Firefighters and emergency medical technicians typically don’t spend much time — if any — training for mass-fatality incidents (MFIs), such as plane crashes, tornados, floods and tsunamis. Consequently, there are few experts among first responders regarding such events. But even though everyone would just as soon avoid having to deal with an MFI, incident commanders should at least have basic knowledge of how to do so.

FEMA defines an MFI as “an incident where more deaths occur than can be handled by local resources.” In practice, the number of victims that each medical examiner can handle depends on locale and available resources. Generally, more resources are available in urban settings than in rural areas. The quantity also is based on the ability to store bodies, which is a function of whether refrigeration facilities are available, and on how many decedents can be processed per hour, which is a function of how many doctors and technicians are on staff. The quantity also depends on the type of autopsy needed and how many of the different types can be done per hour. It gets very complicated and, as a result, it often is difficult to determine the number of victims that can be processed.

Complicating matters is that first responders in the field often have no idea what agency is in charge of planning an MFI response, who is in charge of the initial response, what agencies need to be called and when, or how command is transferred. While they know all of the above regarding mass-casualty incidents, the standard operating procedures and command structure are unclear at an MFI. This is a major, but not unusual problem.

'I Am NOT Trained for This'

In January 1990, I was serving as a lieutenant and was among the first responders dispatched to the site of a plane crash in Cove Neck, N.Y. A commercial airliner ran out of fuel with 150 people on board. After the crash we had to deal with 75 fatalities and 75 injured in a somewhat remote area. While we were attending to the living, I remember thinking, “I am NOT trained for this!” Imagine a large plane cracked in half with bodies and debris everywhere, people screaming, chaos, lights, sirens, and a host of other distractions. I was trained to rescue the injured, not to handle fatalities in mass quantities. Nor was I trained on how to command my crew in this extremely hostile environment.

Consider also that this was a time when critical incident stress management consisted of having a smoke and a beer — tomorrow we get back to work.

Today we have the resources we need to handle everything that could happen, including an MFI, but most first responders still do not train for such incidents, and most municipalities and fire departments don’t have in place realistic operational policies and plans for dealing with them. Of those that do, their plans generally are only a few pages long and give little specific direction on what to do or who to call.

Let’s examine how to address this. The first step is to develop an over-arching policy and standard operating procedures. An MFI response is not like gathering a bunch of people to play flag football 15 minutes before you want to play. An incident of this type requires hundreds of hours of preparation and involves hundreds of trained response personnel.

One option you might consider when drafting your plans is to handle an MFI yourself. But before you select this option you must seriously consider whether your department realistically has the resources to do so. The training and equipment that is required for an MFI response is costly and will tax your department’s resources. Establishing an MFI capability is similar to setting up a hazmat team in that the jurisdiction needs to commit to continued training, drills and up-to-date equipment. However, where a hazmat team consists of roughly eight highly trained personnel, an MFI team requires anywhere from 100 to 200 highly trained personnel.

A better option might be to call in a Disaster Mortuary Operational Response Team, or DMORT, to respond. DMORTs are federal responders — operating under the auspices of the Department of Health and Human Services — and consist of highly trained and experienced personnel. There are 10 teams nationally, and each can be at the scene with advisors within four hours of an incident. A full crew would arrive within eight to 12 hours. DMORTs can assist on many levels, but their primary goal is to assist in processing and identifying victims. They do not provide support to rescue workers or victim assistance unless the incident is declared a federal disaster. It is important to note that the federal government will help by providing advice and certain resources, but you are expected to command and supply all essential components to mitigate the incident.

One last option is to call in a private company with expertise in MFI response, such as Kenyon International. There are others out there, but my research indicates that Kenyon is the largest and oldest of its kind, and operates in almost every country in the world. It also is the only company that offers all of the services that are required to plan and execute an MFI response, including: family and survivor assistance; search, recovery and mortuary services; and call-center and crisis communications. Other private companies offer only some of these services.

The Nuts and Bolts

Sometimes, before an MFI occurs, we are fortunate to receive some advance warning, for instance, that a plane is in distress because it is running low on fuel or has some mechanical problem. But usually there is no warning, such as when a tornado hits or an act of terrorism occurs. When that happens, the police arrive on the scene and radio for the cavalry. Next is a series of “all hands” notifications. Based on policy, if one exists, alerts go out to specific groups and, as command is established, a larger network of alerts are sent out. At the incident, the police generally will secure the area while fire department and EMS personnel search the scene.

But what happens if the event is a larger incident that involves multiple homes or buildings? What if the incident crosses multiple jurisdictions? What if, like the 9/11 attacks, it is an act of terrorism that requires federal response and that potentially affects thousands of people, not hundreds? What if it involves a school full of children? The list of “what ifs” goes on and on.

However, the basic premise is the same. Law enforcement secures and investigates, while fire and EMS search and rescue. But what if there is no one to rescue? What if you are left with only bodies? Who removes them from the scene and takes them to the medical examiner? Who returns the scene to its original condition? The ability to answer these questions depends on a deeper understanding of the options that are available to you.
If you choose either of the first two options above — whereby your personnel will be tasked with doing most, if not all of the work — you will need to consider how they will be trained.

Remember this is very specialized training, so you will need a trainer who is an expert in mass-fatality incidents. Do not treat an MFI as a mass-casualty incident, with the only difference being that large numbers of victims — perhaps all of them — are dead.

Triage or treatment may or may not be needed in the aftermath of an MFI, but such events require a host of unique procedures and rules. For example, expanded psychological training is required.

Also, special scene-management procedures will need to be implemented because your personnel potentially will be operating in a crime scene. Protocols for dealing with the loved ones of victims will need to be developed and followed.

Keep in mind that an MFI will attract the media in droves — you do not want your personnel showing up on CNN doing or saying something inappropriate because they were untrained. There are special communication skills that are unique to an MFI. There are very few organizations that are equipped and trained for this kind of undertaking and most likely yours is not, at the moment, one of them. Remember this important lesson: Wherever the plane, train, bomb, tornado or accident touches last becomes that local jurisdiction’s problem. You cannot pass it off. This goes for Los Angeles, Miami or the proverbial Mayberry — you own it.

Additional Challenges

Another major problem to overcome is deciding who is going to do what. I know of one municipality that is developing an MFI plan, and the biggest challenge that it is facing is that no one wants to play. What I mean by this is that the fire department says an MFI would be a police matter. Meanwhile, the police has no assets or budget to deal with such an event, so they say that, after scene security, it’s the medical examiner’s problem. But the ME says that his office cannot do it alone, so they will need help from fire and police. In other cases, such as in rural or remote areas, there is no one to play at all.

“Key MFI Response Components” lists some of the things that you will deal with when an MFI happens. Start thinking about the different agencies, the quantity and quality of personnel and equipment, and the structures that will be required for each component. Remember to be realistic in determining your needs.

There are additional components, but even at this stage you must be thinking, “Where am I going to get 200 trained people to deal with this?”

A complicating factor is that your department — and the mutual-aid departments that serve your area — still will need to provide their normal day-to-day response. When an MFI occurs, your department quickly can become outmanned and outgunned.

Once the basics of field operations are considered, there still is more to do before a decision can be made as to which of the three options presented above makes the most sense for your department. Specifically, you still need to determine who will play in your sandbox and what toys they have. Again, most response agencies deal with the injured, not the dead.

Organizations like the American Red Cross or the Salvation Army can provide support in the aftermath of an MFI, generally by offering assistance to the victims’ families, but they do not provide any recovery assistance.

Once you identify who will do what, you need to understand the capabilities the each entity has in place for this type of incident. Once that has been done, then you can field a team and equipment. In doing so, you have to take a careful look at every strength and weakness. Most important, a policy needs to be written that everyone will buy into and the department needs to commit to the essential MFI-specific plan.

There are advantages and disadvantages to the third option, which is to simply hire a private company to do the dirty work. Most of these companies charge a retainer fee, which is like insurance — you pay the fee in the hope that you never have to use it, but are really glad you did should you need it. The advantage of this approach is that by the time you secure the scene and remove the injured, the private contractor will have an MFI team at your command post. Such companies have hundreds of team members on standby around the world. You call their headquarters and they deploy an assessment team right away. Soon after, additional team members and full-time staff prepare to deploy with the equipment and additional resources that are needed.

Budget could be the factor that tips the scale in one direction or the other. Should you reallocate funds to support an internal MFI effort? How feasible is it to go back to your city council to secure additional funds for such an endeavor? Or is it cheaper — and more effective — to pay a private company? In most cases, the private company will do it better, faster and cheaper because this is its business — and its performance will shine a positive light on your department.

Additionally, because a private contractor primarily uses its own resources, yours will not be exhausted. This is an important consideration. If a financially sound company with adequate insurance causes the mass-casualty incident, you will be able to recover most, if not all, of the expenses associated with the event. However, if the MFI is caused by a natural disaster, a pandemic, a terrorist attack, a financially unsound company or one that lacks adequate insurance, then guess who does all of the work and pays all of the bills? In some of these cases you might recover some or even most of the money through lawsuits or disaster declarations from the federal government, but that can take a very long time. Better bulk up that rainy-day fund line item in your budget!

By now you understand the profound impact that a mass-fatality incident can have on your department. An incident of this type consumes not only those who perished, but also enormous assets — some that you have and some that you don’t. An MFI response requires specialized personnel, equipment, apparatus, training, support and a host of other resources that first-response agencies typically do not possess. This type of incident cannot be handled without a massive effort — but you simply cannot pass it off by saying, “we don’t want to do it.” Paradoxically, we cannot hope for help, nor can we do it on our own. The only way to handle an MFI is to understand its complexities and plan realistically and accordingly — and most importantly, train for the day that in all likelihood is inevitable.

Robert S. Cook is a 24-year veteran of the fire/EMS service with the Plainview (N.Y.) Fire Department, where he has served as its commissioner and training officer. He holds more than 50 certifications from the Department of Homeland Security, FEMA, OSHA, New York State Fire/EMS, North Carolina Emergency Management, and the American Board of Homeland Security. He is certified as a Homeland Security Exercise and Evaluation Professional (HSEEP), participates in military response evaluation and other preparedness consulting, and is a recognized subject-matter expert on mass-casualty incident management and mass-fatality incident planning.

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