNE attacks in addition to the hazards associated with clean up of the destruction of the WTC and the Pentagon structures.

The panel also noted important lessons for future responses:

• There is a need to coordinate any future responses with local emergency planning committees (LEPCs).
  
  
• The OSHA 10-hour construction safety course was used extensively, and may be appropriate for pre-incident training, particularly for skilled support personnel who may be involved in CBRNE incidents.
  
  
• Leaflet-style safety bulletins were used extensively at the site to supplement other forms of communication.
  
  
• Training curricula needs to concentrate on hazards beyond normal responder training, such as CBRNE hazards, the risks associated with demolition, and the use of air purifying respirators (APRs).
  
  
• There is a need for redundancy/backup plans.

Lessons Learned: Anthrax in the Mail

The second panel reviewed the events surrounding the U.S. Postal Service (USPS) and postal employees’ response to anthrax in the mail. There has already been extensive training for “traditional” emergencies in the USPS. After the introduction of anthrax, the USPS used “just-in-time” training based on recommendations from the Unified Task Force, which consisted of labor, management, and other involved parties. The USPS also had an important role in communicating with the public. Training emphasized emergency management fundamentals. Some of the key findings from this panel included:

• Working through the Unified Task Force and a unified incident command center (UICC) made communications and decision-making between various groups much easier.
  
  
• Standard formats and expectations for information need to be established at the outset.
  
  
• Internal conflicts of authority and responsibility need to be worked out.
  
  
• Union involvement was critical to the success of the response.
  
  
• Contingency planning included the following features:
  
  
  • Existing plans were augmented to address terrorist acts;
    
    
  • Simple goals and objectives worked best;
    
    
  • Interagency commitments were needed; and
    
    
  • The UICC structure was critical to success.

Several issues related to contract administration. The panel felt that contracts for services related to testing and decontamination need to be in place before a crisis occurs; and that resource requirements for items such as personal protective equipment (PPE) or laboratory services need to be in place before a crisis occurs. Finally, in some cases contractors did not have the training required to perform the assigned work. Panelists noted that interagency coordination was required to assure that agencies that prescribe the workers’ training requirements understand the needs of the agencies employing the contractors.

Some of the factors essential for the success of the teams that responded to the reports of anthrax contamination included: round-the-clock support and response; incident commanders with broad authority; and staffing from all of the participating agencies. In addition, the UICC was fully empowered to make key decisions, which was critical in a timely response. Panelists felt that the existing Postal Emergency Management System (PEMS) allowed for the integration of the emergency response to anthrax by the use of an existing structure. The use of the Homeland Security Alert System enabled protective measures to be outlined for each response level.

As a result of this coordinated effort, the panel pointed to the following accomplishments in managing the consequences of anthrax contamination:

• 284 buildings were surveyed in less than one month.
  
  
• A coordinated nationwide policy on sampling and laboratory strategies was established within days.
  
  
• Medical support for contaminated sites was excellent, owing to contract support.
  
  
• A bioterrorism training program was established for safety staff members.
  
  
• “Agents of concern” training, focused on biological threats, was provided to employees, emergency responders, and medical staff.

One challenge noted by the panel was that limited communication between military and civilian agencies slowed the learning curve.

Emergency Response Plans: Lessons Learned and Applied

This panel looked at how lessons learned from these recent events have been or need to be translated into emergency response planning. For a community emergency response, panelists emphasized that there should be a single, unified plan, regardless of the specific agent or threat. Also, the definition of “first responder” has to be broadened. First responders traditionally have been thought of as fire personnel, hazardous materials (HazMat) teams, police, and emergency medical service (EMS) personnel. As has been previously emphasized in several reports, first responders should also include what are termed “skilled support personnel,” These workers bring specialized skills to a disaster, and also need training. Planners need to understand how each responder fits into the response as a whole, and realistic “real-world” training is essential. Planners also need to consider the roles of the volunteers and their families.

The panel discussed findings from the RAND report on protecting emergency responders, noting the factors that had hindered the response: a loss of command staff; inadequate resources; logistical difficulties; jurisdictional and political issues; the treatment of the sites as crime scenes; and the need to deal with citizens at the site. Panelists also discussed the following challenges that confronted the WTC and Pentagon responders that were different from traditional disasters: the nature of the hazards; the major loss of emergency response personnel; the duration of the response; the fact that job requirements and equipment requirements were atypical; and the presence of many skilled support personnel on-site. The implications of these factors for training are shown in figure 4.

Audience members raised several additional issues regarding worker training and protection. Some of the critical questions concerned the appropriate role of the volunteer civil response teams and the potential legal liability of those engaged in training volunteers for disaster response. There were also questions about the psychological and emotional consequences of responding to a disaster, and whether it was possible to train people to recognize and/or respond appropriately if and when such reactions occur. From the ensuing discussion it appeared that there is still a great deal of evolving policy, law, and science related to worker training for CBRNE events. Panelists and the audience identified several of these, including the potential liability for volunteer training, as issues that could use additional clarification.