Inside: Part 1 - Part 2 - Part 3 - Part 4 - Part 5

JIM DWYER, KEVIN FLYNN and FORD FESSENDEN
By THE NEW YORK TIMES

From The New York Times on the Web (c) The New York Times Company. Reprinted with Permission.

Minutes after the south tower collapsed at the World Trade Center, police helicopters hovered near the remaining tower to check its condition. "About 15 floors down from the top, it looks like it's glowing red," the pilot of one helicopter, Aviation 14, radioed at 10:07 a.m. "It's inevitable."

Inside the NY Times Story Part 1 - 9/11 Exposed Deadly Flaws in Rescue Plan Part 2 - Communications: 'Down to the Lobby,' But No One Came Part 3 - Command: Distrust Separates Police and Fire Part 4 - Control: Discipline Broke Down in Eagerness to Help Part 5 - Sacrifice: 'We'll Come Down in a Few Minutes' Interactive @NYTimes.com Off Site: Free New York Times Registration Required to Access Certain Segments At the Scene Audio: 9/11 Dispatch Transcripts and Transmissions Map: FDNY Response 9/11 Firefighters: Interviews/Oral Histories More 9-11 Coverage Firehouse.com's 9-11 Coverage 9-11 Emergency Services Victims Database Insider Forward: E-Mail This Page to a Friend or Co-Worker Interact: Discuss This and Other Topics in the Firehouse Forums

Seconds later, another pilot reported: "I don't think this has too much longer to go. I would evacuate all people within the area of that second building."

Those clear warnings, captured on police radio tapes, were transmitted 21 minutes before the building fell, and officials say they were relayed to police officers, most of whom managed to escape. Yet most firefighters never heard those warnings, or earlier orders to get out. Their radio system failed frequently that morning. Even if the radio network had been reliable, it was not linked to the police system. And the police and fire commanders guiding the rescue efforts did not talk to one another during the crisis.

Cut off from critical information, at least 121 firefighters, most in striking distance of safety, died when the north tower fell, an analysis by The New York Times has found.

Faced with devastating attacks, the city's emergency personnel formed an indelible canvas of sacrifice, man by man and woman by woman. They helped rescue thousands. They saved lives. They risked their own.

From the first moments to the last, however, their efforts were plagued by failures of communication, command and control.

Now, after months of grief, both the Fire and Police Departments are approaching the end of delicate internal reviews of their responses to the attack. Those reviews have concluded that major changes are needed in how the agencies go about their work and prepare for the next disaster, senior officials say.

A six-month examination by The Times found that the rescuers' ability to save themselves and others was hobbled by technical difficulties, a history of tribal feuding and management lapses that have been part of the emergency response culture in New York City and other regions for years.

• When the firefighters needed to communicate, their radio system failed, just as it had in those same buildings eight years earlier, during the response to the 1993 bombing at the trade center. No other agency lost communications on Sept. 11 as broadly, or to such devastating effect, as the Fire Department.
• Throughout the crisis, the two largest emergency departments, Police and Fire, barely spoke to coordinate strategy or to share intelligence about building conditions.
• During those final minutes, most firefighters inside the north tower did not know the other building had crumbled, and how urgent it was for them to get out. Instead, dozens of firefighters were catching their breath on the 19th floor of the tower, witnesses say. Others were awaiting orders in the lobby. Still others were evacuating the disabled and the frightened.
• To this day, the Fire Department cannot say just how many firefighters were sent into the towers, and where they died. It lost track of them, in part because some companies did not check in with chiefs. Individual firefighters jumped on overcrowded trucks, against policy. Others, ordered off the fire trucks, grabbed rides in cars.
• The city's intricate network of safety coverage showed signs of unraveling that morning because of the headlong rush to Lower Manhattan. Police officers left their posts, senior police officials said. A chief with the Emergency Medical Service said they had no ambulances for more than 400 calls. The region's bridges, tunnels, and ports were drained of protection, said the chief of the Port Authority police.
• Although Mayor Rudolph W. Giuliani created the Office of Emergency Management in 1996 and spent nearly $25 million to coordinate emergency response, trade center officials said the agency had not conducted an emergency exercise there that included the Fire Department, the police and the Port Authority's emergency staff.

The Fire Department began its first self-examination in December, when nearly 50 senior fire officials took part in a two-day planning exercise with the United States Naval War College. The college evaluators concluded: "As a function of command and control, it was evident that the Fire Department has no formal system to evaluate problems or develop plans for multiple complex events. It was equally evident that the Fire Department has conducted very little formal planning at the operational level."

Thomas Von Essen, the city's fire commissioner from 1996 through 2001, and a former president of the main fire union, said he agreed with that analysis, which was undertaken to explore the ability to respond to major disasters. The fire commissioner has limited authority to hold senior chiefs accountable, Mr. Von Essen said, because nearly all enjoy Civil Service protection.

"The pain is still there and it'll be there forever," Mr. Von Essen said. "But you have to start thinking about the reality of the world that we live in today. And that demands better leadership, more accountable leadership, a better-trained leadership, a more disciplined leadership that then filters down to a better-trained and more disciplined set of troops."

Many chiefs, for their part, have long cited Mr. Von Essen's leadership as a major department failing. The results of other reviews, covering police and fire performance, are due within a few weeks from the consulting firm McKinsey & Company.

For Mr. Von Essen, a searing topic is the high number of firefighter casualties in the north tower. The collapse of the south tower after 57 minutes shocked the fire commanders. Yet more than a third of the 343 firefighter deaths were in the north tower, even though it stood 29 minutes longer. The failure of more firefighters to escape in those 29 minutes baffles Mr. Von Essen. He believes many got word to leave.

Should we know the answers to all of that stuff by now? Absolutely," Mr. Von Essen said. "But do we really want to know the answers to these questions? I don't think the department really wants to know."

He could not explain why the police had not reported to fire commanders, the official leaders of the response. "That day the police did not hook up with the Fire Department," Mr. Von Essen said. "I don't know why."

Too many firefighters, he said, were sent into the towers, and too many came without being told they were needed. "I've been a firefighter since 1970, and have often stood on floors where we needed 10 people and had 30," Mr. Von Essen said. "There's a lack of control that's dangerous on an everyday basis to firefighters."

Police Commissioner Raymond W. Kelly said the eagerness to respond could put both police officers and the city at risk. "People got on the subway and came down," he said. "We need a much more controlled response these days. Why? Because we have to be concerned about secondary events."

Both Mr. Von Essen and Mr. Kelly said rigorous scrutiny of their agencies was vital. "We should not second-guess the people at the scene, or the way they handled it that day — they did a terrific job at the scene, and you will not find better chiefs anywhere in the country than the ones who ran things," Mr. Von Essen said. "I think we should second-guess our procedures, our policies, our history."

Mr. Kelly, who led the police a decade ago and returned in January, said: "Now, literally, that the dust has settled, we are obligated to look at these things and to learn lessons. We are in the business of emergency response. That's our business, every day. We have to think in a systematic way."

To explore the emergency response on Sept. 11, Times reporters interviewed more than 100 firefighters, police officers, emergency medical workers, government officials and witnesses. Those interviews were supplemented by reviews of 1,000 pages of oral histories collected by the Fire Department, 20 hours of police and fire radio transmissions and 4,000 pages of city records, and by creating a database that tracked 2,500 eyewitness reports of sightings of fire companies, individual firefighters and other rescue personnel that morning. The city has refused to release thousands of pages of accounts by firefighters and their superiors.

On Friday, Fire Commissioner Nicholas Scoppetta said the city intended to create a radio channel that could be shared by police officers and firefighters, among other changes. "There is no question there were communications problems at this catastrophic incident," he said.

Bernard B. Kerik, the police commissioner at the time, said he did not believe that any communication problems between the agencies had significantly affected their performance. "I was not made aware that day that we were having any difficulty coordinating," he said.

Inside: Part 1 - Part 2 - Part 3 - Part 4 - Part 5