Lessons from 9/11: How Systems Fail and People Rise to the Occasion

9/11 is more than just a traumatic scar on our memories. It is also a reminder of how systems lacking due care and preparation can fail in a crisis, and of how human beings with training and empathy can shine a powerful light into the darkness to bring aid to those who need it most. 

For those of us of a certain vintage, it’s hard to believe that 9/11 was twenty years ago. Watching footage of the events of that day brings back memories so vivid that it feels as though we’re experiencing them again for the first time. 9/11 is a scar on our collective consciousness. For those who lost someone in the attacks, it is a trauma that will never completely heal. 

It’s striking that the way we refer to that event—“9/11”—demonstrates an intriguing way we think about time in relation to cataclysmic disasters. “9/11” represents a day, a twenty-four-hour span. Yet what we really mean by that term is the much smaller amount of time between 8:46 a.m. and 10:28 a.m. EDT. 102 minutes out of the 1,440 minutes of that day. 102 minutes that represent the end of one historical epoch and the beginning of another. We simply say “9/11,” not “8:46-10:28 a.m. EDT 9/11.”  

It’s as though our minds don’t want to acknowledge the almost infinitesimal amount of time that separates mundane, everyday existence from unfathomable loss and chaos. “9/11” is the closest we can get to acknowledging the reality that life can end with the speed at which we turn on the lights in our home, and that the consequences of a moment in time can extend beyond our mortal existence. 9/11 changed more than the geopolitical landscape of the world; it changed the way we, as human beings, live in the world. 

Health and safety practitioners will recognize some familiar themes in the story of what happened on 9/11. Despite the singularly unique manifestation of the events of 9/11, it has elements in common with other disasters, such as the Deepwater Horizon or the Space Shuttle disasters. There were, for example, leading indicators testifying to the possibility of this outcome, such as the scattered intelligence that terrorist organizations were planning and preparing for operations against the United States, as well as the previous 1993 attack on the World Trade Center demonstrating its attraction as a primary target. There were multiple organizational frameworks tracking this information but not aggregating it to see the narrative that was obvious in retrospect. There was a story, hiding in the disparate data, waiting to be told, but there was no way to read it and anticipate what was going to happen. Instead, information existed in silos, protected by gatekeepers responsible for their own KPIs and with no awareness of systems thinking that would allow them to see a bigger picture. 

The National Institute of Standards and Technology (NIST) is running a series of blogs that highlight another tragic example that will be familiar to health and safety practitioners. First responders, including firefighters, police officers and paramedics, were unable to coordinate and communicate because, at that time, there was no standard for interoperability between radio communication devices from different manufacturers. Post-disaster investigation determined that this was a significant factor in the failure to communicate the impending collapse of the towers to the firefighters inside, which resulted in 343 firefighters losing their lives when the buildings fell to the ground. 

Yet alongside such failures lie untold moments of heroism, finely tuned situational awareness and deep expertise in a crisis. The maritime evacuation of 500,000 people from Ground Zero represents only one example. With the tunnels and bridges closed to traffic, hundreds of thousands of people were trapped in Lower Manhattan while the disaster unfolded. The United States Coast Guard broadcast a general message to all maritime vessels in the area requesting help getting people to safety. Hundreds of boats, from private boats to tugboats to garbage scows to the Staten Island Ferry, turned up to evacuate over half-a-million people, despite knowing that the boats themselves could also present themselves as potential targets. Throughout the day, boat captains organized themselves and found innovative solutions to difficult problems to get people to safety.  

In unprecedented circumstances, situational awareness, deep expertise and human decency prevailed to bring some order to the chaos of that day. While there is no shortage of anecdotes relating to the failure of organizations to understand the importance of systems thinking and integration, data management and information sharing, those on the ground relied on their training and their safety culture to keep their heads about them. 

9/11 is more than just a traumatic scar on our memories. It is also a reminder of how systems lacking due care and preparation can fail in a crisis, and of how human beings with training and empathy can shine a powerful light into the darkness to bring aid to those who need it most.

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