Emergency response often uncoordinated in post-9/11 era

Courtesy of Kimberly Prellwitz

A July 2009 fire at the Patrick Cudahy meatpacking plant blazed for days, forcing the evacuation of hundreds of people and causing more than $200 million in damage. While many aspects of the response went well, significant problems also occurred, including failures to meet federal emergency response requirements.


The Center is exploring gaps in Wisconsin’s emergency preparedness to answer the question: A decade after 9/11, are we safer?

A joint project of Gannett Wisconsin Media and the Wisconsin Center for Investigative Journalism

Interactive map: Lessons learned

What they learned in the disaster: Agencies’ after-action reports

Emergency responders’ accounts, often frank, of their successes and failures after disasters both real and simulated. These “after-action” reports have never been published in one place; the Center summarized, archived and mapped 75 of them.

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From the Green Bay Press-Gazette.

In October 2007, about 140 firefighters, police officers, paramedics and other responders gathered at the Patrick Cudahy meatpacking plant, just south of Milwaukee. They were told a bomb, believed to be the work of an animal rights activist, had exploded in the cavernous building, and a fire threatened 177,000 pounds of pressurized ammonia.

As firefighters readied their hoses, responders rushed to activate an emergency operations center, evacuate the building and notify the public.

After three and a half hours, they stopped, put away their equipment and sat down to assess their response.

Every year, state and local agencies in Wisconsin perform multiple exercises to test emergency response capabilities, funded by federal homeland security grants created after the Sept. 11, 2001 terrorist attacks.

At Cudahy, an eerily similar real-life disaster took place less than two years after the training exercise.

The Patrick Cudahy fire — which began accidentally July 5, 2009, after a man at a Fourth of July party launched a military flare onto the building’s roof — blazed for days, forcing the evacuation of hundreds of people and causing more than $200 million in damage. It was the largest structure fire in Wisconsin history.

Carol Wantuch, the city of Cudahy’s emergency management coordinator at the time, says the 2007 drill was invaluable in helping prepare for the real-life response. No one was killed or injured, and responders protected the highly flammable ammonia from the fire, which Wantuch attributes in part to the exercise.

But significant problems also occurred during the Cudahy fire, including communication failures, equipment shortages and breakdowns in chain of command, according to Wantuch and an after-action report written about the event.

The Cudahy fire exemplifies the successes and failures of the state’s emergency response since 9/11. Reports prepared after exercises and incidents show that emergency response in Wisconsin often continues to be uncoordinated, despite millions invested in better equipment, training and communications. Experts say the problem is the worst in rural areas.

And there are questions about accountability. Although federal emergency response standards exist, neither the state nor the federal government requires jurisdictions that receive homeland security funding to report compliance with these guidelines.

Cuts in homeland security funding have emergency responders worried they will not be able to maintain current levels of preparedness.

“Our budgets have been slashed,” Wantuch says. “It’s going to get more and more difficult.”

Maj. Gen. Donald Dunbar, chair of the Wisconsin Homeland Security Council. Courtesy of Wisconsin Emergency Management

Officials note successes

The Wisconsin Center for Investigative Journalism reviewed 68 after-action reports from real-life emergencies and exercises that took place in 37 Wisconsin counties between 2005 and 2011. The review revealed a wide range of competency among responders.

In nearly half the exercises and events, responders did not understand proper command structure, did not have appropriate equipment and had problems communicating with the public. Nearly one quarter of the reports indicate problems with evacuation plans and radio equipment.
Click to explore the Center’s interactive map of after-action reports across Wisconsin

Top state homeland security officials have carefully avoided declaring victory in their efforts to ensure that Wisconsin is prepared for emergencies.

Brian Satula, head of Wisconsin Emergency Management, which coordinates the state’s disaster response and recovery efforts, says there is always more to be done, noting that his agency “maintains a posture of constant improvement.”

Wisconsin Emergency Management Administrator Brian Satula.

Satula and others insist Wisconsin is better prepared for disasters than it was before the Sept. 11 terrorist attacks, thanks to more than $425 million in federal money invested in equipment, training and better communication among state and local agencies.

“The training has improved, planning is robust and all-inclusive and our responders are better equipped to help our communities,” Satula says.

Maj. Gen. Donald Dunbar agrees, saying that since 9/11 “there has been a more collaborative approach to preparedness.”

Dunbar, who chairs the Wisconsin Homeland Security Council, adds that “preparedness is a process and we do not anticipate declaring ourselves prepared – rather, we will continue to work to improve.” He notes that exercises and training have helped “response efforts to any emergency.”
Link: Interview excerpts from Dunbar and other Homeland Security Council officials

That training was evident in the Cudahy response, Wantuch says. The city was evacuated rapidly. Hospital staff went to shelters to help special-needs evacuees. The mayor held frequent press conferences. Sixty-three fire departments helped fight the blaze, thanks to mutual aid agreements.

But some responders also struggled to follow aspects of the federal model for emergency response, called the National Incident Management System.

A February 2008 blizzard left an estimated 2,000 vehicles stranded overnight on a stretch of Interstate 39-90. A report about the event led to changes: The Department of Transportation implemented a traffic alert hotline, improved communication among state agencies, installed gates and portable barriers on interstate on-ramps and hooked up traffic cameras that had been collecting dust in storage. Joseph W. Jackson III/Wisconsin State Journal

Breakdowns in coordination

NIMS, a detailed framework of common procedures and terminology, is designed to help agencies that usually do not work together coordinate their efforts. Experts say it works — when followed properly. But communication and command-structure breakdowns can result when responders don’t know the system well enough.

These problems were evident in the Cudahy fire response. Response leaders had too many people to manage; one commander supervised 45 officers. Officers attempted to evacuate areas that had already been contacted by other responders. The incident commander failed to follow federal rules regarding labor shifts, resulting in firefighters working to exhaustion. Two specialized incident management teams offered to relieve the Cudahy command, but were turned down because of a miscommunication.

The consequences of not following NIMS protocols vary. Sometimes repercussions are minor: an over-crowded command center, a delay in getting snacks to evacuees. But in fast-moving events, the stakes are higher.

In 1970, miscommunication and a lack of coordination contributed to 16 deaths in southern California wildfires. Afterward the U.S. Forest Service created the Incident Command Structure, which the federal government adopted for NIMS in 2004.

But some responders have struggled to learn the system, due to a lack of training, compliance requirements and funding.

The after-action reports reviewed by the Center cite dozens of problems caused by responders’ unfamiliarity with NIMS.

In August 2007, flash floods in La Crosse County washed out sections of railroad track, overturning cars containing hazardous materials. An after-action report notes that most responders and local residents “may not have been made aware” of the risk, saying “it is unclear” if information regarding protection measures “was received by the public in the affected area.”

A report prepared after the state Capitol protests this year reveals chain-of-command problems from policymakers to police. “State agencies were not allowed to coordinate and discuss plans, nor were they made aware” of other agencies participating in the response, the report says.

And during a dam failure exercise last year in Menominee County, participants struggled with nearly every task, from contacting the appropriate agencies to activating an emergency operations center to knowing how to notify the public.

“Many participants in the exercise asked the question in one form or another — who’s going to be in charge or who makes the decisions?” the Wisconsin Emergency Management exercise director wrote in the report.

Some after-action reports do lead to improvements. Following the Menominee exercise, for example, the county updated its emergency action plan and began using an emergency notification system.

And after a February 2008 blizzard left an estimated 2,000 vehicles stranded overnight on a stretch of Interstate 39-90, the Department of Transportation implemented a traffic alert hotline, improved communication among the statewide Traffic Operations Center, the State Patrol and the State Emergency Operations Center, installed gates and portable barriers on interstate on-ramps and hooked up traffic cameras that had been collecting dust in storage.

However, experts say the state’s rural areas lag behind in their response capabilities due to lack of funds and, in many cases, assumptions that they are not at risk for large-scale disasters.

Compliance hard for rural agencies

Experts say these problems are due less to responders’ unwillingness to learn federal protocols, and more to agencies being overworked and understaffed.

Mark Stigler, a retired Waukesha deputy police chief, wrote his 2010 master’s thesis on strategies to help rural areas meet federal preparedness standards. He says the lack of training is particularly apparent in rural Wisconsin communities, where one emergency manager typically oversees an entire county, with little to no staff support.
Primary source: Mark Stigler’s thesis for the Naval Postgraduate School

He notes that several NIMS courses require emergency responders to take off two or more days from work — something that “is just not feasible in the part-time and volunteer world of rural communities.”

Coaxing cooperation among jurisdictions is another hurdle. Wisconsin municipalities are guaranteed a level of autonomy under the state constitution and cherish that privilege. Under NIMS, separate agencies must work together and sometimes surrender control in the process.

“These are huge philosophical changes,” says Thomas Bauer, a retired Oak Creek police chief who wrote his 2009 master’s thesis on NIMS. “Any time you cross organizational lines, it’s that much clumsier and more difficult to master.”

Bauer and others say it might be unrealistic to expect smaller communities to learn advanced NIMS guidelines, given cuts in homeland security funding and the slim likelihood these regions will need to respond to large-scale disasters.

A certain number of emergency responders are urged to take NIMS classes, depending on their position. But indicating NIMS compliance is often simply a matter of checking boxes on reports to the federal government.

Depending on the type of grant, county and state agencies that receive federal preparedness funding are required to submit after-action reports to the Federal Emergency Management Agency, which is responsible for leading the federal government’s disaster response efforts. State and local agencies may also submit NIMS compliance questionnaires to a FEMA database, allowing local officials to “evaluate and report their jurisdiction’s implementation of NIMS,” according to the FEMA website.

But it is difficult to assess whether local agencies meet these federal preparedness requirements. There is no federal or state requirement for local jurisdictions receiving homeland security funding to report NIMS compliance, and there is no federal requirement for states to track compliance among local jurisdictions. Furthermore, Wisconsin’s NIMS coordinator was recently laid off after funding for the position ran out.

In a 2008 national survey response, Wisconsin Emergency Management Training Supervisor Jerry Haberl cited the lack of compliance enforcement as one of a myriad of reasons why Wisconsin emergency responders struggle to learn NIMS.

“Many agencies are not taking NIMS seriously anymore and are dropping out or going back to their old ways,” Haberl wrote, summarizing the comments of the state’s NIMS Advisory Group. “NIMS is turning into another federal program that we have gotten all excited about one day and then it fades away to obscurity.”

Click the photo to read about drills at Point Beach Nuclear Plant in Two Creeks, in rural Manitowoc County. Courtesy of NextEra Energy

Reports say public health, nuclear readiness good

It’s unclear how Wisconsin’s preparedness ranks compared to other states; studies on the topic are often of limited use, according to experts.

In the few reports that have been done, the state has fared relatively well.

An after-action report on the 2009 H1N1 flu epidemic notes that public health employees communicated frequently with emergency responders, an online epidemic surveillance system was effective and the state had a stockpile of equipment, such as respirators. While some health professionals involved in the response complained that vaccine distribution was “inequitable,” a Wisconsin health department official says the state distributed more vaccines to minorities and underserved groups than any other state.

The state also received a nine out of 10 ranking in a 2010 report that assesses state health care systems’ ability to respond to a bioterrorism attack or other public health emergency. The report says Wisconsin is well-prepared for a public health emergency because, among other reasons, it has an electronic outbreak surveillance system and enough public health staff to handle an outbreak.

But that high score might not mean much, says Michael Greenberger, who directs the Center for Health and Homeland Security at the University of Maryland.

“My own view is the ranking isn’t very reliable, but people take it very seriously,” he says, noting that the report is based on only 10 metrics, which change annually, and that states’ scores can vary greatly year to year. Wisconsin’s score has been as high as 10 and as low as two since the report was first published in 2003.

Henry Anderson, a member of the Homeland Security Council representing the Department of Health Services, says his department is pleased with Wisconsin’s score. He notes that the report is conducted independently of state cooperation and uses only publicly available information to assess the state’s capabilities.

Anderson acknowledged, however, that federal funding cuts combined with a tight state budget might force DHS to “do more with less.”

“The planning and the disaster response activities are going to have to go on whether we get federal funding or not,” Anderson says. “When we have big conventions in Milwaukee or elsewhere that might be a target — we can’t ignore being prepared for those.”

Wisconsin also received high marks in a report assessing states’ preparedness for a nuclear disaster. The report, written by the Council of State and Territorial Epidemiologists, found states with nuclear power plants, including Wisconsin, are much better equipped to respond to an accident than states without them.

However, a 2009 exercise for the Point Beach nuclear power plant, located on Lake Michigan near Green Bay, was riddled with problems: The county emergency management director did not receive important updates, the emergency operations center was not secure, maps were inaccurate and responders could not understand jargon-filled briefings. The following year, another Point Beach exercise went more smoothly, although responders still faced setbacks, including contamination risks during the drill.

The Marshfield police department's special response team provides cover for members of the hazardous materials team as they carry a victim out of a school during a 2001 drill. Craig DeGrand, deputy fire chief, said the exercise highlighted areas for improvement. "As always, communication is a big one of those areas we need to continue working on." Brady Lane/Marshfield News-Herald

Communication problems emerge

During the Cudahy fire, police couldn’t communicate with the command post because their radios operated on a different channel — a problem that has dogged many responders trying to coordinate with multiple agencies during drills and disasters.

The state has poured money into the problem, investing about $79 million since 2003 in communications interoperability — much of which has come from homeland security funds. Over $18 million has been devoted to developing a statewide emergency communications network that can handle multiple frequencies.

As of July, 66 of 80 Wisconsin Interoperable System for Communications sites were active; the state expects to complete the project by November.

But new equipment can be only part of the solution. Brian Jackson, a scientist with the RAND Corp., which provides nonpartisan research on national security issues, says agencies must practice working together in training and disaster exercises more often.

State homeland security experts say these drills have strengthened the state’s preparedness levels since 9/11. But as funding for training dwindles, many emergency responders worry whether the state will be able to maintain its current response capabilities.

“We have folks who are retiring,” says Linda Kollmann, the emergency management director of Winnebago County. “Where are those dollars going to come from to train those new folks? If funding goes away, I fear we’re going to be facing a difficult time.”

Steve Kreuser, the emergency management director of Wood County, agrees, saying: “I think it’s fair to say that with funding reductions, there’s a potential to be less safe.”

“I don’t know how we’ll manage,” says Wantuch, the Cudahy official. “We’ll do the best we can, and hope for the best. It’s all we can do.”

2 thoughts on “Emergency response often uncoordinated in post-9/11 era

  1. Pingback: The “False Dichotomies” Of The Transportation Debate And Other Local Headlines | South Milwaukee Blog

  2. I have been involved in public schools over 30 years, including 11 years as President of Fox Valley Technical College. After retirement, I set up a consulting company and for 5 years assisting colleges in the U.S.and in ther countries. In 2001 I volunteered as FT president and CEO of Unified Catholic Schools, with 1 H.S. 1 Middle School, and 2 Prek-6 elementaries. Our Costs per student was about $6,500. Public School costs in our city is $12,200. I am a strong advocate of parental choice and have written several editorials. I am very encouraged by the articles onyour website.
    One question: Why can’t Catholic schools establish a Charter in WI?
    Stan Spanbauer President emeritus FVTC & UCS