Rescue Operations
	Andrea Booher/ FEMA News Photo
	New York, NY, September 21, 2001.

Numerous hazards associated with the terrorist attacks were singled out as being particularly unique or severe:

• Large amounts of unburned jet fuel at the Pentagon presented an explosion and toxic-substance hazard.
• At the World Trade Center site, welders inadvertently ignited a store of ammunition. The resulting explosion sent shrapnel flying and injured workers. In another case, a utility worker was burned when he came in contact with a live 14-kilovolt power line.
• At the Pentagon, mold and mildew growth fueled by water from extended firefighting efforts presented a health hazard. There were also serious explosion and electrical hazards that extended beyond the initial response.

Rubble and debris
One of the most striking hazards at the World Trade Center was the large pile of rubble and debris. A great deal of rubble and debris also was encountered in the vicinity of the Murrah Federal Building and inside the Pentagon, where many offices in and near the impact zone were being used to store office furniture and equipment.

Firefighters in particular were not familiar with such an environment: "Some of our folks were getting hung up on rebar, cutting themselves up," said one. Shifting or unstable rubble could cause strains or sprains or, worse, could result in trapped feet. Most work boots used by construction workers provide only limited ankle support, increasing the potential for turned or sprained ankles. The rubble pile at the World Trade Center also hampered efforts to protect workers against falls because there were no tie-off points to secure the ropes and harnesses. A typical building has many places to secure ropes, some designed specifically for that purpose (e.g., for window washers). But the rubble pile did not.

Emergency responders had only limited tools for removing rubble and debris. Indeed, initial debris removal at the World Trade Center was done by bucket brigade. Therefore, heavy construction equipment and crews had to be brought in immediately. The presence of heavy construction equipment on the scenes presented hazards to those in the vicinity, as well as to the equipment operators, who had to cope with tight quarters, uneven surfaces, and poor visibility.

Dust and smoke
Dust and smoke were a pervasive hazard at the World Trade Center--suppression efforts notwithstanding, the air in Lower Manhattan was filled with particulates for weeks after the attack. Particulates also were cited as a problem, although to a lesser extent, at the Pentagon and the Murrah Federal Building. Yet according to participants, the available protective equipment did not shield them from the risk. "I was sick for a month after I got back from Oklahoma City, and it's the same stuff--concrete dust," said one responder.

According to data presented to the trades panel, respiratory injuries were reported frequently at the World Trade Center site, with almost 1,000 occurring in the first nine weeks. Many more may emerge, it was argued, because those injuries caused by inhaling toxic fumes may not display symptoms for some time. In addition, available eye protection reportedly did not work well, resulting in numerous eye injuries. In the first week, 346 people were treated for eye injuries of all types. By the middle of the tenth week, the number exceeded 1,000. Indeed, this was the second largest category of injury reported, accounting for 12 percent of all reported injuries.

According to conference participants, ensuring that the right respirator was available, properly prescribed and fitted, and actually worn by the responder as prescribed posed enormous logistics, training, and management challenges in all of the responses to the terrorist attacks.

Heat
Intense heat--caused in part by the burning of thousands of gallons of jet fuel--was a concern at the World Trade Center and the Pentagon. Intense fires also burned in buildings adjacent to the twin towers--for example, Seven World Trade Center and Ninety West Street--but the FDNY had only limited personnel, equipment, and water to fight them. The heat intensity at the Pentagon was exacerbated, participants noted, by the concrete and slate roof and the bombproof windows, which limited the ability of firefighters to ventilate the structure. "The heat inside the Pentagon was like being in a brick oven." Some of the firefighters who encountered the intense heat were burned even before seeing the fire, noted special-operations personnel.

DoD photo by Staff Sgt. Larry A. Simmons, U.S. Air Force

The effects of the blast and the fire caused when the hijacked American Airlines flight slammed into the Pentagon on Sept. 11th, are evident in this Sept. 14, 2001, photograph. The office was in the section of the Pentagon slated to be renovated next. Offices in the newly renovated section survived the blast and the fire much better. The terrorist attack caused extensive damage to the west face of the building and followed similar attacks on the twin towers of the World Trade Center in New York City.

At the World Trade Center, the ground was hot because of burning material that continued to smolder for weeks. Indeed, the rubble pile was so hot in places that it melted the soles of work boots. Companies donated supplies of work shoes, and construction workers laboring on the hotter parts of the rubble pile reportedly went through a pair a day. A boot wash was established where workers could cool their feet, but ultimately that simply traded one problem for another: Wet boots resulted in serious blisters. In the federal-and-state-agency panel, it was noted that Urban Search and Rescue (USAR) teams were usually the only responder units with gear appropriate for extended use in a hot rubble pile.

In general, the high-heat environment taxed the stamina of emergency responders, who often were suited up in heavy protective garments and labored for long periods without breaks or equipment changes.

Anthrax
Even though the range of risks at the Murrah Federal Building, the Pentagon, and the World Trade Center was broad, the risks were, at least separately, familiar. Anthrax was a different story. Responders did not know what or where the hazards were: "You can't measure the risks and do risk assessment, [so] you don't know what personal protection you need." With anthrax (or other biological agents), it is difficult to assess where emergency response starts and where it ends. Said one law-enforcement official, "The unknown is the big challenge, the invisible hazards." These problems were accentuated by the fact that the number of false alarms made it difficult to determine which anthrax-related incidents were truly hazardous and which were not.

Stress
Firefighters and other emergency responders follow the principle: "Risk a life to save a life." However, in the aftermath of the terrorist attacks, the intensity of responders' work, the long duration of the response campaigns, the multiplicity of risks, the horrifying outcomes of the attacks, and the lack of knowledge about hazards all contributed to stress.

	Long-term campaigns
	DoD photo by Staff Sgt. Larry A. Simmons, U.S. Air Force
	Worker at Pentagon site, September, 14, 2001.

At the World Trade Center, many of the victims recovered were horribly mangled, and in many cases only parts of bodies were recovered. As one trades panel member put it, "Many of these workers had never seen a dead person--not in an automobile accident, not even in a funeral home." It was reported on the trades panel that over 100 cases of psychological stress among construction and trades personnel were treated during the first nine weeks at the World Trade Center. However, the consensus of the panel was that many, many more experienced such stress but did not seek treatment. Conference participants noted that psychological risk for responders remains an understudied hazard.

Stress could affect responders' judgment about their own health and safety. A public health panelist commented, "[There's] almost hysteria with the anthrax group. . . . People get very scared and start asking 'Was I exposed?' and treating themselves." Such a response can be detrimental to a responder's health, since treatments for biological and chemical agents can have serious side effects. The stress can also cause responders to disregard their own health and safety. For example, one firefighter at the World Trade Center reported, "I had guys that needed medical attention that didn't get it for two or three weeks." An anecdote related on the federal-and-state-agency panel was similar: "One guy who was using a gas-powered cutting saw refused to give up to the point where the carbon monoxide dropped him. [He] didn't even want to hand off the tool. It was a semi-confined area. Just ran him down until he collapsed and they took him out."

Crime scene designation
Another characteristic that distinguishes the terrorist incidents from most other large-scale disasters is the terrorist-attack sites are crime scenes. While some fires may be the result of arson and may thus require evidence collection, massive disasters such as hurricanes and earthquakes do not. Designation as a crime scene means that the number of groups requiring access increases and the nature of the activities that take place on-site changes. For example, emergency crews need to worry about preserving evidence. This can have important consequences for protecting the health and safety of emergency responders.

Off-duty and volunteer involvement
The United States has been identified historically and culturally as a nation of volunteers and citizens who provide mutual assistance in times of need. The terrorist attacks proved this. The psychological shock, combined with the large number of deaths and injuries involving emergency responders, resulted in a massive outpouring of community and volunteer involvement in the responses.

	Slideshow
	DoD photo by R. D. Ward
	Public figures visit the terrorist sites.

During the Oklahoma City, World Trade Center, and Pentagon events, many off-duty emergency medical services (EMS), police, and fire personnel responded directly to the scenes, as did private ambulance services, doctors, and nurses. Many traveled hours to reach a site. Most volunteers arrived at the scenes without adequate personal protective equipment (PPE) or radio communications, and they operated outside the direction of the incident commander, yet were willing to enter extremely hazardous locations. Such activity adds to the confusion and compounds the safety and rescue responsibilities of firefighters and other responders who are in the command structure. In the process, both off-duty volunteers and emergency responders may be subjected to greater danger from threats such as a collapse or other secondary events. It was pointed out that a volunteer nurse was killed by falling debris in the Oklahoma City response. As summed up by one special-operations panelist: "We appreciated all the help, but, I don't want to sound . . . it was a huge problem."

Very quickly, community and religious organizations, local businesses, and concerned citizens set up and staffed ad hoc catering, rest, and comfort stations near the disaster sites. Over time, political leaders, high-ranking government officials, and other public figures visited the terrorist sites to view the damage, support the responders, and console the bereaved. This forced emergency responders into new roles--trying to manage large numbers of community volunteers, well-wishers, and onlookers--for which they had few guidelines and little practice.

New roles, new risks
The scale of the terrorist events, their duration, and the range of hazards they presented required that many emergency responders take on atypical tasks for which they were insufficiently equipped or trained.

Structural fires typically involve fire suppression and rescue, and fire departments have well-defined and carefully honed standard operating procedures and PPE for those activities. For responders at the World Trade Center, conditions in the rubble pile were unique: There were very few voids. This reduced opportunities for primary reconnaissance, shoring and stabilization, void searches, and rescue--important tasks in a large structural fire. The number of injured who required extrication, triage, and treatment was relatively small: "Either you were dead or you walked away from it. There was very little in between," observed one special-operations responder that was at the scene. "There really was not that much to do." The experience at the Pentagon was similar, with firefighters commenting that the evacuation consisted of the initial exit only; beyond that, there was "a lot of searching obviously but no rescue really." Conversely, firefighters became engaged in activities they usually do not do: "busting up and hauling concrete," scrambling over the rubble pile, and removing victims and decayed bodies and body parts.

	Slideshow
	The scale of a terrorist event can have a psychological impact and erode procedures, as indicated by the following comments made by firefighters at the NIOSH/RAND conference.

In all of the terrorist-incident responses, EMS personnel were on-scene, performing rescue operations. Moreover, in every incident, EMS personnel were caring for patients in the rubble pile. Several additional groups of personnel--sanitation engineers, food-service workers, and construction workers--were deployed at the scenes and placed in hazardous environments. Classifying the site as a crime scene also had important implications for occupational health and safety: Few crime-scene investigators had had to contend with ongoing fire-suppression and rescue activities and thus had limited knowledge of possible risks.

Those EMS groups with fire department affiliation usually had some knowledge about rescue and hazard recognition, but many did not have access to the personal protective equipment they knew they needed. The typical construction worker arrived at the World Trade Center site wearing essentially street clothes--jeans and shirts or t-shirts. And with some exceptions (for example, welders), most construction workers did not wear protective garments during their shift. Construction workers have well-developed models for erecting buildings and, indeed, for destroying them. However, those models did not mesh well at the terrorist-attack sites because the planning and preparation that normally accompanies building demolitions (e.g., removal of hazardous materials, establishment of traffic patterns) did not occur or took a long time to implement.

To summarize, the definition and roles of an emergency responder expanded greatly in the wake of the terrorist attacks, but few responders had adequate personal protective equipment, training, or information for such circumstances.