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Terror attacks against the World Trade Center, September 11th, 2001 – KAMEDO-report 84

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.

This report is entirely in Swedish. Only summary in English.


New York is one of the world’s leading financial centres and the foremost trade and industrial city in the United States. The island of Manhattan, the heart of the city and its administrative centre, is one of the most densely populated areas in the world. It was there, in the World Trade Center, that the terror attack that can be categorised as the greatest disaster caused by man during peacetime happened.
On September 11th 2001 at 8.46 in the morning, the first airplane crashes into the north building, the 110-story skyscraper World Trade Center 1. The plane is a Boeing 767 that departed Boston with 92 people onboard. It crashes into the building about level with the hundredth floor. The fully fuelled aircraft causes enormous damage and an explosive fire breaks out high up in the building. The damage is so extensive that the fire fighters in the brigades who responded first were doubtful even as they drove to the scene whether they would be able to have any effect on the course of the disaster.
Upon arrival at the scene, fire fighters encountered difficulties reaching the burning skyscraper due to falling objects and despairing people jumping from the building, desperate to escape the flames. A disaster command centre was set up in the lobby of the building. From there, large parts of the fire brigades go up in the tower via the stairwells. On the way up in the building, fire fighters encounter people who had been below the damaged floors, who proceed down and out of the building in a rather orderly fashion. But outside the building chaos reigns, as communications have essentially broken down.
Seventeen minutes later, at 9.03, the second hijacked plane crashes into the second skyscraper, World Trade Center 2. The aircraft is also a Boeing 767 flying out of Boston with 65 people onboard. The immediate consequences are almost even more devastating this time, as the plane hit the skyscraper at a lower level.
Here, as in the other tower, the fire command decides to set up the command centre in the lobby. At that point, there were already indications that the skyscraper hit first might collapse, but the determination to try and save as many people as possible makes it difficult to call off the rescue effort. Once the decision to stop has been made, communications are no longer working. For that reason, the order to evacuate probably does not reach the fire fighters who are up in the second tower.
The first building to collapse is World Trade Center 2, at 10.05 in the morning, 57 minutes after the plane hit the building. About 29 minutes later, the tower hit first also collapses and everyone still inside the buildings are on the way towards certain death. Surrounding buildings in the entire World Trade Center complex are seriously damaged. It is impossible to get a clear view of the disaster scene and the scene is inaccessible for continued rescue efforts for several hours. In addition, all types of communication and power supply across large parts of Manhattan have been almost completely knocked out.
The collapse of the two skyscrapers caused dust and smoke so thick and widespread that it was hard for people in the area to see anything at all. For that reason, the most common injuries suffered by those people were respiratory and eye injuries.
Once the smoke had dispersed, the dust had settled and the surviving fire fighters and paramedics had begun to understand what had happened, the rescue effort could be resumed. A coordinated disaster command could not be immediately re-established. Consequently, most fire fighters and paramedics were acting independently. Ambulance transports went to the nearest hospitals, which a large number of victims were also able to get to on their own. Some of the assembly points set up early in the course of the disaster were able to be re-used to a certain extent. Others were moved due to the risk that other buildings might also collapse. A large number of volunteers also went to the assembly points, but their help was not needed. Disaster teams from other states later joined the effort.
A disaster was declared at the hospitals at a very early stage and they were able to quickly mobilise sufficient resources to accept an expected deluge of injured victims. The most seriously injured arrived relatively soon after the first crash, but after the twin towers had collapsed hospital staff began to realise that the number of survivors would be limited. For that reason, there ensued a painful wait for injured survivors who never came.
As the hours passed, however, many rescue workers injured while trying to extinguish the fire and locate survivors arrived. Most had eye symptoms or other minor injuries.
The attack against the World Trade Center caused extreme psychological stress to emergency service personnel in New York. Even though the fire department is divided into a large number of small fire stations, many of the fire fighters were close friends. Nor were family connections of various kinds unusual. More than 350 fire fighters died, causing traumatic losses to thousands of people along with the risk for severe grief reactions that can bring. Consequently, a significant increase in psychological problems and illness can be expected among New York fire fighters and their families and friends.
The American people and New Yorkers in particular fell prey to what is usually called a national trauma, that is, an event that affects an entire population, whether people were actually physically injured or not. The number of people suffering acute stress disorder, post-traumatic stress disorder and traumatic grief reactions seems to have been of the extent expected in connection with a trauma of this kind. The nature of resulting psychiatric injuries depended on the personal impact of the event and how close people were to the World Trade Center when the attack happened.
The observers’ experiences
• When general disasters are declared in parts of the world considered highly developed, there is a very rapid and effective mobilisation of fire brigades, ambulances and medical personnel at hospitals. The lack of resources that by definition is part and parcel of the disaster scenario is usually short-lived. The World Trade Center disaster was of such a nature that it exceeded human capacity to impede the progress of the fire, the continued destruction of the skyscrapers and their final collapse.
• It was impossible to predict that the twin towers of the World Trade Center would collapse. As a result of the experience with this kind of explosive fire in tall buildings, risk assessment and response planning will certainly be preceded by much more careful analysis than before.
• Once a disaster response has commenced it is very difficult for disaster command to call off the effort because rescue personnel are being exposed to danger. The determination to try to reach everyone in need is so strong that rescue personnel often realise too late that their own lives are in jeopardy.
• When explosive fires of this type break out high up in skyscrapers it is impossible with today’s resources to effectively fight the fire from ground level.
• The communications system, such as the centralised telephone network with its antenna system, was localised in WTC 1. The components of the system should be spread over multiple systems to reduce the risk of damage. Communication problems between rescue personnel at the scene and the medical care system are very common in the context of major accidents or disasters. This is true regardless of how many radio and telephone systems are used. It could be worthwhile to train rescue workers and prehospital personnel to act independently in the absence of command.
• Where there are large numbers of injured victims, all forms of transport should be used, including vehicles not normally used for medical transport.
• Setting up assembly points for injured people adjacent to a disaster scene that is in the vicinity of a hospital is rarely of any value to the most seriously injured, but they may serve a purpose with respect to minor injuries and for providing basic medical care to, e.g., rescue personnel.
• The availability of medical personnel in connection to a disaster scene increases with every hour that passes. By the time personnel numbers are at their highest and an assembly point has been established, the most seriously injured have long since been transported to hospitals. That is often the consequence when prehospital medical personnel do not arrive at the scene fast enough.
• Documentation of the medical care provided at the scene, during transport and at the hospital is often inadequate when there are many casualties. For that reason, the “triage tags” used for reporting should be simply designed. It should be easy to mark injuries on a drawing of a figure where only parameters that apply to unobstructed respiratory passages, breathing and blood circulation are recorded. Identity is established from the outset by means of an ID number.
• It is not unusual for power outages that affect people and buildings to occur in conjunction with major disasters. The reserve power system probably needs to be expanded and improved, not only within the medical area but also for, e.g., computer systems.
• The fire fighters who survived the disaster suffered extreme psychological stress, both during the disaster and for a long time afterwards. For several, this has led to lingering psychological symptoms and higher alcohol consumption. Continuous medical and psychiatric follow-up for everyone in the affected occupations is important.
• About ten percent of the general population developed post-traumatic stress disorder within the first year after the disaster, as evident in the many psychiatric studies performed in its wake. The percentage was higher among those who had survived the attack or were near the scene of the disaster when it occurred. Likewise, post-traumatic stress disorder was observed in more people during the first six months after the attack.
• The enormous attention that this terror attack received has probably had both positive and negative and direct and indirect psychosocial impact on victims. Rarely has it been possible for a disaster to be so closely covered by the mass media and shown over and over again, causing the trauma to constantly recur. On the other hand, a disaster has rarely engendered equally great national and international compassion and solidarity.

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Susannah Sigurdsson
+46 (0)75 247 30 00