Exploring the limits of organization

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9/11

• Exploring the limits of organization

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The highjacking

• Four long range domestic flights
• American Airlines Flight 11 Boston to LA
• United Airlines Flight 175 Boston to LA
• American Airlines Flight 77 Washingt. to LA
• United Airlines Flight 93 Newark to SF
• 4 5 persons, prior flight training
• Take control using knives, teargas, threats
• Turn of tracking device - transponder

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The defense system

• Air control
• Federal Aviation Administration (FAA)
• Military Air Defense
• North American Aerospace Defense Command (NORAD)
• The President / Government

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Federal Aviation Administration FAA

• Responsible for regulating safety and security of
  civil aviation
• Primary task maintaining a safe distance between
  airborne aircraft

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Federal Aviation Administration FAA

• 22 Control Centers regions
• Receive information and make operational
  decisions independently
• 1 Command Center national control
• Operations Center

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North American Aerospace Defense Command (NORAD)

• Responsible for defending the airspace in North
  America and protecting the continent
• After cold war new role
• Some exercise on terror attacks but never on
  domestic aircraft and not as guided missiles

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North American Aerospace Defense Command (NORAD)

• 7 alert sites with 2 fighter aircraft on alert
• 3 sectors
• On 9/11 all aircraft were in Northeast Air
  Defense Sector (NEADS)
• NEADS reports to CONR, CONR to NORAD
• 2 alert sites relevant
• Otis Air National Guard Base in Cape Cod
• Langly Air Force Base in Hampton Virginia

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National Guard troops stationed at NORAD's
Northeast Air Defense Sector (NEADS) in Rome,
New York.
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Interagency Collaboration

• Hijack protocol FAA and NORAD
• Pilots notify controller
• Controller notify supervisors
• Supervisors inform Control Center management
• Manager inform FAA headquarters in Washington
• Hijack coordinator director of FAA Office of
  Civil Aviation Security

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Interagency Collaboration

• Hijack protocol FAA and NORAD
• FAA Highjack coordinator contacts Pentagon to ask
  for military escort aircraft
• Pentagon seek approval from Secretary of Defense
• If approved orders transmitted down NORADS chain
  of command
• Pentagon help FAA coordinate with military

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Interagency Collaboration

• Hijack protocol FAA and NORAD
• Did not have instructions for interception
• Fighter aircraft mission vectored to a position
  five miles directly behind the hijacked aircraft

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Interagency Collaboration

• Protocol assumptions
• Hijacked aircraft readily identifiable and would
  not disappear
• Time to address the problem through proper chains
  of command
• The hijacking would aim at landing the aircraft
  and placing demands

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Interagency Collaboration

• On the morning of 9/11, the existing protocol was
  unsuited in every respect for what was about to
  happen.

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Flight controller Matt McCluskey stands in the
Boston tower where the Flight 11 hijack was
first detected
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American Airlines Flight 11

• Chain of command not followed
• FAA did not contact NORAD through chain of
  command
• Lack of information coordination between FAA and
  military

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United Airlines Flight 175

• Unnoticed disappearance because of AA 11
• No military notification

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American Airlines Flight 77

• First thought to have crashed
• Disappeared
• Was then found by Dulles Control Center
• FAA never reported to the military before crash
• FAA did not ask for military assistance

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Confusion arises

• At 921 FAA misinforms NEADS (NORAD) about the
  number of aircraft
• NEADS acts on the confusion that American 11 was
  still airborne and heading towards Washington
• NEADS scrambles Langley to intercept this
  phantom aircraft

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Confusion arises
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Confusion arises
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Confusion arises

• 9 34 NEADS contacts FAA to find out about
  American 11 (had crashed 846)
• Learns about American 77

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Confusion arises
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Confusion arises

• FAA Boston Center guessed that Delta 1989 might
  be hijacked and heading south
• NEADS orderd figher aircraft from Ohio and
  Michigan to intercept

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United Airlines Flight 93

• Chain of command followed fast from Cleveland
  Center through FAA headquarters (2 min.)
• FAA had established and open line between centers
  and the Command Center
• However, FAA did not seek military assistance
• NEADS informed after crash

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United Airlines Flight 93
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United Airlines Flight 93
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National leadership

• President away
• No serious attention before United 175 hit 2 WTC
• FAA and Department of Defense teleconference. No
  impact.
• White House video teleconference including CIA,
  FBI, DoS, Justice, Defense, FAA, White House
  Shelter.

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National leadership

• National Military Command Center (NMCC)
• Establish the chain of command from National
  Command Authority (President and secretary of
  Defense) and those executing orders.
• Problematic teleconferences between top agencies.

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National leadership

• No success in coordinating information and
  decisions between the top level organizations
• FAA
• NORAD
• NMCC
• National Command Authority
• Direct contacts between Secret Service and FAA

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Vice President Cheney pointing a finger inside
the Presidential Emergency Operations Center.
Footage of the World Trade Center plays on the
televisions in the background (exact time is
unknown).
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The shoot down order

• Unclear when the order was given from the Vice
  President from the White House shelter.
• Confusion within NORAD on the nature of the order
• Orders not passed on to the operational level
  the pilots.

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The Andrews fighters

• Through direct contact between Secret Service
  agents and the commander of the 113th Wing
  fighters were launched from Andrews Air Force
  Base at 1038
• Orders weapons free
• Scrambled outside military chain of command.
• Not known by President and Vice President.

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• The details of what happened on the morning of
  September 11 are complex, but they play out a
  simple theme. NORAD and FAA were unprepared for
  the type of attacks launched against the United
  States on September 11, 2001. They struggled,
  under difficult circumstances, to improvise a
  homeland defense against an unprecedented
  challenge they had never before encountered and
  had never trained to meet.

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What is this a case of?

• The weakness of established routines in
  unexpected circumstances
• How human mistakes creates chains of
  interdependent failure
• The problems of coordinating between large
  organizations that rarely operate together on a
  daily basis
• The impact of an extremely tight schedule