Sandy "Notes" After-Action Report

UNCLASSIFIED//FOR OFFICIAL USE ONLY//RESTRICTED DISTRIBUTION//EYES ONLY

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New York State Division of Homeland
Security and Emergency Services

Hurricane Sandy Response

After Action Report
Notes

July 1, 2013

Prepared by
The National Center for Security & Preparedness

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NOTE: Blue-bolded and italicized texts contain information intended
only for the Commissioner of the New York State Division of Homeland
Security and Emergency Services.


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TABLE OF CONTENTS

Executive Summary 4

Areas of Study

Personnel 6

Technology & Facilities 11

Policies & Procedures 15

Concluding Recommendations 22


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EXECUTIVE SUMMARY

Hurricane Sandy sorely tested a New York State Division of Homeland Security and
Emergency Services Office of Emergency Management (OEM) which was still in the process
of implementing changes and improvements prompted by the response to 2011's Hurricane
Irene and Tropical Storm Lee. Although a relatively weak storm in terms of wind speeds,
Sandy was extraordinarily large in size and impeccable in her timing, striking the New York
and New Jersey coastlines at high tide. The resulting storm surge caused unprecedented
damage, smashing coastal communities in both states, flooding large areas of New York City,
and disrupting transportation, energy and communications for millions of residents.

The storm caused 48 fatalities in New York State, and another 24 in neighboring states.
Property damage exceeded $72 billion (second only to Katrina). Despite efforts by city,
county, state and federal emergency agency personnel that can only be described as heroic,
Hurricane Sandy for a time simply overwhelmed every plan and contingency. The scale
of the event was larger and the needs of the victims greater than most communities had
anticipated.

OEM was and continues to be centrally involved in the Hurricane Sandy response and
recovery effort, with the agency's staff working endless hours and days to meet the needs of
the people of New York State. For the most part, OEM's performance can be considered
successful despite confusion, delays and missteps along the way. In the words of many who
were involved in the process and interviewed for this report, it could have been worse. But is
that outcome acceptable? Moreover, if a Category 2 or 3 hurricane followed the path of
Sandy and struck New York and New Jersey coastlines under similar conditions in the future,
would even that level of marginally acceptable performance be replicable?

Many of the problems OEM encountered in mounting operations for Sandy were predictable,
echoing gaps and shortfalls called out after the Irene and Lee responses the previous year.
Staffing, technology and doctrine were issues in 2011 and they remained issues in 2012
although the challenging circumstances of the Sandy response certainly exacerbated those
problems. Many of these pre-existing conditions were being addressed, albeit slowly, when
Sandy literally appeared on the horizon and forced the question. The answer is still the
same: New York State does not have a world-class emergency management capability.

OEM is extremely understaffed. By comparison, Iowa's emergency management
agency, serving a state with the same area as New York but only a sixth the
population, is as large as OEM. The profound demands on an overtaxed staff during
its many activations, as well as underperformance by a vocal and unmotivated
minority have severely degraded morale and compromised effectiveness. Designating
emergency management staff as nonessential personnel to facilitate early retirements
and a subsequent failure to fill empty positions has further eroded OEM's capabilities.


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OEM's underlying technology base is out of step with other states and even other
jurisdictions in New York. The Emergency Operations Center is a Cold War relic
located in a bunker in Albany, dressed up with updated communications equipment
and computers. It is physically ill-suited to supporting sustained, complex operations,
to the point that the Governor chooses NOT to use the facility personally during
emergencies. DLAN, the emergency management support software used by OEM to
collect and fulfill resource requests, is insufficiently understood by many staff,
requires substantial on-site contractor support, and is incompatible with systems
used by other jurisdictions and agencies (including, prominently, New York City,
Suffolk and Nassau Counties).

Many of OEM's established plans and procedures were inadequate, scarcely
understood, or ignored during the Sandy response, and response personnel were not
trained in their content and use. Improvisation during a disaster can be the highest
demonstration of the emergency manager's art, but it needs to be founded on solid
foundational principle. During Sandy, the gaps between policy and practice, whether
tracking the deployment of generators and other resources, the application of the
Incident Command System in the management of the EOC, or deployment of
headquarters staff to a forward location in New York City to support the State's
response, resulted in confusion, inefficiencies and disgruntled staff throughout OEM.
The sense of confusion was undoubtedly heightened by the downstate deployment of
senior agency leaders, which may have been logical from a tactical perspective but
was, in all likelihood, a strategic mistake.

The lessons learned from the Hurricane Sandy response are clear because many of the
findings are not new. The herculean efforts to meet the "superstorm's impacts
notwithstanding, the State of New York and OEM need to move forward quickly on all fronts
to ensure the citizens of the Empire State have the response capability they not only deserve
but, based on recent events, need.


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AREAS OF STUDY
PERSONNEL

STRENGTHS

An organization succeeds or fails on the quality and commitment of its personnel. While OEM
has a number of significant personnel issues, including staffing, the overall performance of its
staff during the run-up to, during and after Sandy was remarkable. OEM staff worked long
hours supporting a mission that was dynamic, challenging and often frustrating. The
dedication reflected throughout extended operations ultimately made an important difference
between success and failure.

The men and women of OEM were asked to work 12-hour shifts under difficult conditions for
extended days. For some, due to additional tasks and understaffing, that translated into 16+
hour days, which they accepted as a necessary part of accomplishing the mission. The
dedication of OEM staff in Albany and in the field was critical to the success of the response
over a series of seemingly never-ending days. The experience of a small number of long-
serving professionals in past events helped compensate for too many vacant positions in the
organization, allowing OEM to mount a response that met the majority of the unprecedented
needs of the citizens of New York State in a timely and effective manner.

A number of OEM personnel forfeited vacation time to stay at their posts. Others labored to
the point of exhaustion, staying at their position despite the physical and emotional stress
born of a long-term round-the-clock activation. Moreover, OEM staff members were
leveraged to provide needed expertise and leadership to EOC volunteers from other State
agencies.

OEM personnel deserve recognition for their contributions to public safety during and after
Sandy's landfall. As a group they have been asked to do too much with too little for too long;
it is a testimonial to these public employees that they have largely found ways to succeed in
that pursuit.

Strong sense of commitment by most staff to the mission.
Demonstrated expertise delivering emergency management services.
Succeeded in the face of unprecedented challenges.
Effective collaboration with volunteers from other agencies in EOC
operations.

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AREAS FOR IMPROVEMENT

Staffing
Staffing within OEM has been reduced 50% over the past two years, from the 2011 level of
125 to approximately 65 (post-Sandy). Force reductions, including the budget-driven
decision to leave open positions vacant means New York State OEM has roughly the
same number of staff as agencies in states with 80% fewer residents. This translates into a
hard crunch for OEM during both routine and emergency operations.

During routine operations, OEM staff is carrying out a broad range of tasks, including the
development of plans, conduct of exercises and delivery of training. They are also tasked
with managing the disbursement and use of hundreds of millions of dollars of Federal grant
funds and payments, including monies for victims of past disasters. This process is labor
intensive; the shortage of trained personnel delays getting funds into the hands of citizens
and emergency agencies across New York.

The situation is exacerbated during emergencies such as Sandy,
where the lack of personnel (both experienced senior staff and
junior ranks) forced many OEM employees to work beyond their 12
hour shifts for days on end. Some staff were pressed into
positions for which they had not been trained, and many
assignments and requests were delayed due to the lack of
knowledgeable personnel being positioned to fulfill orders and
respond to calls for information. As one consequence, applications for disaster
assistance for victims of Hurricane Irene were put on hold while OEM's overworked
recovery staff labored on the new disaster.

The lack of trained staff also adversely impacted the integration into the EOC of untrained
volunteers from other State agencies. Upon arrival, several representatives had almost no
experience, receiving training (EEOC, 300, and 400 classes) from OEM staff. The lack of
experience impacted the use and assignments of individual volunteers (leading to
tensions). Additionally, there were several conflicts regarding time commitments and
responsibilities of those new to the EOC environment.

Profoundly understaffed for both routine and emergency operations.
Loss of experienced and knowledgeable senior staff through early retirements
and interagency transfers.
Regional personnel must be bolstered.
Poor morale and sense of purpose.
'The Office as it
exists has a lot
of ability but
very little
capacity."

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Loss of Experienced Staff
The reduction in staffing levels noted above was in part achieved by designating
management-level personnel within OEM as nonessential and therefore eligible for
early retirement. The resulting departure of decades of institutional memory and
experience has left the agency with middle and senior managers possessing
considerably less experience in their roles and a severe shortage of 'real world"
response experience. The only professional experience for the majority of Operations
staff has been with OEM Ops. The loss of senior personnel and the gross staffing
numbers mean that a number of key positions are, at times at least, filled by employees
lacking practical experience and the appropriate training for their responsibilities. OEM
needs to recruit and retain more qualified staff, preferably with operational experience. In the
past, there were opportunities to train and partner with replacements; that cycle is not
currently working.

There is a need to address differences among positions to ensure both the slot and
incumbent match OEM requirements. Cross-training among key staff can help to support
retention of staff and institutional knowledge. Moreover, there is a need for a clearly defined
and meaningful professional development/career path for OEM personnel. EMAC staff can
address some of the gaps, as they did during Sandy. It is critical, however, that they
appreciate the NY State and OEM environments and that they be engaged in a more
timely manner, if possible. EMAC supported key shortfalls; which, if provided sooner,
would have helped mitigate some issues that occurred.

Staff Sustainment
The sustainability of OEM staff at all levels does not appear to be a sufficiently high
priority. A strong, extended response requires sustainment of the staff's capabilities
over time. There is no specific office or individual assigned the broad responsibility for the
maintenance of staff well-being. Even prior to landfall, several individuals had been working
14-to-16 hour days. Many in the EOC were already tired and underperforming before the full
activation was ordered.

Currently, professional development, staff sustainment, and succession planning have
not received leadership's sustained commitment. This hinders a sense of
professionalism and personnel retention, as well as the reputation of the EOC with
public and private sector communities.

There were some promising efforts made to address quality of life in the EOC (e.g.,
wellness/stress management, counseling, massage therapy, etc.). However, the lack of
overall investment in the well-being of the regular OEM staffers and the volunteers
from outside agencies, combined with the extremely high pressure associated with the
Sandy response and a strong sense of being underappreciated (see Poor Morale,
below) vastly outweighed those measures.


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Poor Morale
Morale within OEM in general, and among EOC staff in particular, was low before
Sandy made landfall, went downhill during Sandy-related operations, and remains that
way in the post-Sandy environment. Unity of purpose was eroded by inadequately
communicated decisions to go outside standard operating procedures (e.g., actions
taken to support the Governor's new policy of forward-leaning and forward presence),
unavailability of senior and middle leadership at key moments, and slipshod
communication and change management relating to the as of yet incomplete merger.

The current culture within the EOC allows unhealthy, unprofessional, and negative
practices and influences to go unchecked. This is due to a number of factors including
frequent changes in leadership, the physical properties of the EOC itself, deficient
professional development strategies, and weak internal communications at virtually
every organizational level. Many office personnel primarily identify with sub-units
within OEM, perceiving themselves to be in competition or conflict with other teams of
co-workers. Throughout Hurricane Sandy, there were several examples where
individuals specifically withheld or failed to share information with other OEM staff.

Sandy had a strong negative impact on OEM personnel, reflected in the decision of
several senior managers to leave government and/or DHSES service following the
activation. Several people - more than should be reasonably expected - rose to the
occasion and filled multiple positions. But there were instances of "act out: get out"
by staff both within OEM and from outside agencies who wanted to be relieved of EOC
duties during the operation.

The consequences of poor morale can be seen in the dramatic negative reaction within
the EOC ranks to the deployment of key OEM staff to establish a New York City-based
'Regional Operations Center" or ROC. This decision, early in the Sandy response, was
made to better provide supporting information to the Governor and other key decision-
makers who elected to manage events from the State's executive offices in Midtown
Manhattan.

While logical in an abstract sense - one of the primary functions of OEM is, of course,
to provide the Governor and his staff with the information needed to make decisions -
dividing an already understaffed agency placed a heavy burden on personnel in both
NYC and Albany. Openly referring (as one senior official did) to the ROC designees as
the 'A-Team" and those left in Albany as the 'B-Team" contributed to a sense that the
EOC was being denigrated and abandoned. Moving so many senior persons
downstate (including the Director) meant the EOC was functioning without the benefit
of its most experienced managers. It also meant that virtually no one was available to
effectively communicate the reasoning behind the ROC to the Albany staff.


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It also represented just one of many senior-level decisions that, if not contrary to
existing policies and procedures, certainly went beyond established OEM practice. For
many OEM personnel, particularly those with limited non-OEM experience, existing
procedures and policies provide the solid base upon which their positions rest. The
expectation among many staff that there will be an investigation following any major
government operation in New York State has created a sense among many State
employees that the only way to carry on is by practicing a strictly-by-the-book, risk
avoidance strategy. Changes on the fly are unsettling for many, while others view
them as counterproductive and even illegal. The unprecedented challenges posed by
the Sandy response prompted several major decisions to work around established
policy, which in turn created concern, anxiety and even anger among OEM staff.

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TECHNOLOGY & FACILITIES

STRENGTHS

New York State OEM has access to the full range of technology necessary to support
emergency operations across the state. As evidenced throughout the Sandy response, there
were no meaningful barriers to data, voice and visual communications between the EOC in
Albany and personnel operating in County-level operations centers or at the State's offices in
New York City.

Although there has been substantial criticism of DisasterLAN (DLAN), the State's incident
management support system, it should be noted that OEM personnel familiar with and trained
in the use of DLAN feel it is an effective tool for supporting EOC operations. Over the past
decade it has been customized to meet the needs of OEM and has a proven track record with
many of the EOC staff. Contractor staff (on-site at the EOC) is highly knowledgeable of OEM
operations and is responsive to requests to prepare reports and provide assistance to new
users.

The most frequent source of frustration expressed by those who have used DLAN on a
regular basis is that personnel from other agencies as well as county emergency
management agencies have not been adequately trained to use the system. Personnel
that use DLAN every day (e.g., Ops and the Watch Center staff) felt it worked very well.

OEM employs GIS to present information on a wide range of subjects of importance to
emergency managers and response agencies. OEM's GS staff is experienced and eager to
employ a wide range of tools in support of the Office and its mission.

DLAN reflects the requirements of OEM.
EOC technology base is first class.
GIS is being employed to support EOC operations and decision making.

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DLAN
The principal tool used by OEM to obtain and manage requests for assistance from counties
across the State is DisasterLAN. Although the State has invested substantially over the
past decade in making DLAN the electronic backbone for OEM incident management, it
is widely viewed by emergency managers at the local level (as well as by other State
agencies) as cumbersome, inefficient, and inflexible. In addition, other jurisdictions in
New York have invested in other technologies that are unable to communicate with
DLAN. As a consequence, many officials across the State view DLAN as an
impediment to effective incident management.

Criticisms of DLAN were heard at every level of government and centered around
problems of usability and compatibility. Specific objections include:

Preparing a mission request form/ticket is time consuming and non-intuitive;
Since DLAN is felt to be too hard to use, it is not used on a daily basis by most OEM
staff nor by local-level responders, which means most personnel are not familiar with
its operation;
Tracking the status of specific entered requests is difficult, making management and
planning for those resources and assignments challenging;
DLAN does not readily allow users to generate custom reports the DLAN contractor
at the EOC must develop these for users;
DLAN is not compatible with WebEOC and eTeam, the systems in use in most counties
and major cities in the State, including New York City, which means data must be
entered twice and that the databases downstate and in Albany cannot speak to each
other.

Additional complaints speak to gaps between what DLAN provides and what is needed
to support logistics and procurement, particularly during a crisis. DLAN was never
designed to be a resource management tool, but has the capability to do so with
customization. However, unless the state and local jurisdictions are using the same
system, or have the ability to interface with each other's systems, resource
management will continue to be an issue.

DLAN is viewed by non-OEM users as inadequate.
Asset tracking is a major area for investment.
The EOC as configured is not conducive to effective operations.


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DLAN crashed during Sandy operations (though other incident management software
packages used in other jurisdictions also crashed under the workload) requiring
contractor assistance to reboot. Some feel that being forced to have DLAN contractors
in the EOC to support the software reflects the limitations of the product, is expensive,
and constitutes a misuse/waste of limited floor space. Finally, observers felt that EOC
staff was engaged in working with the DLAN system to the exclusion of communicating
with other emergency operations center personnel. This compromised their ability to
share information (this is, to be fair, another criticism that has been leveled against
other software packages).

It is not an indictment of DLAN to note that only one other state uses the software, nor
that OEM is the only major emergency management agency at any level in New York
that employs it. Nor is it necessarily a criticism to observe that many urgent or high
level requests were pushed through not using DLAN, and that the forms for many such
tickets were completed after the fact. It is important, however, to recognize that the
perception of DLAN's inadequacies is widespread and that it is viewed by many
outside of OEM as another example of the agency's dysfunction. The system has few
supporters and many detractors, does not 'play well with others," and does not seem
to do anything better than other, more widely accepted, competing systems.

Asset Tracking
The volume of material flowing into and out of staging areas, most prominently Citi Field, was
staggering. The lack of an up-to-date system to tag and track those resources must be
addressed, not only from a resource management perspective during an emergency
but also from a resource recovery point-of-view during demobilization. The tens of
thousands of items, from generators to pallets of water to light towers to vehicles,
requested and deployed in the recovery operations in New York were tracked using
paper and pen. There is no system in place for advanced bar coding of items, let alone
RFID (radio frequency identification) tagging that would allow tracking across the
region. The State's ability to account for resources 'the old fashioned way" and to
recover the majority of the non-perishable items (such as generators) in this chaotic
environment is a testimonial to the dedication of the men and women that drove the
Sandy response at the grassroots level. It was also an inefficient and cumbersome
process that led to losses and waste. OEM staff spent hundreds of hours on the phone
during the emergency trying to track down resources that could have been readily
accounted for with a modern system. While no system can completely prevent such
incidents, OEM can and should anticipate future requirements.

A modern asset tracking system, tied to DLAN (or some other incident management support
software package) and to the State's procurement system, would streamline the acquisition
and delivery of requested resources to the parties that need them, help assure positive
control during the operation, and facilitate recovery and return of rented, purchased and
borrowed items. OEM should conduct both internal and external software requirements
reviews to ensure that whatever system the state will be using meets the operational and
recovery needs of the state and stakeholders. There are a number of commercial off the shelf
systems (COTS) that provide the functionality the interviewees described as a need.


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New York Emergency Operations Center
The 'bunker" is not conducive to efficient operations. The New York State EOC is a
Cold War relic, lacking the space and flow required in modern emergency operations.
The main floor is a cramped warren of cubicles rather than the modern operations
'theater" model, with an arrangement of functional groups that is inflexible and limited
in seating. The lack of available conference rooms forced EOC staff to scrounge for
space for critical meetings, often in areas not equipped to support GIS or other
technologies. The low ceilings contribute to the acute (and accurate) sense of working
in a bomb shelter; the depression, anxiety and anger expressed by a number of
personnel during the 12-hour, round-the-clock shifts of the Sandy activation seem
understandable. It is not surprising that the Governor is an infrequent user of the
office suite reserved for him there.

Although the communications capabilities of the EOC are completely up to date, the process
of communications within the EOC is a challenging one. Personnel tend to work 'heads
down" in their spaces rather than engaging and collaborating with their colleagues.
For years, emergency managers have recognized that getting out of one's seat and
talking to others who have even small roles in an operation enhances the likelihood of
successful outcomes. During Sandy, this did not take place as it should have. Too
much time was spent on sitting in front of a computer screen in a cubicle, interrupted
by meandering "pass the mic" sessions during which verbal updates were provided
instead of being presented on a main status screen. 'Pass the mic" is an inefficient
substitute for an EOC environment in which technology promotes communications,
shares knowledge, and facilitates tasking and management.

Functional EOCs around the world are wide-open and well-lit, with signage and information
screens that can be seen from anywhere in the room. The facility, including the main floor
but also dedicated conference space and break areas, must facilitate the ability of EOC
staff - whether OEM, other agency representatives, private sector or NGO personnel -
to interact to solve problems and get desired outcomes. The New York EOC fails to
meet this test, and actually contributes to a deterioration of staff capabilities over a
long-term activation.


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PROCEDURES & PLANS

STRENGTHS

Relocating Staff to New York City and the ROC
The decision to move OEM personnel from Albany to New York City was driven by
several factors:
The Governor and his key staff established early on that they were going to be
directly involved in response operations and that they would act from the State's
offices in Midtown Manhattan. The Commissioner determined that it was OEM's
responsibility to provide the Executive Leadership with situational awareness
and operational support of their decisions and commitments, which led to the
decision to establish a Regional Operations Center.
During the early hours and days following landfall, New York City and nearby
counties including Nassau, Suffolk and Westchester were overwhelmed by the
combination of the devastation and the disruptions to power, communications,
transportation, etc. Effective support of the local emergency service agencies
required close coordination that could not be achieved from Albany using
routine channels.
The unprecedented scope of the storm damage and corresponding response effort
challenged "business as usual for OEM, prompting a
lean-forward, operational posture on the part of OEM
leadership. While still playing its traditional role of
supporting resource requests from county and city
governments, OEM personnel (both staff and
consultant) were engaged in hands-on roles across
the region, working in city and county EOCs, staffing
logistics staging areas, performing field inspections and damage assessments, and
augmenting other agency staff.

The decision to put personnel on the scene was characterized by local officials in New York
City and other affected communities as a new, best practice for OEM. It allowed OEM to
effectively follow-up on commitments made by the Governor's Office, coordinating those
requests - which were frequently made outside routine procedures - with the EOC staff
in Albany. Reflecting the political realities of the response, the presence of senior staff
on the scene also enhanced coordination with Mayor Bloomberg's senior staff and the
NYC Office of Emergency Management.
Relocating key staff to the New York City area was hugely successful from
local jurisdiction perspectives.
Emergency Management Assistance Compact (EMAC) personnel were
invaluable to sustaining EOC operations, but need to be effectively managed.
The State Comprehensive Emergency Management Plan (CEMP) provided a
solid basis for operations.

Extremely beneficial
interface with the
Governor's Office, Mayor
Bloomberg's staff and
other elected officials.

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New York City emergency management officials went so far as to describe the forward
deployment of OEM personnel as a game changer and a 180-degree shift from their
experience with the State in past disasters. In their opinion, the presence of OEM staff on the
scene after Sandy resulted in better communication and coordination, more prompt fulfillment
of requests and a stronger sense of collaboration.

EMAC
EMAC assistance was requested early in the activation timeline, although the first "loaned
staff didn't step into the EOC until several days after Sandy's landfall. EMAC personnel were
used to augment logistics and finance, and assisted in planning and operations, while OEM
staff filled most of the core ICS positions. Even though the EMAC deployed staff were not
fully conversant with New York's specific plans and procedures, they knew emergency
management, and most were willing and able to adapt to their roles "filling holes. By one
estimate, 29 staff positions were filled by EMAC.

OEM would benefit from refining their EMAC request procedure to insure that the
requirements for detailees are specified in greater detail. In addition, the request
should be initiated earlier in the activation to help ensure personnel are in place when
needed and most helpful. To make their integration into the EOC operations easier, the
CEMP (see below) should be updated with quick reference guides, job action sheets
and the forms and other tools to perform each function in the EOC. This will help
greatly when augmenting staff with EMAC and other personnel who are unfamiliar with
New York State EOC operations.

This will also help address problems with EMAC personnel that either lack the skills or
sufficient experience to contribute to EOC operations. There needs to be clarification
of credentialing (i.e., professional accreditation, certification, and professional
accomplishment), roles, and duties to be assumed. During the Sandy response, one
detailee assigned to a management position on the generator task force was not
professionally or emotionally prepared to handle that responsibility. Another EMAC
assigned individual acted in an erratic fashion, caused significant disruption and
adversely impacted coordination and response, eventually leading to his expulsion
from the EOC. He subsequently made several accusations of impropriety and
wrongdoing at OEM, prompting questioning of State government purchasing
processes and triggering an inquiry and changes to procurement processes that
hampered the fulfillment of critical resource requests.


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CEMP
The State's Comprehensive Emergency Management Plan reflects many years of OEM work,
analysis, and institutional lessons-learned. Although a number of staff indicated that the
CEMP was not employed during the move of personnel to New York and the
establishment of the ROC, those decisions reflected circumstances not necessarily
envisioned by the CEMP's authors. The CEMP remains the "bible for OEM operations; it
clearly needs to be revised to reflect changes in the operational and decision-making
environments (e.g., the more active role played by the Governor's Office). While the plans
and procedures embodied within the CEMP were the basis for actions taken in the field
and at the EOC throughout the activation, modifications are needed to address
insights gathered throughout the Sandy response. In addition, greater familiarity with
the CEMP should be encouraged at all levels of the response structure. For example,
some hurricane pre-landfall actions spelled out in the CEMP were not triggered. As a
consequence, there was uncertainty over what steps were to be taken in the run up to
the activation and response.

Existing processes and systems worked as designed when they were allowed to play
out. Based on decisions that were made by the Governor and his staff during the
incident, there is a need to promote greater understanding of the CEMP and supporting
procedures among senior officials in the State, delineate their roles and resonsibilities
during a disaster, and establish the working rules of engagement between the
Executive Leadership and the agencies charged with coordinating emergency
response. This is not to rein in the Executive's prerogatives, but rather to enhance the
effectiveness of those decisions within context of the larger response.


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Regional Operations Center
Establishing a so-called Regional Operations Center, or "ROC, at the State offices in Midtown
Manhattan was seen by the Commissioner as a straightforward task to ensure the Governor
and his key staff had access to the same information they could receive in the NY State EOC
in Albany. To this end, he had OEM personnel go to New York City to assemble the systems
necessary to convert a conference room into a viable Regional Operations Center. While the
equipment, including video screens and computers, was purchased for this purpose and
much of it was employed in another command and control facility, the ROC was never
assembled as envisioned due to a determination by the Governor's Office that such an
outlay was unnecessary. (Interestingly, concerns were voiced frequently during the
operation that the State's Executive Leadership did not have a high altitude
perspective on the status of response and recovery efforts, and were being 'captured"
by individual, high profile issues.)

The decision to send so many senior OEM staff (including the Director) to establish a
ROC in New York City was perceived by personnel in Albany as a de facto
abandonment of the State EOC. Compounding the perception that State EOC
operations were being downgraded was the Director's apparently voiced
characterization of the personnel from the Day Shift who were sent to NYC as the 'A
Team" vice those left behind to support Albany operations who were dubbed the 'B
Team." The accompanying shift of responsibilities to managers in Albany with less (or
in some instances no) experience in their assignments within the EOC further
compounded staff concerns.

The failure to convincingly communicate the rationale for the ROC along with the belief
of personnel remaining at the EOC that they were held in lower regard by OEM
management became an open and lingering wound to agency morale. The lack of
experience with field operations by OEM headquarters staff (OEM's Regional staff
previously carried much of this responsibility, though cutbacks have greatly
diminished that capability) led to a strong sense of 'that's not our job" and resentment
toward the downstate deployments on the part of EOC staff. The move downstate was
perceived by those left behind and even some that were working in New York City and
adjacent counties as a mistake that was stretching the agency's staff to the breaking
point rather than being seen as a necessary part of the OEM mission.

The decision to establish the so-called ROC was not understood nor
supported by OEM rank and file.
The OEM leadership team must be bolstered.
The change in procurement rules installed for OEM during the Sandy
response is inconsistent with effective emergency operations.
OEM must do a better job of building and sustaining its staff.
OEM and Executive Leadership expectations need to be better defined and
integrated into planning and operations.
Planning needs to be strengthened across the board.

19
If OEM is going to continue to support a forward leaning posture in major events, including the
utilization of assets in the field in the manner displayed during Sandy, it must:
Incorporate the ROC concept into the CEMP;
Strengthen its available staff resources, both at the headquarters level and in the State
Regions (see discussion under Personnel, above); and
Clarify and define, train and exercise the roles of OEM support to Executive
Leadership in a major emergency.

OEM Leadership Team
Due to the retirement or voluntary transfers of key staff over the past two years, OEM entered
the Sandy response with a seriously depleted leadership cadre. Effective emergency
management is frequently a function of strong hands-on leadership and pre-existing personal
relationships; OEM's institutional knowledge, its most experienced leaders, and its
managers (in Albany and the Regions) with professional and personal ties to city- and
county-level public safety officials have been allowed to walk out the door in the
interests of reducing costs. The Commissioner and then Director clearly recognized this
problem and had taken steps to address gaps in the organization, but this process was in its
very early stages when the storm hit in October. The division of OEM staff to support
operations in both the New York City area and the Albany EOC simply aggravated what
would have been a serious issue in any event.

OEM leadership's decision to bring in experienced senior consultants to bolster the
operations in New York City and Albany was viewed by some within OEM as an insult.
Others questioned how such personnel fit into the organizational structure,
complaining about a lack of clear lines of responsibility/accountability. The
introduction of experienced consultants did, however, allow OEM to actively engage on
a variety of issues that would have probably been outside the range of available State
personnel. Still, bringing in consultants without more effectively communicating their
roles and responsibilities to OEM staff created perceptions that leadership lacked faith
in their ability to deal with the challenges.

What was, in effect, the firing of the Director of Emergency Management in the middle
of the Sandy response presented major problems for OEM. While the reasons for the
termination are not within the purview of this report, the timing of that disciplinary
action essentially decapitated the agency at a critical moment, forcing the
Commissioner to assume many of the Director's responsibilities in addition to his own.
This, in turn, resulted in delays on some decisions during the response (despite the
Commissioner routinely working 16 hour days), the absence of a senior political
appointee in the EOC, and a day-to-day leadership vacuum within OEM. The Director,
although not necessarily well-liked by some in the agency, did have the experience and
energy to lead OEM operations; the absence of a deep bench of experienced
emergency managers within the office was felt almost immediately.


20
Procurement Rules
In response to allegations of waste and malpractice within OEM in the purchase of
material during the Sandy response, the new State Comptroller made substantial
changes to existing purchasing approval practices, reporting systems, controls and
general oversight of purchasing within the agency. Although the charges (made in the
media by an EMAC-assigned volunteer) have not been fully substantiated, a review by
the Comptroller's Office found concerns and systemic issues relating to current OEM
audit and vetting practices. The changes instituted an additional layer of review (and,
inevitably, delay) in the processing of requests from county emergency management
agencies and other stakeholders.

The process modifications introduced new requirements designed to provide the
State's Finance staff with not only greater visibility into, but also actual responsibility
for all stages of the procurement process. OEM would process a request from a
county-level emergency management agency or other stakeholder, conduct the
requisite research and triage, approve the purchase and forward the package to
finance for final approval. Finance would then conduct the same research and review
of the request, often delaying much needed resources to the jurisdictions. The
immediate impact of the changes instituted by the Comptroller was to dramatically
slow down the purchase and delivery of resources and services by OEM.

The changes further complicated a process that was already hampered by the DLAN
package. In many instances, DLAN requests did not provide enough detail for the
procurement process to function properly; once a request was entered, key
information necessary to execute procurements was often not being provided (for
example: buy a generator for a gas station, no other details). One DLAN procurement
function is to issue dummy purchase orders to initiate the procurement process. Later
these dummy orders are replaced with real purchase orders. As a result, the vendor
received paperwork from the state twice. This practice was a concern to the
Comptroller.

The CAO and staff are working with the new Comptroller and Pricewaterhouse Coopers
to leverage recommendations and are making major efforts to restructure disaster
controls and oversight, purchasing, and reporting systems. New processes or not,
OEM needs more qualified and trained staff with expertise in logistics and
procurement. It would also be useful to have Finance representatives in the EOC who
are able to work with the Logistics and Operations Sections in order to streamline the
process.


21
OEM and Executive Leadership Expectations
The Governor and his senior leadership team assumed an aggressively forward
leaning posture in the response to Sandy, relocating to Midtown Manhattan to be close
to the incident, traveling frequently to impacted sites and actively engaging with local
government officials and other citizens. This assertive role in the field challenged
OEM's existing organizational structure, its procedures, and the overall institutional
culture. OEM's leaders responded to this new standard of executive activism by
improvising a number of measures, such as the move of staff to New York City to
support the Governor, the effort to establish a ROC in the State offices in NYC, and
procedures to attempt to capture and implement resource commitments made outside
the usual channels by the Governor and his team.

The Governor was making policy and commitments that were, in some instances,
contrary to both the State's CEMP and established OEM procedures. It is important to
note that the Governor's approach, which at times created substantial additional work
for OEM and EOC staffs, was well-received by both the public and the media. It seems
likely this 'point of the spear" posture will be the model in future responses.

OEM needs to modify its current organizational structure, procedures, and culture to
accommodate such forward leaning and proactive senior leadership styles. This will
require close coordination with the State's executive leadership to define expectations and
evolve standard operating procedures, addressing "breaks" with pre-Sandy processes.

At the same time, the Governor and senior leadership need to better understand how OEM
functions and can support them during a disaster. This will require executive reinforcement of
cabinet and interagency roles and support in preparedness, participation, and response so that
the overall state response is stronger.


22
CONCLUDING RECOMMENDATIONS

The New York State Office of Emergency Management was in poor condition on October 28,
2012. Too few experienced staff members, a system based in part on tools that the users in
the field didn't understand or use, and a leadership that was trying to build a team while
fighting too many fires around the State. All of these weaknesses were exposed when Sandy
made landfall on October 29.

While the core strength of OEM its staff includes many dedicated professionals, there are
too many others that lack the commitment or the experience to effectively meet the needs of
New York's citizens. The technology backbone of the State EOC is solid, but undercut by an
incident management software system that is not accepted by the local communities that
need to use it and a physical plant that is not conducive to efficient operations. It is also
operating in a dynamic government environment in which its plans and SOPs are being
overtaken by new demands and challenges, many of which are seen by entrenched
careerist staff at OEM as being a threat, rather than an opportunity.

The path forward, in a perfect world, would be written on a blank sheet, rebooting OEM
to meet a new reality. Given the practical difficulties with such a bold move, the
leadership of the New York State Division of Homeland Security and Emergency Services
should initiate a ground up review of each position and the personnel filling those roles. This
bench review should assess the position's role and the capabilities and experience of the staff
filling that role. Personnel should be reassigned to maximize strengths, and replaced if
necessary to obtain the level of commitment to emergency management required for
this role. Personnel should also be shown a career path and an opportunity for professional
growth commensurate with their efforts and sacrifices.

DLAN should be replaced. A competitive process should select a replacement which is
more flexible, better integrated with other systems in the State, and fully capable of
providing the functionality and flexibility needed in an evolving emergency. The EOC
needs to be reconfigured to create more flexible and dedicated space for use by planners,
working groups, and other personnel during activations.

The new paradigm of leading from the front, demonstrated by the Governor during Sandy and
likely to be replayed in future disasters, demands OEM adopt a fresh approach to supporting
the State's executive leadership while still fulfilling its core responsibilities to the counties,
cities and citizens of the Empire State. To this end, the CEMP needs a thorough review and
revision, specifically addressing responses to "all in scenarios. The resulting roadmap for
OEM operations must then be effectively communicated to New York's local jurisdictions and
to its senior officials, ensuring coordination and efficient use of resources.

New York State's Office of Emergency Management has been a standard for the world. It
should be again.

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