`Introduction
`
`The World Trade Center tragedy on September 11, 2001 was unparalleled in
`nature and magnitude. Never before had anyone intentionally flown
`commercial jetliners carrying thousands of gallons of fuel into a skyscraper.
`Never before had such buildings been so severely damaged by explosion and fire
`that they collapsed to the ground. Never before had a single terrorist act caused
`such a massive loss of life – 2,823 people in all. It was the worst terrorist attack in
`the history of terrorism.
`
`In the aftermath of this extraordinary event, the enormous heroism of the members
`of the Fire Department of the City of New York stands out as an inspiration in the
`face of calamity. Three hundred forty-three FDNY personnel sacrificed their lives
`while trying to save others. They facilitated the safe evacuation of more than
`25,000 people, the largest rescue operation in United States history.
`
`This tragedy has reshaped our expectations about future threats and created a new
`urgency to increase preparedness. Many people believe that more large terrorist
`attacks on the United States are a certainty. The president and Congress are
`seeking to increase the nation’s preparedness through a massive reorganization of
`homeland security agencies. The state, the city, and the FDNY must also take
`steps to prepare for the future.
`
`At the Fire Department’s request, McKinsey & Company spent five months
`working with Department personnel to develop recommendations for change to
`enhance the FDNY’s preparedness. To do this, we studied the Department’s
`response to the attack on September 11 in detail. Our goal was to learn from this
`incident and to define specific recommendations that the Department should
`implement. We did not attempt to reconstruct an exhaustive, minute-by-minute
`history of what the Department and its members did and did not do as they
`responded to the incident.
`
`As our work progressed, we found many examples actions by FDNY personnel
`that saved lives, but we focused on identifying procedures, organization, and
`technology that should be improved to increase the Department’s preparedness in
`the future.
`
`Our team conducted more than 100 interviews with FDNY personnel who
`responded to the attack. We also examined the transcripts of hundreds more
`interviews that the Department conducted internally, and we reviewed a large
`number of dispatch records and about 60 hours of communications tapes.
`Throughout our effort, we had unfettered access to FDNY records and personnel,
`including the Fire Commissioner, his staff and all senior operations personnel. We
`spent more than 1,000 hours working closely with FDNY personnel who
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`U.S. Patent No. 9,445,251
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`responded to the World Trade Center attack, and with personnel who will be
`involved in implementing the recommendations of this report.
`
`We also spoke with more than 100 experts in the United States and abroad,
`including those in other fire departments, emergency agencies and the military, as
`well as researchers and technology vendors. This helped us understand the diverse
`methods and best practices used around the world in responding to major disasters.
`
`During the last three months of this effort, multiple FDNY task forces, involving
`about 50 Fire and EMS personnel (see Exhibit 1), joined us to develop detailed
`recommendations for change on a broad set of issues. Many of these
`recommendations were based directly on work and ideas that the FDNY
`developed. Even as this report was being prepared, several recommendations
`were already being implemented.
`
`This report contains recommendations to the Fire Department in these key areas:
`operations, planning and management, communications and technology, and
`family and member support services. As background, the report also contains a
`description of the key events related to these areas during the Department’s
`response to the attack on September 11.
`
`The Fire Department now faces two major challenges: implementing the
`recommendations successfully and helping the city improve its inter-agency
`planning and coordination. Implementing these recommendations will bring about
`substantial change in the Department, requiring a renewed commitment to
`leadership, accountability, and discipline. But internal change is not enough. The
`FDNY and other government agencies must improve inter-agency planning and
`coordination if they are to fulfill their mission to protect the citizens of New York
`City. The last section of our report discusses this challenge.
`
`* * *
`
`The response to the World Trade Center attack was tremendously complex. We
`hope that this report will help the Fire Department, the city and the country be
`better prepared should we ever be forced to face such a crisis again.
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`Executive Summary
`
`The terrorist attacks on the World Trade Center on September 11, 2001 reshaped
`expectations about future threats and created a new urgency to increase
`preparedness. At the Fire Department’s request, McKinsey & Company spent five
`months working with Department personnel to develop recommendations for
`change to enhance the FDNY’s preparedness.
`
`These recommendations stem from the lessons that emerged from our detailed
`review of the Department’s response on September 11, and from the many
`interviews we conducted with FDNY personnel and with other emergency service
`agencies, experts in fire operations, the military, and technology vendors. Many
`of the recommendations represent the joint efforts of several McKinsey-FDNY
`task forces involving approximately 50 FDNY members.
`
`This Executive Summary contains recommendations to the Fire Department in
`these key areas: operations, planning and management, communications and
`technology, and family and member support services.1 As background, the
`Executive Summary also contains a description of the key events related to these
`areas during the Department’s response to the attack on September 11.
`
`FIRE AND EMS RESPONSE: KEY EVENTS OF SEPTEMBER 11
`
`The FDNY’s response to the attack began at 8:46 a.m., the moment the first plane
`hit Tower 1 of the World Trade Center. The FDNY’s First Battalion Chief
`witnessed the first crash from a nearby street and was the first arriving chief
`officer on the scene. In accordance with FDNY protocols, he established an
`Incident Command Post2 in the lobby of World Trade Center 1 (WTC 1) at
`approximately 8:50 a.m.
`
` 1
`
` Family and member support services are the infrastructure and processes used to notify families of death or injury to
`FDNY personnel, along with post-incident peer and family counseling and support.
`2 The Incident Command Post is the location from which all aspects of an incident response are managed.
`
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`Chief of Department establishes command
`
`At about 9:00 a.m., the Chief of Department took over as Incident Commander.
`At that time, he moved the Incident Command Post from the lobby of WTC 1 to a
`spot across West Street, an eight-lane highway, because of falling debris and other
`safety concerns. Chief officers considered a limited, localized collapse of the
`towers possible, but did not think that they would collapse entirely.
`
`After the Incident Command Post was moved to West Street, several fire chiefs
`remained behind in the lobby of WTC 1, which became an Operations Post for fire
`units operating in that building. Their presence in the lobby was necessary so they
`would have access to important building systems, such as controls for alarms,
`elevators, and communications systems.
`
`Within minutes, the chief officers in WTC 1 decided to focus efforts on rescue and
`evacuation. They sent firefighters up into the building to help the hundreds of
`people trapped in elevators, stairwells, and rooms, along with those who were
`unable to evacuate because they were injured. They also ordered firefighters to
`make sure that floors were fully evacuated.
`
`At the same time, EMS commanders began to set up geographic areas around the
`scene where ambulances could be staged and patients triaged, treated and
`transported to hospitals. The EMS Assistant Chief of Operations assumed overall
`EMS Command at the Incident Command Post, reporting to the Incident
`Commander.
`
`At 9:03 a.m., the second plane hit World Trade Center Tower 2 (WTC 2). Chiefs
`immediately called in additional Fire units3 and deployed units from WTC 1.
`
`Chiefs designate staging areas
`
`As the mobilization escalated, dispatchers instructed responding Fire units to
`report to staging areas4 that senior chiefs had designated near the World Trade
`Center. However, as these units approached the area, many failed to report to the
`staging areas and instead proceeded directly to the tower lobbies or other parts of
`the incident area. As a result, senior chiefs could not accurately track the
`whereabouts of all units. In addition, the failure to stage prevented Fire units from
`getting necessary information and orientation before going into the towers. For
`instance, several units that were not familiar with the World Trade Center layout
`
` 3
`
` A Fire unit is a group of firefighters who have the same assignment, e.g. an engine or ladder company. Most units
`include four to five firefighters and one officer.
`4 A staging area is a resource management area in close proximity to the incident. Units directed to stage are expected
`to respond to the staging area and await further deployment instructions.
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`had problems differentiating WTC 1 from WTC 2. Also, because some units did
`not stage and chiefs were unsure of their location, additional units, that might not
`have been required at that time, were deployed to the incident.
`
`Units arriving at the lobby of WTC 1 checked in with the chief officers at the
`Operations Post to obtain their assignments. Chief officers sent these units up into
`the building in an orderly, controlled way. We believe the same happened in
`WTC 2.
`
`Communications limitations emerge
`
`A number of communications difficulties hindered FDNY chief officers as they
`coordinated the response.
`
`For instance, problems with radio communications left the chief officers in the
`lobby of WTC 1, and probably those in WTC 2, with little reliable information on
`the progress or status of many of the units they had sent up into the buildings. The
`portable radios that were used by the FDNY on September 11 do not work reliably
`in high-rise buildings without having their signals amplified and rebroadcast by a
`repeater system. The World Trade Center had such a system, but chief officers
`deemed it inoperable early in the response after they tested it in the lobby of WTC
`1. With the repeater malfunctioning, the chiefs in the lobby of WTC 1 would not
`have been able to communicate with any units whose radios were tuned to the
`repeater channel, even if such units were just a few feet away from them. On the
`other hand, the command and tactical channels5 on these radios do support some,
`albeit unreliable, communications in high rises. Therefore, the chiefs decided to
`use their command and tactical channels for operations in WTC 1.
`
`Radio communications between chief officers in the lobby of WTC 1 and the units
`they sent in the building were sporadic. The chiefs were able to get through to
`some units sometimes, but not others. Some units acknowledged receiving radio
`communications some times, but not others. This left the chiefs not knowing
`whether their messages failed to get through, whether the units failed to
`acknowledge because they were busy with rescue operations, or whether the units
`did acknowledge, but the acknowledgement did not get through. Because
`information about civilians in distress continued to reach the Operations Post in
`the lobby, the chief officers decided to continue their attempts to evacuate and
`rescue civilians, despite the communications difficulties. We believe that the
`chiefs and units in WTC 2 faced similar communications problems.
`
` 5
`
` Tactical radio channels are used for on-scene communications among chiefs and the units they command. Chiefs
`provide directions to units on this channel while units provide status reports to the chiefs and each other and request
`assistance. Command channels are used by chiefs at an incident to communicate with each other.
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`Chief officers in the lobbies of WTC 1 and WTC 2 also had very little reliable
`information on what was happening outside the towers. They had no reliable
`sources of intelligence, and had no external information about the overall status of
`the incident area, the condition of the towers, or the progression of the fires. For
`example, they had no access to television reports or reports from an NYPD
`helicopter that was hovering above the towers. This lack of information hindered
`their ability to evaluate the overall situation.
`
`EMS chiefs and ambulances also faced communications problems due largely to
`radio traffic congestion. This occurred partly because two EMS channels are on
`the same frequency: the command channel, normally reserved for chief officers,
`and the citywide channel, normally used by ambulances and EMS Dispatch. This
`congestion problem was exacerbated by a number of ambulances that repeatedly
`asked to be dispatched to the World Trade Center.
`
`Radio communications difficulties were one of several factors that led EMS
`Dispatch operators to be overwhelmed with work on September 11. In addition to
`communicating with ambulances and chief officers by radio, EMS operators must
`also act on requests for help sent by the 911 call center and the NYPD via phone
`calls or computer messages. They must assign ambulances, record actions in the
`computer system, monitor information from multiple sources and handle other
`phone calls. The complexity and amount of information related to the World
`Trade Center attack made it extremely difficult for EMS operators to review
`everything they received from multiple sources and take appropriate action
`quickly.
`
`WTC 2 collapses
`
`WTC 2 collapsed at 9:59 a.m., killing many civilians and first responders.
`However, firefighters and chief officers inside WTC 1 were initially unaware of
`precisely what was happening. Many believed that a partial collapse had occurred
`in WTC 1. As the lobby of WTC 1 filled with blinding dust and debris, the First
`Battalion Chief, who was at the Operations Post in WTC 1, immediately issued an
`evacuation order for WTC 1 over his portable radio. However, a number of
`firefighters did not hear that order. Several left the building only because they
`were told by other firefighters that an evacuation ordered had been issued.
`
`The collapse of WTC 2 destroyed the Incident Command Post across West Street
`and weakened the command and control structure, as fire and EMS chiefs at the
`post sought shelter in surrounding structures. The collapse of WTC 1 at
`10:29 a.m. killed the Chief of Department and other officers, temporarily leaving
`the incident without a commander. In addition, following the collapses, many
`EMS personnel were unaware of who was acting as EMS Command.
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`At 11:00 a.m., the Chief of Planning, a high-ranking EMS officer, assumed EMS
`Command, but overall incident command remained unclear for nearly another half
`hour. During this time, several senior fire chiefs took the initiative to restore
`overall command, sometimes leading to multiple incident commanders. Overall
`command was restored at 11:28 a.m. by Citywide Tour Commander 4C, 6 who
`replaced the Chief of Department as Incident Commander.
`
`Inter-agency coordination was minimal
`
`Throughout the response on September 11, the FDNY and NYPD rarely
`coordinated command and control functions and rarely exchanged information
`related to command and control. For example, there were no senior NYPD chiefs
`at the Incident Command Post established by the Fire Department. We believe
`there were very limited communications, either directly or through a liaison,
`between senior FDNY chief officers and the senior officers in charge of the NYPD
`response. In addition, some potentially important information on the structural
`integrity of the buildings never reached the Incident Commander.
`
`Resource management was complex
`
`The response of firefighters and EMS personnel to the World Trade Center on
`September 11 was unprecedented in scale and scope. More than 200 Fire units
`responded, approximately half of all units in the city. More than 100 ambulances
`in the emergency services system responded, about 30 percent of the total
`available. This massive response taxed the FDNY’s efforts to manage its
`personnel and equipment in several ways.
`For example, as the mobilization increased, a number of Fire units that had not
`been assigned to the incident – but wanted to help – contacted the Fire Dispatch
`Center repeatedly by radio, asking that they be authorized to respond. In some of
`these cases, Dispatch relented and assigned them. Many EMS, private, and
`community-based ambulance units did the same with the EMS Dispatch Center.
`This complicated efforts by the dispatchers to manage the response and, in some
`cases, led to the deployment of units that probably would not have been deployed
`had they not insisted.
`
`Only four Fire units proceeded to the World Trade Center without being deployed
`by Fire Dispatch; however, a number of ambulances, both EMS and privately
`operated, responded without authorization from EMS Dispatch.
`
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`
` A Citywide Tour Commander is a staff chief responsible for FDNY operations throughout the city. One citywide
`tour commander is on duty at all times. On September 11, seven citywide tour commanders were designated
`CWTC-4A through H, except for the designation CWTC-4F, which was unused.
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`Another factor that increased the size and complexity of the response was the
`timing of the attack. Because the attack came near a regular tour change, many
`firefighters and EMS personnel who had just finished their tours of duty responded
`with their units, complicating the Department’s ability to keep track of who was
`on the scene.
`
`When the Chief of Department issued a full recall, thousands of off-duty
`firefighters and EMS personnel left their families to help the city and the
`Department respond to the attacks. While the Fire Department had a recall
`procedure for Fire Operations personnel, it had not been activated for more than
`30 years and personnel received no training in its activation. The Department had
`no recall procedure for EMS personnel. As a result, the recall was disorganized
`and ineffective. For instance, recalled firefighters and EMS personnel did not
`have clear guidance on where to go and the Department had substantial logistics
`problems transporting and equipping recalled personnel.
`
`The FDNY requested and received mutual aid from Nassau and Westchester
`counties on September 11. However the Department had no process for
`evaluating the need for mutual aid, nor any formal methods of requesting that aid
`or managing it. Therefore, the Department had limited ability to evaluate how the
`mutual aid could be integrated into its operations. On September 11, this aid
`consisted mostly of engine and ladder companies, some of which deployed to the
`incident and some of which were used to help maintain citywide coverage. As the
`mobilization of personnel and resources grew, all senior fire and EMS operations
`officers responded to the scene. The experience and leadership of these senior
`chiefs proved crucial to re-establishing command and control after the towers
`collapsed. However, had some officers remained at a separate, protected location
`with the appropriate communications infrastructure, they may have been better
`able to support maintenance or re-establishment of incident command and control.
`Or they could have improved management of the Department’s resource pool to
`ensure that all appropriate resources were sent to the scene, while at the same time
`fully protecting the rest of the city in case of another major incident.
`
`In addition, most senior civilian FDNY staff members went to the scene, including
`several deputy and assistant commissioners. Many of them had no role or
`responsibility in the response.
`
`The Fire Department Dispatch Center relocated dozens of firefighting units around
`the city during the incident and successfully maintained citywide coverage for
`regular fire operations. But the Department committed nearly all its special
`operations units such as Hazardous Materials and Rescue teams to the World
`Trade Center, leaving the rest of the city with extremely limited
`special operations coverage. For example, the Department would have been
`unable to respond quickly and effectively to another incident in the city requiring
`advanced hazardous materials capabilities.
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`Record keeping systems were insufficient
`
`FDNY systems to track its own personnel proved insufficient on September 11, as
`did its ability to track patients treated by EMS and taken to hospitals.
`
`Chief officers at the World Trade Center scene kept track of the location and
`assignment of units, but they had no way of backing-up their records. For
`example, the FDNY Field Communications Unit was responsible for tracking the
`assignment of Fire units to different alarms, towers, and staging areas. This unit
`worked next to the Incident Command Post and kept records on a magnetic
`command board, using small magnets placed on a diagram to indicate unit
`locations. Chief officers at the Operations Posts in the two towers also used
`magnetic command boards to track the units assigned to their buildings. These
`boards and the records they kept were destroyed when the towers collapsed. As a
`result, the Department could not quickly create a reliable list of missing and dead
`personnel.
`
`In addition, the Department did not have a complete and accurate family
`notification database with records of whom to contact in case of death or injury of
`a member. Because of this, and because of the large number of firefighters
`missing and dead, there were substantial delays notifying families of the loss of
`loved ones, and the procedures to notify families varied substantially over time.
`
`Throughout the incident, EMS patient-tracking capabilities, which are performed
`manually by EMS personnel, did not hold up well. Because of the large number
`of victims and patients requiring immediate treatment and transport, EMS
`personnel decided they could not accurately complete the paperwork required to
`enable accurate tracking of patients as those patients were transported to different
`hospitals.
`
`Planning and logistics capabilities evolved
`
`During the FDNY response on September 11, officers were not selected to
`coordinate planning or logistics functions7 on a dedicated basis. However, the
`planning and logistics requirements of this incident, particularly post-collapse,
`were well beyond anything FDNY had experienced before. In the days
`immediately following, planning and logistics improved significantly as the
`Department assigned chief officers to coordinate these tasks and received support
`from the Federal Emergency Management Agency, the U.S. Department of
`Forestry Incident Management Teams (IMTs), the U.S. Army Corps of Engineers,
`
` 7
`
` Incident planning includes determining resource requirements and managing information flow. Logistics includes
`managing the deployment and tracking of supplies and equipment.
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`the city’s Office of Emergency Management, construction companies and private
`donors.
`
`RECOMMENDATIONS
`
`Our detailed examination of the FDNY’s response to the World Trade Center
`attack on September 11 indicates that the Fire Department should focus its efforts
`to improve preparedness in the following key areas: operations, planning and
`management, communications and technology, and family and member support
`services.
`In operations, the FDNY needs to expand its use of the Incident Command System
`(ICS), a blueprint for emergency response widely used around the country. This
`will lead to the creation of a well-defined, flexible, and complete command and
`control structure for major incidents, with clear and consistent responsibilities and
`roles. In addition, the FDNY should improve the support it provides incident
`commanders so that crucial functions can be effectively performed, including
`command and control, planning, logistics and inter-agency coordination. And, the
`Department must improve its ability to assess the needs of the rest of the city
`during major incidents and deploy necessary resources to meet those needs. The
`Department would also benefit from having specialized teams that are highly
`trained in managing the response to large and complex incidents. Among other
`operational needs, the Department should have a formal, flexible procedure for
`recalling off-duty firefighters and for activating mutual aid from agencies in
`surrounding areas. It needs to improve its process for ensuring that firefighting
`units stage as required. And, it must expand its hazardous materials capabilities.
`
`Planning is another important component of enhancing preparedness. The FDNY
`must do more to anticipate its future needs, plan ahead for them, and better
`manage the initiatives that will meet these needs. This includes developing,
`expanding and updating procedures and exchanging operational information with
`other agencies. It also involves improving the Department’s ability to assess risks
`and threats across the city so it can create specific response plans for key locations
`and prioritize training and investments in new resources, including special
`operations.
`
`Multiple difficulties involving communications and technology hindered
`firefighters and EMS personnel on September 11. These difficulties pointed out
`the FDNY’s need for an improved process to evaluate, acquire and deploy
`technology and communications equipment and infrastructure. September 11 also
`highlighted a number of critical communications and technology needs that must
`be addressed immediately. These include improving radio communications,
`improving the Department’s ability to receive and disseminate critical information
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`about incidents, and improving the tracking of Department personnel and patients
`treated by EMS.
`
`September 11 also showed that the Department needs a broader and more flexible
`system for providing support services to members and their families, i.e., notifying
`family members when a member of the Fire Department is injured, missing or
`killed, and providing counseling and other services to families and affected
`Department members.
`
`This report has a series of broad and detailed recommendations to address all of
`these needs. However, in order for the recommendations to have any major
`impact, the FDNY must make a renewed commitment to leadership, accountability
`and discipline at all levels, in the field and at headquarters.
`
`We point this out because the FDNY had contemplated several of the
`recommendations in this report before, but never fully brought them to fruition.
`For instance, the Department purchased new UHF radios in 1999, but was
`unsuccessful in an attempt to deploy them in 2001. A few years ago, chief officers
`discussed and planned the creation of a robust Fire Department Operations Center
`that would provide the infrastructure and communications capabilities necessary
`for effective citywide command and control and planning. These plans were never
`implemented. When units failed to stage properly in the past, the Department did
`not follow up systematically so that it could retrain those units, and, if necessary,
`sanction them, their officers, and their commanders. On September 11, as they
`took part in a response of unprecedented scale and complexity, many Fire units did
`not stage properly. They went directly to the lobbies and immediate surroundings
`of WTC 1 and WTC 2.
`
`In an effort to help the Department improve accountability and discipline, we have
`included in this report a number of recommendations for enhanced planning and
`management processes. Ultimately, however, recommendations and processes
`will only go so far. Success will be predicated on managers, civilian and
`uniformed, who are committed to bringing about profound change, are capable of
`leading all personnel by example and are eager to embrace full accountability for
`their own performance. As this report was being completed, the FDNY increased
`the number of staff chief officers in management positions. This additional
`management capacity will help the Department implement these
`recommendations.
`
`We have computed the cost of our recommendations to the greatest extent
`possible. The largest cost could go to ensuring reliable communications in high-
`rise buildings. It would cost $150 million to $250 million to install repeater
`systems in all high-rises in the city. (This figure could be substantially reduced if
`the FDNY finds it can use an existing citywide infrastructure, such as the
`NYPD’s, to help address the in-building communications problem.) The
`remainder of our recommendations would cost $15 million to $25 million, a figure
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`that could rise because several recommendations require that Department bureaus
`and groups change their composition and broaden their skill sets. Many of these
`changes will, no doubt, be accomplished with existing personnel. However, the
`Department may also need to add personnel, expertise and additional equipment to
`fully achieve what is required. Such steps could result in substantial additional
`costs that are difficult to quantify at this time. In addition, the cost estimate does
`not include the expansion of hazardous materials capabilities that we are
`recommending. Since the Department has yet to decide the specifics of the
`expansion, it is impossible to estimate its cost.
`
`Below is a summary of our recommendations for increasing operational
`preparedness, improving planning and management, improving communications
`and technology capabilities and enhancing family and member support services.
`
`Increase operational preparedness
`
`We have seven recommendations regarding operational preparedness, centered on
`establishing procedures and command and control structures that are flexible and
`can be quickly expanded in the event of major emergencies.
`
`1) Expand use of the Incident Command System. This system is used by many
`local, state and federal emergency response agencies around the country. It
`provides a basis for establishing a flexible command and control structure with
`defined roles, clear communications protocols and adaptable procedures. We
`recommend that the Department:
`
`¶ Review all its procedures to ensure consistency with ICS principles.
`¶ Train all FDNY personnel likely to be involved in incident response in
`ICS principles, and continue this training on a regular basis.
`
`¶ Create dedicated, ongoing training programs for FDNY chiefs so that
`they are proficient in using ICS principles during large and complex
`incidents involving terrorism, chemical, biological and radiological
`materials, and attacks to critical infrastructure.
`
`2) Further develop the Fire Department Operations Center. This center,
`which now monitors and reports on daily Department activities, should be
`expanded into a fully functional emergency operations center. It should have
`infrastructure and communications capabilities to provide citywide command,
`control, and operational planning, and support for inter-agency coordination
`during routine operations and major incidents. During resource-taxing events,
`senior operations personnel should report to the center to set operational priorities;
`manage resources and citywide coverage, including the initiations of recall and
`mutual aid requests; and ensure that command and control is maintained for
`incidents across the city.
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`3) Create Incident Management Teams. These teams should be comprised of
`specialized, highly trained personnel who would be activated in response to major
`incidents. Each team member should have expertise in a particular aspect of
`incident management, such as operations or planning. We recommend
`establishment of two teams of 21 individuals to ensure around-the-clock coverage
`over a period of weeks.
`
`4) Deploy a flexible r