PUEBLO COMMUNITY CSEPP EXERCISE 2002 (PCD CSEPP EX

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1 PUEBLO COMMUNITY CSEPP EXERCISE 2002 (PCD CSEPP EX 02) MARCH 20-21, 2002 LOCAL CHEMICAL STOCKPILE EMERGENCY STATE PREPAREDNESS PROGRAM FEDERAL FINAL EXERCISE REPORT November 15, 2002 This report replaces the report dated June 20, 2002

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5 PUEBLO COMMUNITY CSEPP EXERCISE 2002 (Pueblo CSEPP Exercise 02) EXERCISE REPORT Table of Contents Section Page INTRODUCTION... 1 COMMUNITY PROFILE... 2 EXERCISE SCENARIO... 6 LISTS OF FINDINGS REQUIRING CORRECTIVE ACTION... 7 SECTION 1: COMMUNITY EXECUTIVE SUMMARY HAZARD MITIGATION HAZARD ASSESSMENT POPULATION WARNING PROTECTIVE ACTION IMPLEMENTATION VICTIM CARE EVACUEE SUPPORT PUBLIC INFORMATION SECTION 2: JURISDICTIONAL REPORT PUEBLO CHEMICAL DEPOT STATE OF COLORADO PUEBLO COUNTY SECTION 3: SIGNIFICANT EVENTS TIMELINE SECTION 4: ACTION PLANS SECTION 5: COMMUNITY MASS CASUALTY EXERCISE SECTION 6: TABLE TOP RECOVERY EXERCISE APPENDIX 1: ANNUAL EXERCISE RECAP...App. 1-1 APPENDIX 2: ACRONYMS AND ABBREVIATIONS...App. 2-1 APPENDIX 3: DISTRIBUTION...App. 3-1 i

6 List of Tables Number Page Table 1. List of Findings Requiring Corrective Actions... 7 Table 2. Significant Events Timeline Table 3. Action Plans ii

7 PUEBLO COMMUNITY CSEPP EXERCISE 2002 (Pueblo Community CSEPP EX 02) FINAL EXERCISE REPORT INTRODUCTION The Pueblo Community CSEPP Exercise 2002 (Pueblo Community CSEPP EX 02) was conducted on March 20-21, 2002 to demonstrate the emergency response capabilities of the Pueblo CSEPP Community and to validate the correction of findings identified during past CSEPP exercises. This years Alternate Year Exercise was composed of three separate events. The first event was based on an accident at the Pueblo Chemical Depot (PCD) involving the chemical munitions stored at the Depot. The results of this event are in section 2 of this report. Another event, based on a terrorism/mass casualty scenario was used to evaluate the communities abilities to respond to a mass casualty incident. The results of this event are in Section 5 of this report. The last event was a Recovery Table Top Exercise held on March 21, 2002 involving selected Pueblo community agencies. The Recovery Table Top Exercise focused on hypothetical re-entry and restoration challenges that would require resolution in the event of an accident or incident at the Pueblo Chemical Depot that would result in the possibility of offpost contamination. This event is documented in Section 6 of this report. The requirement for conducting Chemical Stockpile Emergency Preparedness Program (CSEPP) exercises was established in the August 1998 Memorandum of Understanding (MOU) between the Federal Emergency Management Agency (FEMA) and the U.S. Army. Exercise design, planning, evaluation, and reporting guidance is contained in the Chemical Stockpile Emergency Preparedness Program Exercises document, dated March 19, 1999, currently under revision. Exercise design and planning for Pueblo Community CSEPP EX 02 was accomplished for the Army by the Army Exercise Planning Co-Director and representatives from the Pueblo Chemical Depot (PCD). The FEMA Exercise Planning Co-Director and representatives from the State of Colorado; Pueblo City-County Health Department; and Pueblo County Department of Emergency Management accomplished design and planning for off-post play. This exercise served as another pilot-test for the Integrated Performance Evaluation (IPE) process; an evaluation method based upon seven response streams. 1 Hazard Mitigation 5 Victim Care 2 Hazard Assessment 6 Evacuee Support 3 Population Warning 7 Public Information 4 Protective Action Implementation The scope and substance of play for the Army and off-post jurisdictions are described in individual Extent of Play Agreements and are summarized in the Exercise Plan. 1

8 PUEBLO CSEPP COMMUNITY READINESS PROFILE The following table presents the benchmark/capability assessments developed by the Pueblo Community as of 22 January, Benchmark/Capability Review for the Pueblo Community Alert and Notification Systems - Initial Alert and Activation. - Protective Action Recommendations and Decision Making. - Public Notification, Instruction, and Emergency Information. - Communications Systems, Facilities, Equipment and Displays. Status: 19 outdoor warning sirens installed, operational, tested weekly. Purchased 3000 Tone Alert Radios Initial distribution completed. Automated call-down operational. New system being implemented for FY 02. Community Self-Assessment Rating FC. Automated Data Processing - Hazard Assessment. - Protective Action Recommendations and Decision Making. - Public Notification, Instruction, and Emergency Information. - Communications Systems, Facilities, Equipment and Displays. Status: Automation System operational - All EOCs have data transfer capability State FEMIS installed. EMIS installed at PCD and Pueblo County EOC. Community Self-Assessment Rating FC. Communications - Communications Systems, Facilities, Equipment and Displays. Status: Microwave system and high-band radio system approved, funded and implemented. County has some problems with radio system- Identified solution. Funding request in 2002 budget. Implementation to follow funding. System Operational. Community Self-Assessment Rating FC. 2

9 Coordinated Plans - All Emergency Response Functions Status: Pueblo County: Latest revision to CSEPP Plan February State of Colorado: Latest revision to CSEPP Plan August, 1994 Joint information Center (SOP): Latest revision January, PCD; CAIRA Plan dated April 2001, w/ change 1 dated January All work plans complete. PCD system operational. Community Self-Assessment Rating FC. Decontamination - Medical Services - Medical Facilities. - Field Response. - Screening, Decontamination, Registration, and Congregate Care of Evacuees. Status: Decon Capabilities One Hospital decon unit at Parkview Hospital. One Hospital decon unit at St. Mary Corwin Hospital. Two mobile decon units and 1 animal decon system in Pueblo County. Requested funding for FY Budget to enhance non ambulatory capability of field units. PCD; one fully operational mobile decon unit. One mobile decon unit with limited capabilities. Community Self-Assessment Rating FC. Emergency Operations Center. - Command and Control. - Communications Systems, Facilities, Equipment, and Displays Hour Operations. Status: State EOC fully operational communications center staffed 24/7. Pueblo County EOC fully operational communications staffed 24/7. PCD OC fully operational staffed 24/7. Community Self-Assessment Rating - FC. 3

10 Exercises - All Emergency Response Functions. Status: Last FME conducted March 28, Last AYE conducted April 26-27, Off-Post community participates in PCD quarterly CAIRA exercises. Next exercise scheduled for Mar 20-21, 2002 (AYE). Community Self-Assessment Rating FC. Personnel - All Emergency Response Functions. Status: Required and authorized CSEPP staff in position at County level. State planner position vacant. Pueblo County fully staffed. PCD fully Staffed. Community Self-Assessment Rating FC. Personal Protective Equipment - Traffic and Access Control. - Medical Services - First Response. - Medical Services Transportation. - Medical Services - Medical Facilities. - Field Response. - Screening, Decontamination, Registration, and Congregate Care of Evacuees. Status: Hoods, boots, gloves and Kappler suits received. Pueblo County; 610 sets of PAPRs, Kappler responder suits, hoods, boots and gloves distributed. Additional 120 sets of PPE requested in FY 2002 budget to meet additional Pueblo County staffing needs. PCD PPE fully equipped. Community Self-Assessment Rating FC. 4

11 Training - All Emergency Response Functions. Status: Initial response training for new personnel ongoing for PDC, State and Pueblo County. Refresher training ongoing. Community Self-Assessment Rating FC. Medical Support - Communications Systems, Facilities, Equipment, and Displays. - Medical Services - First Response. - Medical Services Transportation. - Medical Services - Medical Facilities. - Screening, Decontamination, Registration, and Congregate Care of Evacuees. - PCD Occupational Health Center fully staffed. Status: Emergency medical staff at hospitals and first responders trained (CSEPP curriculums). Community Self-Assessment Rating FC. Public Awareness - Public Notification, Instructions, and Emergency Information. - Communications Systems, Facilities, Equipment, and Displays. - Protective Action Implementation for Special Populations and Facilities Status: Annual CSEPP calendar distributed. 98 to 99% of IRZ population given a TAR and PIO briefing. JIC operational since August, JIS in place and operational since Public education programs ongoing. Quarterly news letter written and distributed. Participat in IPTs, working groups and provide exercise support at National level. Community Self-Assessment Rating FC. 5

12 EXERCISE SCENARIO Pre-STARTEX Situation Pueblo Chemical Depot (PCD) stores a portion of the nation s chemical weapons. On March 20, 2002, a re-warehousing operation of pallets containing HD-filled, 155mm projectiles was scheduled for igloo G203. Initiating Event At 0856, the forklift operator had removed two pallets from the leaning stack and placed them near the front of the igloo, to one side of the central aisle. While moving another pallet of 155mm projectiles toward the front of the igloo, the forklift operator suffered a seizure, causing the forklift to lurch forward out of control, which in turn caused the forklift driver to fall from the forklift. The forklift first collides with the ground guide knocking him against two pallets, stacked near the igloo door up against the east igloo wall, and then knocking him onto the igloo floor. The collision with the forklift also resulted in a tear to the ground guide s explosives handlers coveralls exposing an area of skin 3 by 3 on his upper thigh. After hitting the ground guide, the forklift struck the igloo doorframe. Upon impact with the doorframe, the pallet broke open and all eight rounds fell to the igloo floor. The lifting plugs on two of the rounds were sheared off resulting in pebble-sized agent being released onto the igloo floor. The particles of solid agent extended from the doorway to a point approximately 1.5 feet onto the apron, just in front of the door. Two other rounds showed evidence that they have previously exuded agent near the lifting plug, on the ogive. At approximately 0858, the security guard radioed a request to the Site Security Control Center (Post 5), calling for the fire department and emergency medical assistance to the accident site Other members of the work crew removed the driver and the ground guide from the immediate areas of the igloo and the spill, and rendered first aid to both patients. The ground guide was semi-conscious and as he was being dragged from the igloo, came into contact with solid agent on the exposed skin on his upper thigh. Once on the ground guide s exposed skin, the solid agent melted resulting in a small amount of visible liquid agent on the ground guide s exposed skin. Crewmembers also decontaminated the injured driver and the ground guide. While removing the forklift driver and ground guide from the interior of the igloo, members of the work crew became contaminated as they walked through the area containing solid agent particles. 6

13 LISTS OF FINDINGS REQUIRING CORRECTIVE ACTIONS A list of findings requiring corrective actions identified during the Pueblo Community CSEPP EX 02 are listed in the following table. They are grouped by the responsible jurisdiction. Required corrective actions have an assigned identifying number that may be used to identify the corrective action throughout the report and in completing the action plans. The number is structured as follows: XX02.Y.1. The "XX" is a two-letter identification of the response organization to which the corrective action applied [e.g., PU for Pueblo Chemical Depot, CO for Colorado, PC for Pueblo County, and PP for the Pueblo Community]; "02" represents the year of the exercise; Y" indicates the response stream the finding requiring corrective action was found, this will be an Arabic number representing the appropriate stream [e.g., 1 for Hazard Mitigation, 2 for Hazard Assessment, 3 for Public Warning, 4 for Protective Action Implementation, 5 for Victim Care, 6 for Evacuee Support and 7 for Public Information]and:.1" is the sequence number of the corrective action under the response stream. Action Plans can be found in Section 4 of this Report. ID Number Description Page PP On-Post Siren and TARs Activation 1-6 PP Incomplete Patient Medical Documentation 1-10 PU Use of Improper Protective Clothing 2-2 PU Fire Department Establishment of the Hot Line 2-3 PU Failure to Wear Proper Protective Equipment 2-6 PU Initial Patient Stabilization 2-13 PU Delayed Evacuation of Patients 2-14 Table 1. List of Findings Requiring Corrective Actions 7

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15 SECTION 1. COMMUNITY STREAM REPORT The following is a summary of the Pueblo CSEPP Community s performance during the exercise sequenced by response stream. Jurisdiction specific information can be found in Section 2 of this report. Hazard Mitigation Hazard Assessment Population Warning Protective Action Implementation Victim Care Evacuee Support Public Information 1-1

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17 1. HAZARD MITIGATION The Hazard Mitigation Stream includes all response tasks at the accident scene to contain the source and limit the magnitude of the hazard s impact. It includes all tasks at the accident scene except for those specifically associated with the Victim Care Stream. On March 20, 2002, a re-warehousing operation was initiated at igloo G203, which contained 155mm HD-filled projectiles. A Real Time Analytical Platform (RTAP) began monitoring the igloo at At 0745, the RTAP operator had completed three monitoring cycles and the site was reported clean. The crew supervisor then initiated First Entry Monitoring (FEM). At 0832, the crew reported to the Operations Center (OC) that FEM was completed and re-warehousing would begin. At 0856, the simulated accident occurred. Installation personnel immediately initiated emergency response actions in accordance with previously approved plans, policies, and procedures. Individual areas requiring corrective actions are identified in Pueblo Chemical Depot (PCD) portion of the jurisdictional sectional of this report. Due to the limited nature of the accident, some components of the Hazard Mitigation Stream were not fully exercised. The assessment of the Hazard Mitigation Stream activities that were observed during the exercise indicates that the Pueblo Chemical Depot is Capable of performing Hazard Mitigation activities in an emergency. 2. HAZARD ASSESSMENT The Hazard Assessment Stream includes tasks beginning with detecting the accident, gathering information, determining its impact, classifying the event, conducting environmental monitoring, and making government-to-government notification. On-post, it also includes tasks related to Emergency Operations Center (EOC) direction and control. It also includes government-to-government updates and situation reports and briefings. At 0700, on March 20, 2002 the PCD hazard analyst prepared a work plan for a rewarehousing operation of 155mm HD-filled projectiles at igloo G203. The maximum credible event (MCE) for this operation is one round leaks. The work plan and MCE was broadcast by the Emergency Management Information System (EMIS) to both the State of Colorado and Pueblo County Emergency Operations Center (PC EOC). A simulated accident occurred at At 0859, PCD OC was notified by radio of the accident, the agent released, and the number of injured personnel. At 0901, the initial hazard assessment (three rounds leaking) was modeled for this chemical accident resulting in a limited area emergency and the off-post protective action recommendation (PAR) was that no protective action was required. The PCD OC operations officer approved this hazard assessment and broadcast it by EMIS to both the State of Colorado 1-3

18 and Pueblo County EOCs. In addition, the PCD commander also declared an on-post protective action decision (PAD) to evacuate all non-essential personnel within the former ammunition storage area. Both the State of Colorado and Pueblo County EOCs reviewed and analyzed the initial and subsequent EMIS hazard assessments broadcast by PCD reflecting significant changes based on the agent release scenario. Based on the hazard assessments received from PCD and internal discussions by decision-makers, both off-post jurisdictions accepted the chemical event notification level of limited area emergency and the PAR, which recommended no off-post protective actions. Ongoing two-way communication between the PC EOC and PCD supported the above decisions throughout the course of the exercise. In accordance with procedures and the scope of release, no independent confirmation of the PCD hazard modeling or support for response phase monitoring and sampling was demonstrated in the off-post jurisdictions. Throughout the exercise, all required government agencies and officials were notified and updated on the status of the chemical accident. PCD OC staff specialists continuously monitored field communications to determine if changes to the initial PAR were necessary. As the exercise progressed, information was updated and new hazard assessments were made in a timely fashion. The analysis of the Hazard Assessment Stream activities that were observed during the exercise indicates that the Pueblo CSEPP Community is Capable of performing Hazard Assessment activities in an emergency. 3. POPULATION WARNING STREAM The Population Warning Stream includes tasks associated with protective action decision making and warning the affected population. Off-post, it includes all tasks from receipt of the PAR and Chemical Event Notification Level (CENL), through making the Protective Action Decision (PAD), to activation of warning systems, including, for example, sirens, tone alert radios, route alerting, cable interrupts, telephoning those in special-needs database, and the first EAS message. It also involves mobilizing EOC staff and activating the EOC. At 0856 hours, a simulated accident occurred at PCD. At 0857 hours, on-post sirens were activated, and a test exercise message was broadcast. The pre-recorded outdoor warning system message that followed each of the siren tones instructed people to go inside and listen to a local radio or television station for further information. Further questioning of the EM director revealed that the system is designed to provide instructions that ask people to take shelter inside a building while awaiting further instructions via the Emergency Alert System. This has somewhat an effect of an initial protective action message. The instructions are the same if the system is activated because of an incident at PCD, a hazardous materials incident elsewhere in the area or a 1-4

19 tornado that has been sighted in the area. This allows the public to be trained in a consistent manner, regardless of the type of system activation. At 0901, PCD provided electronic notification to Pueblo County (PC) and the State of Colorado of a limited area emergency by broadcasting the first hazard assessment D2PCw run by EMIS. Upon receipt of the EMIS notification, the PC EOC Operations Chief immediately telephoned PCD to confirm the CENL, to verify that off-post protective actions were neither recommended nor required, and to obtain additional incident details. At 0903, PCD made standard telephone notification to the Pueblo County Communications Center (PCCC), where a dispatcher recorded the information on a chemical emergency notification form. A copy of the same form (as completed by PCD personnel) was FAXed to PCCC for verification. No on- or off-post PAR was indicated. At 0903, the PCD Commander made the on-post PAD to evacuate the ammunition area and Pueblo County EOC was informed of the on-post PAD at this time. However, Pueblo County EOC staff did not record this information in the EMIS log nor did this information get announced to the Pueblo County EOC staff. While not required by CSEPP guidance or applicable MOA/MOU, recommended actions include the logging of this information in the Pueblo County s EMIS log. However, not logging and/or announcing this information did not materially impact the overall response in this scenario. At 0906, PCD initiated telephonic notification of tenants and contractors with work sites in the ammunition area. The message indicated that this was an exercise, but that had it been an actual chemical event, persons in that area would have been evacuated. The telephone contact team also delivered a similar message to post residents. The telephone contact list was completed by The telephonic contact arrangement did not provide for timely notification of tenants and contractors within the eight minutes required by CSEPP guidance. However, the notification process in this event did not place anyone in harms way during the response to this simulated accident. Response observed during this exercise suggests that as much as 20 minutes might elapse before on-post tenants and contractors would be told what protective actions should be taken. Under mutual agreement not yet formally written, PC EOC is responsible for activating tone alert radios (TARs), both on- and off-post. At 0912, PCD asked PC EOC to activate on-post TARs and broadcast a pre-scripted test message specifically designed for TAR activation during this exercise. The TARs activation request from PCD to the County was initiated after the County PIO called the PCD PAO to inquire about the use of PCD TARs. TARs activation occurred at PCD s request for on-post TARs activation did not include verbiage for a message that would have been appropriate for the simulated chemical event and on-post PAD. The PC EOC operator who activated the TARs did not know what message should have been provided, and made no effort to ascertain the content of an appropriate message. The effective use of TARs to alert and notify on-post populations of protective actions depends on timely broadcast of appropriate messages. (The lack of pre-scripted 1-5

20 messages for each CENL may have contributed to PCD not providing PC EOC with emergency instructions to accompany TARs activation.) The population alert and notification section of the Planning Guidance for the CSEPP applies to the entire IRZ, which includes the PCD. CSEPP guidelines on alert and notification that pertain to the IRZ apply to on-post and off-post populations. All endangered populations in the IRZ should be provided a timely alerting signal and instructional message. The language in the Planning Guidance for the CSEPP does not express a clear standard for on-post alert and notification. At 0927, PC EOC was asked by PCD to assume responsibility for continued on-post siren and TARs activation as required in established CSEPP alert and notification guidelines. PC EOC agreed verbally to assume responsibility, but no directive was given to EOC staff to perform this task. This resulted in the PCD sirens not being sounded at the required intervals. No apparent procedures have been developed to implement this cooperative arrangement and no Memorandum of Understanding or Agreement has been formalized to cover TAR activation. Since there is a verbal agreement between PC EOC and the PCD regarding the activation of TARs, protocols should be formalized and documented to perform these vital procedures in a timely manner to include ensuring that Pueblo County knows what message to broadcast on the TARs. In the interim, PCD should develop appropriate messages within each CENL to broadcast on the TARs. Pueblo County should solicit this information from PCD if PCD is not forthcoming with this information. Finding Requiring Corrective Action: PP Description: On-post Siren and TARs Activation. Discussion: In accordance with the extent of play agreement, the PC EOC activated on-post TARs with a pre-scripted test message. It was stated on more than one occasion in the PC EOC that TARs were continuing to be activated at required intervals (simulated), but no actions to complete this task were observed and no procedures have been drafted in writing. Pueblo County did not know what emergency instructions they were simulating to provide over the TARs to PCD personnel. The use of TARs to alert and notify on-post populations of protective actions depend on timely broadcast of appropriate messages. The lack of pre-scripted messages for each CENL is a contributing factor for PCD not providing the PC EOC with emergency instructions to accompany on-post TARs activation. Referring to an informal agreement, PCD requested PC EOC to assume responsibility for continued on-post siren activation at required intervals. Again, no procedures have been developed to implement this cooperative arrangement and no Memorandum of Understanding or Agreement has been executed. 1-6

21 Coordination between PCD and PC EOC needs to be improved relating to outdoor and indoor alert and notification systems activation. Procedures should be jointly developed addressing both initial activation and subsequent sounding of both the siren and TARs devices, specifically outlining steps for the transfer and acceptance of system activation responsibilities between PCD and Pueblo County. Reference: Planning Guidance for the Chemical Stockpile Emergency Preparedness Program, 17 May 1996, page 8-18, paragraph 8.18 Recommendation: PCD should provide Pueblo County with the on-post PAD at the time it is made. Pre-scripted TAR messages should be drafted for each CENL, addressing anticipated on- and off-post requirements, covering all possible contingencies. Written protocols should be developed to ensure that on-post TARs will be activated in a timely manner with accompanying emergency instructions. Develop and formalize in writing a comprehensive MOU/MOA reflecting the mutual agreement regarding initial activation and subsequent sounding of the indoor and outdoor warning systems, on-post and off-post, and methods of implementation. Due to the limited extent-of-play in this exercise, some components of the Population Warning Stream were not demonstrated. The assessment of the Population Warning Stream activities that were observed during the exercise suggested that the Pueblo CSEPP Community is Capable of performing Population Warning activities in an emergency. 4. PROTECTIVE ACTION IMPLEMENTATION Protective Action Implementation includes the flow of activities related to evacuation and sheltering-in-place, of residents, schools, special populations, and special facilities. It also includes transportation support activities, establishing traffic and access control points, adopting declarations of emergency, host facility support, responses involving infrastructure and agriculture, and screening and decontamination of the general population. Populations on PCD were notified of the accident and given required instructions. Security elements took effective measures to ensure all personnel were evacuated from the former ammunition storage area and maintained access control to the evacuated area. Pueblo County received notification from PCD at Pueblo County accepted the PCD PAR as their PAD. The Pueblo County PAD was that no protective actions were required. At 0914, the PC EOC notified Thatcher Ranch and District 70 schools of the event and instructed them to stand by only. No evacuation or sheltering actions were required. These particular entities received appropriate attention as a precaution due to 1-7

22 their proximity to the Chemical Limited Area (CLA). Since the event never escalated further, there were no other protective actions taken or needed by Pueblo County. There are no recommendations for improvement. Due to the limited extent-of-play in this exercise, many components of the Protective Action Implementation Stream were not demonstrated. The assessment of the Protective Action Implementation stream activities that were observed during the exercise indicated that the Pueblo CSEPP Community is Capable of performing Protective Action Implementation activities in an emergency, but this conclusion has to be tempered by the limited extent of play upon which this assessment is based. 5. VICTIM CARE STREAM The Victim Care Stream includes all activities related to treating on-post contaminated casualties at the accident site and depot, victim transport, treatment at off-post medical facilities, patient tracking, and handling and tracking disposition of human remains. Approved plans and procedures were demonstrated in response to the simulated accident at PCD. Response personnel demonstrated required actions in response to the simulated injuries. First aid, buddy aid, decontamination and transport of patients to the PCD Occupational Health Clinic (OHC) were adequate to stabilize patients prior to transport to local hospitals. Specific concerns with initial patient stabilization, expedient extraction of the patients from the accident site to the PCD OHC, and complete patient history documentation are noted below and/or included the PCD jurisdiction evaluation summary. Parkview Medical Center Parkview Medical Center (PMC) is a Level II trauma center licensed for 305 beds, with staffing for 225 beds. It is equipped with a thirteen-bed medical/surgical intensive care unit (ICU), a six-bed neuro ICU, and an eight-suite operating room. The ED has a bed capacity of 17 with an additional four beds for urgent care situated in the back hallway and a seven bed chest pain center. It can utilize 20 more beds in the same day surgery suite after hours. Daytime staffing consists of seven registered nurses (RN), three rotating physicians, nine support staff and an emergency medical technician (EMT). At 0904 the ED charge nurse received a call from the PCD relaying information that this was a test message regarding a possible problem at the PCD. At 0947, the ED director contacted the PC EOC to advise them of an accident at the PCD. No other information was available or transmitted. At 1115 the PCD alerted the PMC ED that two ambulance patients were inbound from the PCD to local area hospitals. One patient was ambulatory and one was a stretcher patient. It was reported both patients had been decontaminated at the PCD. At 1123 an ambulance arrived at PMC with a stretcher patient from the PCD. Prior to ED entry, the patient was triaged and vital signs were recorded. At 1129, the 1-8

23 patient was transferred to the ED and appropriate continuing medical management of chemical and traumatic injuries was performed. The patient was admitted to the hospital and immediately sent to surgery for severe traumatic injuries. Saint Mary-Corwin Regional Medical Center The Saint Mary-Corwin Regional Medical Center (SMC RMC) is a two hundred-bed, Level III trauma center serving the city and county of Pueblo. Saint Mary-Corwin Regional Medical Center acute care capability consists of a seventeen-bed emergency department (ED) and a sixteen-bed intensive care unit (ICU). The staff of the SMC RMC ED consists of physicians, physician assistants, nurses, emergency medical technicians, and clerical personnel. The number and discipline of on duty staff is determined by projected patient volume and acuity. In preparation of an incident involving a hazardous material release, SMC RMC has trained personnel to perform patient decontamination. All personnel have been medically evaluated and cleared to wear PPE. In addition, before donning PPE, all personnel are screened to identify those at risk of heat related illness. From 0902 to 0956, SMC RMC took necessary actions to prepare for patients from PCD. At 1200, one patient arrived unannounced by EMS from PCD. The patient had a simulated open femur fracture (right leg). The triage staff demonstrated assessment and triage. The SMC RMC staff took appropriate actions to care for the PCD patient. Observation Description: Inadequate Victim Information Flow Discussion: At 1200 hours, one patient arrived unannounced via EMS from the depot to the triage area with simulated right open femur fracture. Because of long delay from initial notification and lack of updated time of arrival notifications from the depot, the triage staff did not initially fully recognize the source of this victim. Communications between the PCD and medical center were minimal. Investigation into this problem indicated that it was probably due to incomplete medical documentation (noted in finding PP02.01). Reference: PCD, SMC, and PC EOC operating procedures and communications guidelines. Recommendation: Involved parties should identify sources and solutions to this problem, incorporate the later into their respective procedures and ensure mutually acceptable alternatives for situational variations to standard or recommended lines of communication. Consideration should be given to a mutually acceptable frequency of situational updates among entities during relatively static periods. 1-9

24 Finding Requiring Corrective Action: PP Description: Incomplete Patient Medical Documentation Discussion: Standard Form 558 from PCD was incomplete and lacked critical informational elements such as mechanism of injury, date, time, current medications, allergies, primary complaint, subjective data, pertinent history, disposition, repeat vital signs. There was no forwarded documentation of recurrent exam findings and vital signs over the course of the time the patient was observed at the depot clinic. The Standard Form 558 and 600 become part of the patient s official medical record. Reference: DOD and standards of patient care documentation. Recommendation: Ensure victim assessment and treatment documentation is complete and includes all essential and useful information relevant to injuries and potential exposures. The assessment of the Victim Care Stream activities that were observed during the exercise suggested that the Pueblo CSEPP Community is Capable of performing Victim Care activities in an emergency. 6. EVACUEE SUPPORT The evacuee support stream includes those tasks associated with opening, operating, and supporting reception centers and shelters. Evacuee Support was not part of the Extent of Play Agreements and was not demonstrated. However, the Emergency Operations Plans for Pueblo County, the State of Colorado, and PCD make provisions to support evacuees with reception centers, shelters, counseling and religious support should it be required. 7. PUBLIC INFORMATION STREAM The Public Information Stream includes all tasks related to providing public information, exclusive of the initial Emergency Alert System messages. It includes the dispatch of persons to an activated Joint Information Center (JIC) and a Joint Information System and capability at the JIC and in jurisdictional EOCs to respond to information needs, prepare additional EAS messages and news advisories, handle rumor control, and conduct media briefings. The Public Information Stream encompasses all activities needed to provide accurate and timely emergency information to the media and the public following the initial alert and notification of a chemical emergency at Pueblo Chemical Depot (PCD). This includes 1-10

25 public information activities at PCD and at higher Army headquarters, in Emergency Operations Centers in Pueblo County and the state of Colorado, in the offices of elected officials, and at medical facilities in Pueblo County. This effort is connected by a Joint Information System (JIS) to validate, coordinate, and expedite the flow of information among jurisdictions, to the media and to the public. Major components of this process include the sharing of current information about how the event is evolving and how PADs are being implemented. The process also includes news releases, responses to public and media queries, news conferences, and interviews with decision-makers and their spokespersons. These reinforce protective action messages broadcast on primary alert and notification systems, and allay concerns among populations that are not affected. A Joint Information Center (JIC) that is staffed to validate, coordinate, and expedite the flow of public information is an important tool to support the JIS if public and media interest is high. There are plans to activate a JIC at the University of Southern Colorado in Pueblo, Colorado. However, PCD and county officials decided that the scope of this event did not warrant the activation of a JIC. Public Information Activities. Public information activities began at PCD and in Pueblo County almost immediately after the initial alert and notification. Army Public Affairs Officers (PAOs), state and local Public Information Officers (PIOs), and their support staffs deployed to EOCs and satellite support offices promptly. They quickly ascertained the nature of the event and the protective actions required (if any) within their respective jurisdictions. The depot issued five news releases concerning the event, and the Commander met reporters at the entrance to PCD two hours after the event began to provide the media with insights into the problem and the ongoing Army response. These proactive efforts, in addition to the routine actions of notifying elected officials and Army higher headquarters PAOs, and responding to media and public queries, were judged to be very effective. Pueblo County told the media that the county EOC was operational as a contingency to support Army activities to protect the post population, and reaffirmed the Army statements that off-post citizens were not at risk. These efforts also were judged effective. Due to the limited extent-of-play in this exercise, many components of the Public Information Stream were not demonstrated, JIC operations being the most obvious. The assessment of Public Information Stream activities that were observed during the exercise suggested that the Pueblo CSEPP Community is Capable of performing Public Information activities in an emergency, but this conclusion has to be tempered by the small sample of information upon which this assessment is based. 1-11

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27 SECTION 2. JURISDICTIONAL EVALUATION SUMMARIES PUEBLO CHEMICAL DEPOT Response Stream 1 Hazard Mitigation On March 20, 2002, a re-warehousing operation was initiated at igloo G203, which was filled with 155mm HD-filled projectiles. A Real Time Analytical Platform (RTAP) began monitoring the igloo at At 0745, the RTAP operator had completed three monitoring cycles, and the site was reported clean. The crew supervisor then initiated First Entry Monitoring (FEM). At 0832, the crew reported to the Operations Center (OC) that FEM was completed and rewarehousing would begin. At 0856, the simulated accident occurred. The crew safety person at the igloo door immediately removed the forklift operator who was simulated as having suffered a seizure which resulted in injury to not only himself but to his ground guide as well. The forklift operator was firemancarried to the previously established crew mini hot line. The outside crew immediately masked. Although the Standing Operating Procedure (SOP) required responders to don Level B, necessary butyl rubber was not available. Various other levels of dress were worn (level C and D). Both the driver and ground guide were removed from the igloo and placed on a spill-control tarp at the mini hot line. At 0901, a report was made to the OC that a pallet had broken, one round opened, one plug was off, and three rounds were in the door. Additionally it was stated that two individuals had been removed from the igloo. The patients were appropriately identified by their badge numbers during radio transmissions. At 0902, patient decontamination was begun on site. Reports were made to the OC regarding type and extent of injuries to operating personnel. At 0913, upon completion of decontamination patient #0257 was moved across the mini hot line to the crew van for transport to the Emergency Personnel Decontamination Station (EPDS). The patient was not monitored for contamination prior to transfer across the hotline. At 0916, the crew reported that patient #0253 was undergoing decontamination. At 0921, patient #0253 was transferred across the mini hot line at the accident site. The stretcher was placed on the transport vehicle without being decontaminated. There was potential contamination on the handles and runners of the stretcher. At 0922, the crew began to decontaminate the accident site and clean up any possible spill or leakage. Some crewmembers also began to decontaminate themselves at this time. At 0925 plastic was placed over a portion of the rounds and some of the material on the igloo apron. Although there was no confirmation of agent, the crew made the assumption that matter 2-1 Pueblo Chemical Depot

28 on the igloo floor and apron was agent contamination and treated it as such when attempting to mitigate risk at the accident site. However, the ogives of the rounds were not fully covered and this was the area that visually exhibited possible contamination. At 0928, a report of igloo status was made to the OC. The report stated that four rounds were outside the igloo and four rounds were inside the igloo. The rounds outside were covered with plastic and there was possible contamination on the outside of the igloo and on the igloo floor. They were unable to close the igloo door. The crew departed the accident site and proceeded to the EPDS at The radio communications from the site were excellent. The teamwork by the Chemical Operations crew was very good, although there were several medical problems noted by the medical evaluators. Overall, the crew performed field operations in a satisfactory manner. Finding Requiring Corrective Action: PU Description: Use of Improper Protective Clothing Discussion: Personnel processing and assisting individuals at the mini hot line (accident site) failed to don appropriate PPE to conduct required procedures. Personnel at the mini-hot Line wore level C and level D protective clothing and equipment in lieu of level B identified in installation SOP, which references that Level B PPE will be worn when assisting individuals being processed though the mini-hotline. Reference: (SOP) PU-0000-T-486, Chemical Operations, dated 04 Sept `01, Rev 26, change 1, Operation No. 2, Mini hotline Set-up, page 13, paragraph 3 Recommendation: Operators and/or potential responders be issued Level B protective clothing and equipment. At 0858, the Chemical Accident/Incident Control Officer (CAICO) received a phone notification of the simulated accident. After the fire department personnel were briefed on the situation and their assignments, the CAICO departed for the intersection of igloo G301 and the east internal patrol road to set up his command post and ensure the establishment of the Emergency Personnel Decontamination Station (EPDS). The CAICO did a very good job throughout the accident scenario of maintaining command and control of the accident site. He ensured that he received critical information from the individuals coming back from the accident site. In addition, he made certain that accountability of all personnel on site was maintained and that other responding elements (EOD, Decontamination Team) were properly briefed on the situation prior to departure down range. At 0915, fire department personnel and equipment arrived at the Chemical Limited Area (CLA) gate. At 0921, the fire department arrived at the east internal patrol road and the G300 row. The equipment consisted of one fire truck, two ambulances, and an RTAP. 2-2 Pueblo Chemical Depot

29 Fire department personnel began setting up the hot line and the RTAP operator started monitoring operations for contamination. At 0930, a vehicle from the accident site arrived with the injured and non-injured personnel. At 0935, an injured person on a stretcher was passed across the hot line. That person was declared still contaminated and the hot line was re-established in front of the contaminated injured person. That person was decontaminated and once again transferred to the cold side of the hot line. At 0945, the first patient left the site. At 0950 the second patient left the site. At 1010 the MPDS arrived on site. All personnel had processed through the fire department hot line by The fire department hot line personnel completed their operation at 1021 and walked back to their vehicles without decontaminating themselves. The MPDS was operational at Between 1230 and 1310 three personnel processed through the MPDS, in level B dress. Upon exiting the MPDS they failed to report to the medical station for heat stress monitoring. At 1230 decontaminating equipment arrived at the hot line, which was proceeded by the end of field play at Observation Description: Establishment of Hot Line Location Discussion: An RTAP was used to monitor at the proposed hot line location. The monitoring operation was conducted concurrently with the fire department setting up a hot line. Three tests were conducted by the RTAP, at which time the area was declared contamination free. Four-point monitoring was not conducted. There were no written procedures for this operation. Reference: DA PAM , March 1997, page 44, paragraph D-4c; and page 20, paragraph 6-3; and AR , 12 October 2001, page 6, paragraph 2-4d. Recommendation: Establish four point monitoring SOPs in compliance with references. Finding Requiring Corrective Action: PU Description: Fire Department Establishment of the Hot Line Discussion: The fire department sets up the initial hot line prior to the arrival of the MPDS. Strictly speaking, this is not an emergency personnel decontamination station (EPDS) since the hot line processes all field workers, injured or not. There are no written procedures for the establishment of this hot line. The contamination control line (CCL) was only 10 meters upwind from the hot line, rather than the mandatory 50 meters. The 2-3 Pueblo Chemical Depot

30 fire department hot line personnel failed to decontaminate themselves at the end of their hot line operations. Reference: DA Pam , 31 Mar `97, page 44, paragraph D-3c(2); and D-4a; and page 20, paragraph 6-3; AR ,12 Oct `01, page 6, paragraph 2-4d Recommendation: Prepare an SOP and hazard analysis for this hot line operation. Make sure there is employee participation in the development and implementation of the hazard analysis and in development of other process safety management elements. Observation Description: Unclear Guidance Regarding Security Relationship to CAICO Discussion: Paragraph 2f, PCD CAIRA Plan, requires the security supervisor responds to the CAICO command post upon arrival into the area. The requirement as written implies any number of possible actions, e.g., the supervisor comes under control of the CAICO, responds to requests from the CAICO, reports to and remains at the command post, etc. In any event, the only observed contact between security and the CAICO occurred when the CAICO entered the area under emergency entry procedures. Recommendation: The requirement be rewritten to communicate exactly what is intended. Observation Description: Chemical Event Report Discussion: The PCD safety specialist did not complete the chemical event report accurately during the CSEPP exercise. The header of this form should specify the category number, in this case category II. In addition, the chemical event time was not annotated on this form. Reference: AR 50-6, 26 Jun `01, page 36, paragraph 11-2 and page 38, Figure 11-1 Recommendation: Recommend that the PCD CSEPP Planner review the above reference and update local references, such as the PCD CAIRA Plan, EOC Letter of Instruction and associated personnel checklists with the most current data/instructions. 2-4 Pueblo Chemical Depot

31 Observation Description: EOC Activation Security Process Discussion: During activation of EOC, personnel signed a sign-in roster that required entering full name, as well as time of arrival. This created a bottleneck at the security desk. Recommendation: A form including names of responders and potential visitors who would access the EOC be provided, requiring only an initial and time of arrival. Observation Description: Operational Update Discussion: During the fourth operational update, each functional leader briefed the status of their functional area. This was not done during all updates. Recommendation: Use this procedure during all update briefings. Status of Previous Findings: Finding: PU01A04.1 Description: Emergency Personnel Decontamination Station (EPDS) and Mobile Personnel Decontamination Station (MPDS) Location Setup Resolved: YES Finding: PU01A13.1 Description: Non availability of Mobile Personnel Decontamination Station (MPDS) SOP Resolved: YES Finding: PU01A13.2 Description: Chemical Agent Monitor (CAM) Battery Low Indicator Resolved: YES 2-5 Pueblo Chemical Depot

32 Finding: PU01A13.3 Description: Mask Control Inside the Limited Area Resolved: YES Finding: PU01A13.4 Description: Escape Mask Availability Resolved: YES Finding: PU01A13.6 Description: Failure to Wear Proper Protective Equipment Resolved: No, not demonstrated this year. EOD simulated by Controllers. New Finding Number: PU Response Stream 2 Hazard Assessment At 0700, the hazard analyst submitted a work plan for re-warehousing HD-filled 155 MM projectiles. The maximum credible event (MCE) for this operation is one round leaks. The work plan MCE was submitted via emergency management information system (EMIS) to PC EOC. At 0856, employees in the Chemical Limited Area (CLA) notified the PCD OC of a simulated chemical accident. The PCD OC declared a Limited Area Emergency level and announced this information to personnel in the OC. Meteorological data at the time of the accident indicated wind out of the northwest at 307 degrees at 3.8 miles per hour with a temperature of 42 degrees Fahrenheit. Pueblo County was notified via telephone at 0902 and provided CAI information utilizing the PCD s CAI notification form. Information provided to Pueblo County (both verbally and in writing via FAX) indicated the correct wind direction (from the NW) but an incorrect wind direction of 42 degrees. This error was of no practical consequence since the projected hazard was limited to the CLA. Phone communication providing chemical emergency notification was concluded at The chemical emergency notification form was FAXed to Pueblo County at Pueblo County 2-6 Pueblo Chemical Depot

33 receipt of the form was confirmed at The PCD OC accomplished chemical emergency notification to Pueblo County within the required ten minutes. Management and leadership of all response activities under the direction of the EOC were proactive and effective. Operational updates were provided in a timely and informative method throughout the exercise. Required alert and notification of Pueblo County and higher headquarters elements was timely, although there were relatively minor anomalies regarding the accuracy of information to the county. However, this would not have resulted in a degradation of the protection of either on post or off post personnel. Additional resources needed from external organizations were quickly identified and requests made. The determination was made that, although some personnel and equipment resources needed augmenting, the installation could manage the response to conclusion and the Service Response Force was not needed. Observation Description: Inaccurate Initial Emergency Notification provided to Pueblo County Discussion: The MOA between PCD and Pueblo for notification of a CAI requires PCD to notify Pueblo County within ten minutes of the detection of a CAI by PCD personnel. PCD will provide telephonic notification to the Pueblo County Sheriff s Communication Center via a phone call to 911 followed by a facsimile transmission. Recommendation: Ensure accuracy of essential elements of information provided in response to a CAI. Observation Description: There was no mechanism to periodically capture information displayed on the EOC Status Board during the response. Discussion: As conditions changed or additional information regarding the accident and response efforts became known, the manual Status Board in the EOC was updated. However, there was no comprehensive means by which to periodically capture the information displayed on this board as known at specific points in the response. While some information was recoverable from the electronic status board files, some (e.g., status of damage to munitions) was not there. Information regarding what was known when, could be important after the response is over for after action analyses and reviews, safety investigations, and legal defenses. Recommendation: Consider one of several fixes, depending on the budget available. An inexpensive fix would be to take Polaroid or digital pictures of the current manual board every 20 minutes or so for archive (and assigning specific responsibility for this action). Another possibility is to obtain a manual board that allows making hard copies 2-7 Pueblo Chemical Depot

34 of the board periodically. An expensive but highly flexible fix is to purchase a SmartBoard, which permits making electronic copies of the contents of the board. The hazard analyst was informed that two HD-filled 155MM projectiles were leaking on the apron of igloo G203. The hazard analyst correctly adjusted the above MCE to account for two rounds leaking to make the initial assessment. The initial assessment was broadcast via EMIS to Pueblo County EOC at The hazard analyst reassessed the hazard and re-broadcasted via EMIS the assessment frequently throughout the exercise. The re-assessments were based on changes to the meteorology and the number of rounds reported leaking. Observation Description: Initial Hazard Assessment Modeled at an Incorrect Location Discussion: The initial hazard assessment was incorrectly made for a location that was approximately 80 meters South of the igloo door/apron. The error was quickly reversed and a revised assessment was broadcast. This error did not put additional personnel at risk. Recommendation: For a chemical release outside an igloo ensure the proper coordinates are input into EMIS prior to broadcast to the off-post community. Provide additional training to properly and efficiently input data as noted in the EMIS Users Manual, dated 1 Nov 98 w/change 1 dated 1 Mar Observation Description: Improper Modeling of Meteorological Variables in Hazard Reassessments Discussion: Hazard reassessments were made when the meteorology changed. As the meteorology changed significantly during the course of the exercise and new meteorological records were available every 15 minutes this resulted in numerous reassessments. The reassessments that were made did not correctly model this changing meteorology. This resulted in hazard reassessments that were broadcast off post that incorrectly identified the area(s) where the potential hazard existed. It is important to note that the PCD command and control correctly used the reassessed model outputs from these hazard reassessments for their purposes and it did not result in risk to personnel. Additionally, some of the hazard assessments used a default ground temperature (59.9 degree F) that was lower than would have been obtained using the recommended 2-8 Pueblo Chemical Depot

35 Observation derived from air option. A lower ground temperature would result in a less conservative hazard prediction. Recommendation: Train and become familiar with guidance in the EMIS Users Manual, dated 1 Nov 98 w/change 1 dated 1 Mar 2001, subject SBCCOM Guidance on use of Time to Meteorological Change (TMC) in the EMIS D2PCw Model. Description: Hazard Analysis did not reflect actual release conditions Discussion: All of the hazard reassessments that were made during the course of the exercise were MCE-based assessments and did not consider the reported release conditions. The MCE for the operation was one round leaks its contents outside of the igloo on a surface with a temperature no lower than 59.9 degrees F and evaporates for 120 minutes. MCE-based assessments were made during this exercise by simply increasing the number of rounds from 1 to the number reported to be leaking (i.e., initially 3 outside, then 2 outside, and finally 4 inside). While this MCE has been carefully crafted by PCD to conservatively model the hazard for this operation and scaling it to match the number of leaking rounds is reasonable for an initial assessment it should be used with great care in making additional hazard reassessments. A command and control decision was made to stick with the MCE-based assessment. For this exercise scenario, the hazard was small and accounting for the reported release conditions would also have resulted in a small hazard. For a more significant release, the consequences of not revising the hazard assessment based upon the reported information could result in broadcast reassessments with ever-growing hazard areas. For a more significant release than in this exercise, the following reported variables should be considered in reassessments: 1. The reported location of the release (indoor versus outdoor or both) should have been considered. In all cases the release was modeled as being outdoors, but the final report was for 4 leakers inside the igloo. 2. The surface temperature of the release should have matched the model location of the release (for an outdoor release the surface temperature should have been derived from air temperature while some representative interior temperature should have been used for an interior release). 3. The duration of the release should have been increased to match the reports (120 minutes was used throughout and never changed, even after 120 minutes had elapsed and the hazard analysts were assuming there might still be an uncovered spill). Recommendation: Train EOC hazard analysts as required. 2-9 Pueblo Chemical Depot

36 A RTAP operator arrived at the worksite, effectively set-up the equipment, and performed preentry monitoring in accordance with the installation SOP. He assisted in the rescue, first-aid treatment, decontamination, and evacuation of casualties when the accident occurred. As directed by the OC, an RTAP operator (utilizing point sampling) monitored the hazard from the agent release. Observation Description: RTAP Operator Performance of Duties Discussion: The RTAP operator dispatched to G203 was very knowledgeable and professional in the set-up and operation of monitoring equipment. He was very methodical, efficient, and followed the SOP to the letter. The operator donned protective equipment and was instrumental in administering life saving first aid and gave constant reassurance to casualties. He also assisted with the decontamination and evacuation of casualties. Status of Previous Findings: Finding: PU01A01.1 Description: Inaccurate Emergency Notification Level Provided to Higher Headquarters Resolved: YES Response Stream 3 Population Warning The PCD EOC was completely staffed within 11 minutes of the accident. Sirens were activated as required. They were repeated at the appropriate intervals except for the first repetition, which was a few minutes late. At 0927, Pueblo County assumed responsibility for siren and TARs activation for PCD. The individual managing the on-post siren system did not note this information. He continued to simulate activation of the on-post siren system at 0934, 0946 and At 0959, the siren manager acknowledged the county had assumed siren activation responsibility and he would discontinue management of the on-post siren system. It is mutually agreed (although not yet formally in writing) that the PC EOC will be responsible for activating the tone alert radio system (TARs), both on- and off-post. Because this incident was classified as a limited area emergency, no off-post protective actions were recommended and PCD requested activation of on-post TARs only. The depot s request for TARs activation 2-10 Pueblo Chemical Depot

37 did not include verbiage for a message that would have been appropriate for the simulated chemical event and on-post PAD. A pre-scripted TARs message was neither available nor requested. TARs were activated at 0914 with a test message. It was announced (on more than one occasion) in the County EOC that TARs were continuing to be activated at required intervals (every twelve minutes for the first hour, and every 20 minutes thereafter), but no actions to complete this task were observed and no procedures available. The PC EOC was informed of the PCD Commander s PAD for on-post populations at 0903; however, no effort was made to ascertain the content of the appropriate TAR message. Therefore, the PC EOC had no idea of what emergency instructions they were simulating to provide repeatedly over the TARs to PCD personnel. If this had been a real emergency, Pueblo County would not have known what protective actions, if any, were being implemented at PCD. Moreover, TARs activation would have been delayed while PCD drafted a message providing specific emergency instructions and provided it to the PC EOC. Observation Description: Activation of the PCD Outdoor Warning System Discussion: The PCD siren system was initially activated at Subsequent siren activations (simulated) should be every 12 minutes within the first hour of the event. The second simulated siren activation was conducted at 0913, 17 minutes after the initial activation, which is 5 minutes beyond the required interval. All other siren soundings made by PCD were within the required time intervals. Recommendation: A timing device (watch, stop watch, etc.) be utilized by the siren manger to ensure 12 minute intervals are maintained between siren activations. Status of Previous Findings: Finding: PU01A05.1 Description: No Repeated Siren Sounding Resolved: YES Response Stream 4 Protective Action Implementation Populations on post potentially affected by the accident were notified and evacuated where necessary. However, this seemed to take a long time due to the need to telephonically notify all tenants Pueblo Chemical Depot

38 Field security elements took effective measures to ensure employees and contractor personnel were not left unprotected in vicinity of the CLA. Coordination and communications was maintained with the Chemical Site Defense Force, and a transportation control point was established and maintained at the entrance to the ammunition storage area (Checkpoint 1), to prevent unauthorized personnel from entering the hazard area and control route of entry/exit of emergency responders. Security personnel effectively secured the accident scene. Response time was excellent. They properly secured the site; collected and reported essential elements of information, establish an appropriate security cordon, implemented emergency ingress/egress into the area, maintained accountability of responders, and kept EOC staff informed of the situation. Observation Description: Failure to Don Protective Mask Discussion: Security personnel in the Site Security Control Center (SSCC) failed to immediately don their protective mask upon notification of the chemical accident, as required for all occupants of the CLA. The affected individuals were not in a contaminated area; however, failure to follow established masking procedures could result in injury and loss of use of personnel. It should be noted that the security supervisor understood the requirement, and readily admitted that his decision not to mask based on his knowledge of the wind direction and assumption about the extent of the accident was incorrect. Reference: PCD CAIRA Plan, Annex G (Evacuation Procedures), paragraph 2a(2)(b), page G-1, April 2001 Recommendation: Conduct operations IAW approved plans. Response Stream 5 Victim Care Initial patient care (self-aid/buddy-aid) continues to be problematic. Recognition of injury significance, provision of appropriate care by initial responders and the rapid evacuation/transfer to competent medical care of injured personnel needs improvement. Due to the simulated continued blood loss from an improper dressing, and non-response to repeated evaluator clues that blood loss was still not addressed, the litter patient went into respiratory arrest and then cardiac arrest shortly after crossing the hot line. While receiving CPR, the patient was then loaded into the receiving ambulance for transportation to the clinic. While in route, the casualty regained a weak pulse, giving ambulance personnel time to put in a life saving IV line. The clinic personnel then further resuscitated the litter patient with another IV line, and he eventually revived to stable status Pueblo Chemical Depot

39 After properly decontaminating the litter patient by re-cleaning the fracture wound and changing his dressings he was prepared again for transport to hospital care. He was then evacuated to Parkview Medical Center, who then assessed his condition and sent him to the operating room for fracture surgery. The ambulatory patient was also evacuated to the clinic and then sent on to St Mary Corwin hospital for additional care. Finding Requiring Corrective Action: PU Description: Initial Patient Stabilization (repeat PU01A10.1) Discussion: Initial responders applied a loose gauze dressing to what was described as a spurting artery in the left leg. Consequences were continued bleeding at the site after the dressing was applied. The patient decompensated from a normal pulse, to a thready weak pulse, and finally to no pulse (from 0903, when the bleeding was first exposed to view, to 0943, when the patient had no pulse). Numerous injects were given by evaluators, describing the extent of bleeding, but the responders did not remedy the discrepancy. First aid for a spurting artery is a pressure dressing, not a wrapped dressing. Alternatively, a constriction bandage upstream from the site of bleeding may be used. If the spurting artery is left to bleed under the wrong dressing, it might not take long for the casualty to bleed to death (five to thirty minutes, depending on the size of the artery, tightness of the wrap, etc.) Reference: American Red Cross Basic First Aid Recommendation: That remedial first aid training be given to reinforce the importance of pressure dressings, with follow up training at more frequent intervals. Finding Requiring Corrective Action: PU Description: Delayed Evacuation of Patients (repeat PU01A11.1) Discussion: Thirty-two minutes elapsed from the time of accident to the time in which initial responders moved the two casualties to the fire department hot line and an additional thirty minutes to get to the clinic: During this time, the following was accomplished: 2-13 Pueblo Chemical Depot

40 Identification that an accident had occurred Sounding the alarm and establishing and maintaining continual communications Mobilization of initial responders Dressing into PPE by initial responders Removal of the casualties out of harm s way Initial assessment of injuries and extent of contamination for each casualty Working through problems associated with both casualties being unconscious or semi-conscious for the first five minutes of response. Application of initial first aid Removal of casualty clothing in a controlled manner to minimize contamination spread Decontamination of casualties, to include on open wound Preparing casualties for transport (movement to stretchers, spinal stabilization, etc.) Moving casualties across initial responder hot line Loading casualties into evacuation vehicle Ensuring that all who are loaded into evacuation vehicle are safe before moving forward Receiving radio permission to move forward from incident site commander All of these actions were conducted while wearing a protective mask which results in restricted field of vision, difficulty in hearing and being heard. Reference: DA Pam 50-6, 17 May `91, page 45, paragraph 6-5 Recommendations: 1. Purchase and train with approved voicemitters for all protective masks 2. Purchase and train with special razor blade cutters for removal of clothing 3. Don t wait for hot-side responders to self-decontaminate before evacuation of casualties, any available clean personal should drive them to the hot line Observation Description: Contaminated dressings were never changed Discussion: Each time a hot line is crossed, contaminated dressings must be evaluated for contamination, and removed if contaminated. Both initial and fire department responders evaluated these dressings for contamination in the litter patient, but failed to make the necessary changes. Although pink bracelet was affixed to signify full decontamination, evaluators were saying the opposite. An order was given to remove the bracelet, but no one actually did it. Consequently, the ambulance and the clinic were unnecessarily contaminated by unwitting personnel, despite all that evaluators were saying to the contrary Pueblo Chemical Depot

41 Reference: Medical Management of Chemical Casualties Handbook, page 203, that states. During clothing removal, aid man removes tourniquets after placing a new one an inch or two or so higher, and cuts away bandages and irrigates wounds (replacing the bandage only if bleeding recurs). Recommendation: 1. Purchase and train with approved voicemitters for all protective masks. 2. Incident site commander must ensure that contaminated dressings be changed before crossing the fire department hot line 3. Bracelets used as a go no go decontamination control device should only be placed after decontamination has in fact been done. Observation Description: Improper reporting of victim information. Discussion: During the course of the CAI, the names of chemically injured personnel were reported over the security radio net. Not only is this a violation of principles of operations security, and the Privacy Act, it violates DA s policy prohibiting public release of victims names before official notification of their next of kin. Reference: AR 360-1, 15 Sep `00, page 17, paragraph 5-20, and AR , 20 Oct `94, page 7, paragraph 2-24 Recommendation: Use employee badge numbers in lieu of employee names when discussing employee injuries. Status of Previous Findings: Finding: PU01A10.1 Description: Initial Patient Stabilization. Resolved: NO. Incorporated into Finding PU Finding: PU01A11.1 Description: Delayed Evacuation of Patients. Resolved: NO. Incorporated into Finding PU Pueblo Chemical Depot

42 Finding: PU01A12.1 Description: Lack of Narcotic Medications Resolved: YES Finding: PU01A13.5 Description: Security Policemen Drive Through Hazardous Area. Resolved: YES Response Stream 6 Evacuee Support Not applicable. Response Stream 7 Public Information The PCD Public Affairs Officer (PCD PAO) was augmented by six people who came to her office to help respond to the emergency. They produced five news releases that were timely and informative. Public affairs staff returned reporters calls to answer previously asked questions. Media Monitoring appeared to be effective; the PCD PAO called the mock media to clarify news stories and to update reporters. The PCD PAO worked from the EOC to ensure she had direct access to information, and she used an open phone line to her office to keep her staff informed and obtain feedback about their activity. The PCD PAO scheduled an early news conference at the PCD gate. The PCD Commander presented a very effective statement and demonstrated an appropriate mix of confidence and control. Observation Description: Incorrect/Outdated information released Discussion: Despite the open phone line system between the PAO and the staff working from her office, that staff did not always appear to have current information and sometimes gave conflicting information in response to media inquiries. As late as 0945, the media was told that there were no injuries, all the munitions are intact and that there was no release, contradicting a PCD news release at 0935 that announced the accident and two injured PCD workers. At 0956 an augmenter in the PAO office 2-16 Pueblo Chemical Depot

43 maintained that there was no agent release. Another augmenter told a reporter at 1053 that there was no plume and no release. As late as 1140, at least one of the public affairs staff did not have information on the injured workers; however, she was able to put the reporter on hold and find the information once the reporter pushed her to do so. Recommendation: Information must be shared with all public affairs staff to ensure that the most timely and accurate information is disseminated. Consideration should be given to using the PAO office computer to access the shared files generated by the PCD Emergency Operations Center. Continuous review of these files by PAO staff augmenters would ensure that only current & accurate information is provided to media representatives. Strength Description: Effective Command Presence Discussion: When the commander spoke to reporters at the gate at 1100 he offered useful information and answered questions effectively. He appeared confident and in control without coming across as aggressive or uncaring Pueblo Chemical Depot

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45 STATE OF COLORADO Response Stream 1 Hazard Mitigation Not applicable. Response Stream 2 Hazard Assessment According to the State s concept of response/exercise operations, the State s role is to monitor situations and events at PCD and Pueblo County but not issue protective action decisions (PADs). The State EOC staff members effectively demonstrated their ability to monitor hazard analysis stream activities. The Colorado Office of Emergency Management (COEM) received a limited area emergency notification call from the Pueblo County Emergency Operations Center (PC EOC) at The first EMIS/D2PCw run was received at The last of eight plume projections was received at Plume projections of 50 meters long and 20 meters wide and the attendant limited area emergency classification, supported the decision by the State EOC Operations Manager to initiate a partial EOC activation, limiting the initial EOC manning to COEM staff only. At approximately 1100 the State Network Administrator, looking to update plume information, erroneously pulled up the maximum credible event plume which showed the agent leaving the PCD boundaries. Prior to making any operation changes, the State Operations Manager called the Pueblo County Operations Manager to verify the confusion with the new plume data. Response Stream 3 Population Warning The State s decision to call for a partial activation of the emergency operations center continued throughout the exercise. EOC staff for the exercise included the State EOC Operations Manager, Infrastructure Manager, two State Network Administrators and State Public Information Officer (PIO). The staff-only EOC activation was initiated at 0920 and the EOC activated by The State EOC staff monitored Pueblo County population warning actions. State agencies notified and available for exercise play from their normal office locations included, the Governor s Office, Colorado State Patrol, and Department of Public Health and Environment. Additionally, and as an enhancement to the exercise extent of play agreement, six amateur radio volunteers assisted in delivering event notification, tracking and calls for service messages throughout the course of the exercise. Notification of the Colorado State Patrol, 2-19 State of Colorado

46 Colorado Department of Health and Environment and the Governor s Office representatives began at 0923 and was completed at The State Public Information Officer remained at the State EOC, effectively fielding public affairs, mock media, official and citizen inquiries. The State successfully demonstrated necessary support of and involvement with the Joint Information System (JIS). Response Stream 4 Protective Action Implementation The State EOC official response role is to monitor protective action implementation events and activities at Pueblo County and provide supplementary assistance and support. The State EOC staff was successful in monitoring the few protective actions taken in the County and in providing requested supplementary assistance. State EOC staff demonstrated their ability to qualify and satisfy requests for external assistance from federal and other support agencies. Response Stream 5 Victim Care The Colorado Office of Emergency Management (COEM) was successful in demonstrating capability to monitor events and situations relating to the victim care response stream for this exercise. Monitoring and tracking of the two PCD patients status through the PCD Public Affairs Office news releases was sufficient information. Response Stream 6 Evacuee Support Not applicable per extent of play. Response Stream 7 Public Information The State Public Information Officer remained at the State EOC effectively fielding public affairs, mock media, official and citizen inquiries. The State PIO successfully demonstrated necessary support of and involvement with the Joint Information System (JIS). The primary function of the information system is to establish pre-jic public affairs contact and coordination and provide subsequent, timely and accurate information to the public and media. The State EOC extent of play agreement for this exercise focused on the State s responsibility to provide information pertaining to special populations and schools, protective action decisions, traffic and access control, evacuees and EAS messages. The State Public Information Officer and EOC staff provided timely and accurate information to the public and media State of Colorado

47 The State received news releases from PCD and Pueblo County, as well as mock media stories. The State s PIO notified surrounding states of what was happening at the depot in case they heard media reports. The State PIO conferred with the depot prior to releasing information. The State PIO verified that previously released information was appropriate and the depot should be the point of contact for information State of Colorado

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49 PUEBLO COUNTY Response Stream 1 Hazard Mitigation Not applicable. Response Stream 2 Hazard Assessment Prior to 0856, Pueblo County Emergency Operations Center (PC EOC) staff had received and reviewed the Pueblo Chemical Depot (PCD) work plan describing the scheduled re-warehousing operations at igloo G203 for March 20, At 0901, PC EOC received an initial event notification over the Emergency Management Information System (EMIS) from PCD of a Limited Area Emergency and an associated plume projection [Run 001]. This plume described a release of mustard agent (HD) from three 155mm rounds originating at a location 113 meters south of Igloo G203, producing a no effects distance of 97.7 meters. The PC EOC contacted PCD by telephone and confirmed the information. The corresponding chemical emergency notification form was received from PCD by telephone at 0903 and by FAX at Although the notification form correctly cited the wind direction as from the northwest, it numerically listed the direction as 42 degrees. Due to the prior receipt of the actual plume projection from PCD through EMIS with the accurate wind direction, this error had no impact on actions taken at PC EOC. A second plume [Run 002] was received at 0905 shifting the modeled release point to 30 meters south of Igloo G203 and presenting a no effects distance of meters, based on revised air temperature, wind speed and direction, and atmospheric stability. The Operations Chief announced the adoption of the Limited Area Emergency classification at 0907, along with the associated PAR -- no off-post protective actions required. Two subsequent plumes received from PCD prior to 1000 [Runs 006 and 007] reflected an increase to an estimated four 155mm projectiles involved in the release, which was confirmed by telephone with PCD at In conjunction with slight shifts in wind direction and speed, this change led to a plume [Run 007] at 0945 in which the far edge of the 30-degree safety wedge reached the boundary of the Chemical Limited Area (CLA). This result, in turn, led to further discussion with PCD on the need to change the designation of the event to a Post-Only Emergency. After consultation with the EM Director, the Operations Chief announced a decision at 0948 to retain the Limited Area designation. Under current procedures no further action would have been required by Pueblo County even if the designation had been changed. At 1005, the EOC received a revised plume [Run 008] primarily reflecting a shift back to atmospheric stability class B that reduced the no effects distance to meters. During the next hour, the EOC tracked considerable changes in wind direction although there were no associated increases or decreases in the no effects distance for theses plumes. In the last hour of 2-23 Pueblo County

50 the exercise, increased air and surface temperatures increased the no effects distance to meters [Run 020], but the wind shifted the plume in a northerly direction, away from the closest boundary of the CLA. No additional response actions on the part of Pueblo County were necessitated by the plume projections received subsequent to Following receipt of notification from PCD that the Explosive Ordinance Disposal personnel had safely canned the leaking munitions at 1249, ENDEX was called at Pueblo County. During the course of the exercise, approximately twelve separate plume projections were received at PC EOC through EMIS from PCD; all projections broadcast by PCD (based on significant changes in the release scenario) were received by PC EOC. In several instances, the PCD liaison was able to provide a heads up regarding subsequent plume projections. The computer specialists in the EOC quickly reviewed, analyzed, and projected the text-based and graphical plume information on the large front and rear EOC display panels. They coordinated closely with the Operations Chief to ensure that changes were reviewed immediately to support an ongoing determination of the need for additional response actions. The Operations Chief acted quickly to confirm the nature of any significant changes with PCD and ensure that no complicating factors (e.g., fire) had taken place. Due to the scope of the release, no independent confirmation of the PCD hazard modeling or support for response phase monitoring and sampling was demonstrated at the EOC. Response Stream 3 Population Warning Pueblo County received electronic notification from PCD of a limited area emergency via EMIS at The Pueblo County EOC (PC EOC) immediately telephoned PCD to confirm the CENL, verify that off-post protective actions were neither recommended nor required, and obtain additional incident details. Meanwhile, the PCD OC was making standard telephone notification to the Pueblo County Communications Center (PCCC), where a dispatcher recorded the information on a chemical emergency notification form. A copy of the same form, as completed by PCD personnel, was FAXed to the PCCC for verification. It appears that the notation on both forms under Wind direction in degrees is actually the atmospheric temperature. Ongoing training for both PCD OC and PCCC personnel should address this matter. In accordance with established protocols for a limited area emergency, the PC EOC Operations Chief initiated partial EOC activation, mobilizing Department of Emergency Management (DEM) and Geographical Information Systems (GIS) personnel to staff the EOC. Beginning from a cold start at 0906, DEM personnel quickly reconfigured tables, plugged in phones, hung position identifiers and efficiently transformed space serving day-to-day as a conference room into the heart of a functional EOC. The EOC was declared operational at The EM Director, after reviewing incident information and discussing the situation with the EOC Operations Chief, agreed that no off-post protective actions or EAS message were required and that Pueblo County would standby at its enhanced level of readiness while continuing to monitor the situation. At 0908, the EM Director notified the County Commissioners of the incident and provided a short status briefing of Pueblo County s actions. At 0911, a similar call was made to 2-24 Pueblo County

51 the Colorado Office of Emergency Management (COEM). A news release regarding the limited area event was issued, reiterating that there was no danger to the public and that no protective actions were necessary. It is mutually agreed, although not yet formally in writing, that the PC EOC will be responsible for activating the tone alert radio system (TARs), both on- and off-post. This simulated accident was a limited area emergency; therefore no off-post protective actions were recommended and PCD requested activation of on-post TARs only. PCD s request for TARs activation did not include verbiage for a message that would have been appropriate for the simulated chemical event and on-post PAD. The Pueblo County operator who activated the TARs did not know what the accompanying message should have been, and made no effort to obtain the information. TARs were activated at 0914 with a test message. It was announced, on more than one occasion, in the PC EOC that TARs were continuing to be activated at required intervals, every twelve minutes for the first hour, and every 20 minutes thereafter, but no actions to complete this task were observed and no procedures available. The Pueblo County EOC staff was informed of the PCD Commander s PAD for on-post populations; however, Pueblo County EOC staff did not record this information in the EMIS log nor did this information get announced to the Pueblo County EOC staff. While not required by CSEPP guidance or applicable MOA/MOU, recommended actions include the logging of this information in Pueblo County s EMIS log. However, not logging and/or announcing this information did not materially impact the overall response in this scenario. Pueblo County EOC had no idea of what emergency instructions they were simulating to provide repeatedly over the TARs to PCD personnel. If this had been a real emergency, Pueblo County would not have known what protective actions, if any, were being implemented on-post. Moreover, TARs activation would have been delayed while PCD drafted a message providing specific emergency instructions and provided it to the County. In a related arrangement, PCD and the PC EOC have informally agreed that during a chemical event, on-post sirens will be initially activated by PCD. However, after the first sounding, PCD may request PC EOC to assume responsibility for continued on-post siren and TARs activation at the required intervals outlined in CSEPP alert and notification guidelines. At 0927, PCD made such a request, and the PC EOC agreed verbally to assume responsibility for continued siren activation as well as TARs activation, but no directive was given to EOC staff to perform this task. This resulted in the PCD sirens not being sounded, through a silent test, at the required intervals. No apparent procedures have been developed to implement this cooperative arrangement and no Memorandum of Understanding or Agreement has been executed. Pro-active, ongoing dialogue between PCD OC and the PC EOC facilitated information flow and accuracy. For example, initial information received from PCD OC indicated that three workers were injured during a simulated accident. That number was corrected from three to two, when inconsistencies between electronic and verbal information were noted in the PC EOC, which prompted a phone call to PCD to determine which number was accurate. The PC EOC also demonstrated its ability to troubleshoot and rectify problems as they occurred during emergency response activities. At one point, a radio communication problem between the PCCC and the 2-25 Pueblo County

52 State EOC was identified, but communications technicians responded quickly and resolved the matter. In keeping with Pueblo County s extent-of-play agreement, a full-system, audible siren test was demonstrated at 1200, broadcasting both alert tone and verbal test message. At approximately 1115, the National Weather Service, the alternate activation point for Pueblo County s TAR system, also performed its regularly scheduled weekly test, which broadcast was heard from the TAR located in the EOC policy room. Although physical space in the operations area of the EOC is limited, it is well utilized and sufficiently equipped. Running all EOC functions off generator power from 0707 through ENDEX tested the EOC generator s operational capability and demonstrated the ability to supply backup power for extended EOC operations. It was obvious throughout the response that PCCC, DEM and GIS personnel were knowledgeable and well-trained in the performance of their response duties. The limited scope of this particular exercise scenario didn t offer opportunity for PC EOC personnel and other offpost responders to demonstrate the full competence and capability of the Pueblo Community to respond to a PCD chemical agent accident. Response Stream 4 Protective Action Implementation Due to the nature of the accident (Limited Area Emergency), the protective action recommendation (PAR) provided by the Pueblo Chemical Depot (PCD) was that there were no off-post protective actions required. Pueblo County found it necessary to make only limited protective action decisions (PAD). Pueblo County received notification from PCD at At 0914, the Pueblo County Emergency Operations Center (PC EOC) notified Thatcher Ranch and District 70 schools of the event and instructed them to stand by only. There were no required evacuation or sheltering actions. These particular entities appropriately received attention as a precautionary measure due to their proximity to the Chemical Limited Area. Since the event didn t escalate further, there were no other protective actions taken by Pueblo County. Response Stream 5 Victim Care At 0901, the Pueblo County Emergency Operations Center (PC EOC) was notified that a simulated accident occurred at 0856 involving chemical weapons stored at PCD. The PCD call to the Pueblo County Communications Center (PCCC) stated that three HD-filled 155mm projectiles were dropped from a forklift and that three workers were injured. A FAX confirming this information was received in the PCCC at At 0922, discussions between PC EOC and PCD personnel updated the number of injuries from three to two. No further victim care information about this Limited Area Emergency was available 2-26 Pueblo County

53 until at 0950, information was broadcast that the patients were being transported to the PCD Occupational Health Clinic (OHC). Based on radio traffic, two victims were transported, one to Parkview Medical Center and one to St. Mary-Corwin Regional Medical Center. This was the last of the victim care information available due to the limited PC EOC play for this exercise. According to the Emergency Operations Plan the EOC Medical Coordinator would have coordinated Victim Care functions had there been a full activation of the EOC. The Extent of Play Agreement required only partial activation of the EOC. At 0902, the SMC ED received a telephone call from PCD stating that there had been an unspecified accident at PCD and the hospital should stand-by. At 0904, the ED charge nurse promptly notified the hospital administrator on call of the PCD notification. At 0912, the hospital issued an overhead page Standby Disaster Drill. At 0913, a hospital disaster cart arrived at the ED and various response support supplies such as identification vests were distributed. Hospital security staff also arrived in the ED, reported that they and assigned maintenance staff simulate lock down of facility, and established perimeter control. At 0915 hospital administrators, nurses, and other assigned staff began to set-up the hospital EOC in a pre-designated room in the basement not far from the ED. The EOC had adequate telecommunications setup with several telephones, numerous radios, and community emergency response maps on the wall. In addition, well-organized task assignment booklets containing checklists and job actions sheets were distributed to EOC staff. Several whiteboards were available. The EOC has connectivity to the hospital s networked computer system or associated software applications for patient tracking, logistics management, and alternative communications channels such as and Internet FAX. EOC staff wore yellow-green vests. It is recommended that the vests include position indicators to facilitate quick identification of staff roles. The ED and security personnel did have position indicator labels on their vests. The hospital chief financial officer (CFO) was the hospital incident commander and initially was in the EOC. At 0923, the hospital EOC staff requested and received a status update from the ED demonstrating functioning communication systems and information sharing. At 0928, area assignments were made to the decontamination team members. The decontamination team members were medically screened, per Occupational Safety and Health Administration (OSHA) requirements, with vital signs and recorded on a PPE status board. The board was also used to track the time the decontamination team was in PPE during the exercise. The Safety Officer later indicated that work-rest times would be followed using the American Conference of Governmental Industrial Hygienist (ACGIH) guidelines based on ambient conditions, level of PPE, and estimated work intensity. At 0930 two decontamination team, members completed donning OSHA level C PPE. Two more members began the level C donning process with two additional members on standby as back ups. The PPE consisted of blue Kappler over-garment (splash gear), rubber boots, and gloves taped at ankles and wrist, respectively, full-face tight-fitting powered air purifying respirators (PAPR) respirator and hood with filter canisters. The PAPRs worked properly and facemasks appeared to fit well with no reported hot spots or face-piece fogging noted. The participants were proficient in donning and wearing the PPE. Several members of the decontamination team were from the Pueblo City Fire Department, again indicating the excellent support provided by that department to the hospital Pueblo County

54 One of the fire chiefs was present supervising their personnel and general situation in the decontamination area. The decontamination area was located immediately outside the ED and consisted of a decontamination supply and PPE storage room, a large, well-equipped decontamination trailer, decontamination water run-off storage tank, and pre-decontamination areas were surrounded with clearly visible marker tape and orange street cones. However, there was not clear delineation of an actual hot line. This was later a problem and led to violation of the hot zone by several staff including the Safety Officer and Hospital Incident Commander. At 0930, the ED obtained operating room (OR), critical care bed status, and current inpatient census, and a Level I disaster drill notification was declared utilizing the overhead paging system. At 0931, the ED charge nurse called the EOC to clarify the basis for the change in disaster level. At 0935, the hospital EOC was fully operational. At 0938, the PPE status board in the decontamination support area indicated that eight team members had completed and passed medical screening. At 0940, the Hospital Incident Commander was observing activities in the ED and decontamination area reporting status back to EOC over a handheld radio. From 0956 to 1159, the hospital was mobilized and responding to a mass casualty incident drill at the Colorado State Fair Grounds. Thirty-four total victims from that simulated incident were fully processed while the EOC and staff waited for updates on the PCD simulated accident and any patients to be forwarded to the hospital. At 1200, one patient arrived unannounced via EMS from PCD to the triage area with simulated right open femur fracture. The triage staff did not initially recognize the patient as a victim from PCD. However, the triage staff demonstrated assessment and triage. Because distal pulses were assumed intact, he was designated as a delayed category to the Post Anesthesia Care Unit (PACU) for further surgical triage. Staff recognized that there is not currently any antidote for mustard exposure effects. The patient arrived with written medical records which included a single one-sided physician note from PCD handwritten on a Standard Form 600. The note provided exam findings and medication as well as a single set of vital signs. However, it was lacking in not providing circumstances of the injuries, degree (body surface area estimate) of skin and inhalation exposure, extent and location of decontamination, and results of any successive evaluations. The patient also had an emergency care and treatment form (SF 558) that only had the victim s name and very brief summary of the physical injuries but no vital signs or other information such as treating facility name and location and duration of observation. In summary, this hospital demonstrated a mature emergency response capability with excellent and timely mobilization of personnel and resources. Strengths included managerial support, staff enthusiasm and participation, dedication to making the exercise a worthwhile learning experience. They demonstrated the ability to deal with simulated and real patients simultaneously without any compromise of quality care to the later. The decontamination team and exercise ED charge nurse performed their tasks with commendable skill. Decontamination equipment was not fully demonstrated, due to inclement weather. The decontamination process 2-28 Pueblo County

55 was simulated but seemed adequate. Personal protective equipment functioned properly. The nurse, physician, and admissions staff at the internal triage point performed well. EOC operations were also well executed and controlled. However, the PCD aspect to the hospital incident response revealed problems with maintaining an adequate stream of information between PCD and SMC hospital which resulted in relaxation at the hospital of mental preparedness for a potential mustard agent contaminated patient. Clinical documentation forms from PCD were incomplete and lacked critical informational elements and there was no forwarded documentation of recurrent exam findings and vital signs over the course of the time the patient was observed at the PCD OHC. There were also no recommendations from PCD medical staff regarding mustard-specific surveillance for complications, need for urinary thiodiglycol levels, or other relevant communications. Status of Previous Findings: Finding: PC01CV.1 Description: Proper Triage Resolved: YES Response Stream 6 Evacuee Support Evacuee Support was not part of the Extent of Play Agreements and was not demonstrated. However, the Emergency Operations Plans for Pueblo County make provisions to support evacuees with reception centers, shelters, and counseling should it be required. Response Stream 7 Public Information Four minutes after Pueblo County received notification at 0905 of the simulated accident at Pueblo Chemical Depot (PCD), the Pueblo County PIO initiated the development of a news release from the Pueblo County. While the circumstances did not mandate a news release, the county PIO issued a news release after viewing the PCD initial news release and considering the level of activity within the EOC. The Pueblo County news release was distributed by FAX at 0958 to the media, county commissioners, the state and PCD. It was also hand delivered to the EOC staff. The Pueblo County PIO did not write any more news releases. Pueblo County EOC received four of five PCD news releases. PCD news releases included information concerning the nature of the event and the absence of a threat to the community. The public affairs staff in the EOC handled incoming public, media and county jurisdictional calls quickly and accurately. The staff members also returned calls as quickly as possible Pueblo County

56 The EOC staff politely welcomed the mock media and provided an interview upon request. The Pueblo County EOC Operations Chief briefed the mock media, providing an overview of Pueblo County actions and clearing up general misconceptions about the nature of the chemical munitions and the plume. However, during the course of the interview, the Operations Chief inappropriately briefed the media representative on the technical details of the accident and PCD s response. Even though this was based upon information that was supplied to the Operations Chief by the PCD liaison, it is a good practice to limit comments to the press to those issues and actions within the speakers jurisdiction Pueblo County

57 SECTION 3 - SIGNIFICANT EVENTS TIMELINE A chronological summary of response activities is provided in Table 2, Significant Events Time Line. This listing was developed from observed player actions at each exercise location, as well as incidents introduced by the Simulation Cell (SIMCELL). (NOTE: Times are based on a 24- hour clock.) Time 24 hr Location Activity Stream 0856 PCD STARTEX 0857 PCD Sirens Activated PW 0857 PCD Broadcast message via PA system directs responders to go to assigned areas 0859 PCD Responders begin arriving at the OC HM 0900 PCD Security personnel secured depot gates PAI 0901 PCD 0901 PC EOC First hazard assessment D2PCw run broadcast notification of CAI Received initial event notification via EMIS Limited Area Event; 3 injuries noted 0901 PC EOC Received event notification via telephone HA 0901 PCD Limited Area Emergency declared HA 0902 SMC 0903 PC EOC Telephonic notification from PCD stating there had been an accident at PCD and request the hospital should standby Communications Center receives initial event notification and CENL via telephone 0903 PCD Telephonic notification of CAI with PAR HA 0903 PCD PAD determined HA PI HA HA VC PW 0904 PC EOC 0904 SMC 0904 PMC Automated call-down of EOC personnel initiated in Communications Center Emergency Department (ED) charge nurse notified hospital administrator of PCD emergency PCD called the ED nurses station regarding a possible problem at the depot PW VC VC 3-1

58 0905 PC EOC 0906 PC EOC 0906 PC EOC PIO directed to prepare draft news release - no EAS message necessary Communications Center receives FAX from PCD verifying event information EOC staff receive automated call-down notification via pager 0906 PCD OC provides downwind hazard plot to CAICO HA 0907 PC EOC 0908 PC EOC 0908 PC EOC Decision made to partially activate EOC (DEM and GIS staff only) PIO unsuccessfully attempts to confirm event with PCD PAO - PCD contact indicates event began at 0906 County Commissioner informed of event and county actions 0909 PCD PAO makes contact with PC PIO PI 0909 PCD AMR Ambulance Service alerted of CAI VC 0910 PC EOC 0911 PC EOC PIO receives corrected time of event (0856) from PCD PAO and informs PCD PAO that a county EAS message will not be issued State CSEPP PM notified of status of county actions and 3 injuries at PCD 0911 PCD PAO makes contact with Colorado CSEPP PIO PI 0912 PC EOC 0912 STATE EOC PIO requests information on TARs activation from PCD PAO - PCD PAO indicates on-post TARs should be activated by PC using pre-scripted Test message Initial notification of limited area emergency at PCD 0913 SMC Hospital security reports simulated facility lock-down VC 0914 PC EOC PIO begins preparation of news release PI 0914 PC EOC 0914 PC EOC Thatcher residence notified of event - no action necessary at this time On-post TARs activated - pre-scripted Test message read 0915 PCD Ambulances arrive at CLA to transport patients VC 0915 SMC Hospital administrators begin setting up hospital Emergency Operations Center (EOC) 0916 PC EOC First EOC briefing conducted PW PI PW PW PW PI PW PI PW PW HA PW PW VC 3-2

59 0919 PCD CG, SBCCOM, apprised of CAI HM 0922 PC EOC PCD notified of status of county actions and activation of on-post TARs - based on discussion, number of injuries corrected from three to two with one possibly contaminated 0922 PCD Work crew initiates self-decontamination HM 0922 PCD Emergency Personnel Decontamination Station (EPDS) operational 0922 PCD Staff requested to determine SRF needs HM 0923 PCD PAD implementation completed PAI 0923 PCD PCD first news release PI 0923 SMC Hospital EOC request status update from ED VC 0923 STATE EOC Manual call-down of State EOC staff for a limited activation of State EOC 0924 PC EOC Initial press release from PCD received by FAX PI 0925 PCD RTAP arrives at hotline HA 0926 PC EOC EOC declared operational PW 0928 PC EOC Second EOC briefing PW 0928 PCD HQ notifications completed. SBCCOM asks about evacuations on-post - told that evacuations not necessary 0930 PCD First worker processed through EPDS HM 0930 STATE EOC 0930 PCD 0931 SMC 0935 PC EOC Limited activation of State EOC complete EOD detachment notified support requested ETA at PCD 1130 ED charge nurse calls EOC to clarify change in disaster level PCD called to discuss event based on latest plume; 4 rounds outside (2 leaking) and 4 rounds inside (2 leaking) 0935 SMC Hospital EOC fully operational VC VC HM PW PI PW HM VC HA 3-3

60 0936 PCD PCD ambulance in CLA VC 0937 PC EOC PCD liaison arrives at EOC and successfully tests radio link to PCD 0942 PCD Point monitoring complete HA 0946 PCD First ambulance leaves CLA VC 0947 PC EOC 0947 PMC 0948 PC EOC Technical difficulties discovered in radio contact between Communications Center and State EOC corrected Contacted PC EOC - advised accident at the depot - no other information is available Discussion with PCD regarding need to change incident level based on tip of plume touching edge of limited area - no action taken 0948 PCD Patient next-of-kin notifications made PI 0949 PC EOC Notified through PCD liaison and PCD PAO of transport of two injured personnel to on-post clinic 0950 PC EOC Third EOC briefing PW 0950 PCD Second ambulance leaves CLA VC 0952 STATE EOC First D2PCw plume received from PCD 0953 PCD PCD requested ambulance support for patient #1 VC 0955 PCD PA office informs media that no one has been injured PI 0956 PCD Second News Release PI 0957 PC EOC Second press release from PCD received by FAX PI 0958 PC EOC First news release FAXed to County Commissioners, PCD PAO, and mock media 0958 PCD Patient #1 arrives at PCD clinic via depot ambulance VC 1000 PC EOC ARES communications between PC EOC and State initiated 1003 PCD Patient #2 arrives at PCD clinic via depot ambulance VC 1010 PCD Mobile Personnel Decontamination Station (MPDS) arrived in CLA 3-4 PW PW VC HA VC HA PI PW HM

61 1011 PCD PDS crew responding to hotline HM 1015 PCD Press Conference announcement FAXed PI 1017 PCD PCD requested ambulance support for patient #2 VC 1023 PC EOC Medical coordinator arrives at EOC VC 1025 PCD Media conference scheduled for 1100 PI 1030 PC EOC Environmental coordinator arrives at EOC PAI 1035 PCD PCD third News Release PI 1037 PC EOC Third press release from PCD received by FAX PI 1040 PC EOC Fourth EOC briefing PW 1040 PCD MPDS operational HM 1040 PCD EPDS shut down HM 1043 PCD Front gate alerted to expect media PI 1049 PCD AMR ambulance arrived at PCD clinic for patient #1 VC 1050 STATE EOC 1054 PCD 1115 PMC First State News Release AMR ambulance departed PCD clinic with patient #1 destination PMC Received PCD notification of two ambulances enroute to local hospitals - one ambulatory and one stretcher patient PCD AMR ambulance arrived at PCD clinic for patient #2 VC 1123 PMC PCD patient arrives by AMR ambulance - vital signs taken and patient triaged to ED 1129 PMC PCD patient directed to ED room VC 1130 PCD AMR ambulance departed PCD clinic with patient #2 destination SMC 1130 PCD EOD arrives at EOC HM PI VC VC VC VC 3-5

62 1135 PCD EOD briefed by EOC staff HM 1200 SMC PCD patient arrives by AMR ambulance - moved to triage area with right open femur fracture - patient was presumed to be decontaminated prior to arrival - transferred to the Post Anesthesia Care Unit (PACU) 1230 PCD Decon team arrives at CLA HM 1232 PCD Decon team dispatched to accident site HM 1236 PCD Fifth News Release PI 1236 PC EOC 1240 PC EOC 1240 STATE EOC Fourth press release, titled release #5, from PCD received by FAX PCD liaison reports EOD Team has canned all leaking munitions Last of eight plumes received from PCD 1306 PCD Site personnel processed through the MPDS HM 1306 PCD ENDEX VC PI HM HA 3-6

63 SECTION 4: ACTION PLANS This section contains the action plans of the Pueblo Community jurisdictions for corrective actions identified during the PCD CSEPP EX 02 and/or the resolution of corrective actions (findings) from previous Pueblo CSEPP exercises. Pueblo Community Pueblo Chemical Depot Pueblo County

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65 ACTION PLANS FOR THE PUEBLO COMMUNITY Pueblo Community CSEPP Exercise 2002 (20 March 2002) FRCA NUMBER PP SHORT TITLE On-Post Siren and TARs Activation RESPONSIBLE FOR CORRECTION Chief, CSEPP Division and PAO COMPLETION DATE 30 Sep 2002 CORRECTIVE ACTION/COMMENT: PCD and Pueblo County will renegotiate the Alert and Notification Memorandum of Agreement, to include 1) the development of appropriate messages (providing protective instructions to PCD residents, contractors and tenants); 2) a formal mechanism initiated by PCD to request activation of on-post tone alert radios (TARs) by Pueblo County emergency dispatch personnel and 3) a mechanism by which PCD will confirm in writing the message requested and the request for activation from PCD to Pueblo County. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other Equipment Staffing X Procedures FRCA NUMBER PP SHORT TITLE Incomplete Patient Medical Documentation RESPONSIBLE FOR CORRECTION Physician, PCD Occupational Health Clinic (OHC) COMPLETION DATE 30 May 2002 CORRECTIVE ACTION/COMMENT: PCD s OHC physician will review current patient medical record procedures and, as required, revise them to ensure that appropriate medical records are transmitted to the local medical facility at the same time the patient is transferred to the medical facility. In addition, following the transfer of any patient from the OHC to any private medical facility for follow-on treatment, the OHC physician will establish contact with the treating physician at the private medical facility to ensure that the treating physician has the information required to effectively treat the transferred patient. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other Equipment Staffing X Procedures 4-3

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67 ACTION PLANS FOR THE PUEBLO CHEMICAL DEPOT Pueblo Community CSEPP Exercise 2002 (20 March 2002) FINDING NUMBER PU SHORT TITLE Use of Improper Protective Clothing RESPONSIBLE FOR CORRECTION Toxic Material Handler Leader COMPLETION DATE 30 June 2002 CORRECTIVE ACTION/COMMENT: Provide additional training to ensure personnel are properly attired during CAIRA operations. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing Procedures FINDING NUMBER PU SHORT TITLE Fire Department Establishment of the Hot Line RESPONSIBLE FOR CORRECTION Chief, Fire and Emergency Services COMPLETION DATE 30 June 2002 CORRECTIVE ACTION/COMMENT: Prepare an SOP and associated hazard analysis for Fire Department hot line operations. Provide training on a new SOP. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing X Procedures 4-5

68 FINDING NUMBER PU PU01A13.6 PU00A13.1 SHORT TITLE Failure to wear proper protective equipment RESPONSIBLE FOR COMPLETION CORRECTION DATE Chief, Chemical Operations Division 30 Sept 2001 CORRECTIVE ACTION/COMMENT: The depot is in the process of changing over to the Trelleborg encapsulated suits for use by EOD and decontamination teams. These suits do not require the use of CPU's. Until this transition is complete, change house personnel will double check to ensure that EOD teams have the proper equipment and that they know how to use it. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other X Equipment Staffing X Procedures FINDING NUMBER PU PU01A10.1 SHORT TITLE Initial Patient Stabilization RESPONSIBLE FOR CORRECTION Operations and Risk Management Directorates COMPLETION DATE Ongoing CORRECTIVE ACTION/COMMENT: Medical staff from the Occupational Health Clinic (OHC) will conduct regular periodic training with OHC, Fire Department and Chemical Operations staff. Training sessions will include critical care, trauma assessment and treatment protocols. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing Procedures 4-6

69 FINDING NUMBER PU PU01A11.1 PU00A11.1 SHORT TITLE Delayed evacuation of Patients RESPONSIBLE FOR CORRECTION Clinic Physician, Fire Chief, Chief Chem. Ops. Div. COMPLETION DATE Ongoing CORRECTIVE ACTION/COMMENT: Medical staff from the Occupational Health Clinic (OHC) will conduct regular periodic training with OHC, Fire Department and Chemical Operations staff. Training sessions will emphasize the need for rapid evacuation of the most severely injured personnel from the accident site. The OHC physician will assess treatment progress and, as required, provide additional follow-on training during future CAIRA exercises. In addition to the increased medical training listed in PU01A10.1, First responders and Hot Line Crew will train on reducing the time required to evacuate injured personnel from the site and assessment of injuries at the hotline. Procedures will be demonstrated during upcoming CAIRA Exercises. CORRECTIVE ACTION/COMMENT: During open door operations a second hot line will be set up-wind (minimum of 450 meters) from the operation site. This will expedite the evacuation of critically injured and allow early medical treatment of personnel once certified clean during future operations. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing Procedures 4-7

70 FINDING NUMBER SHORT TITLE RESPONSIBLE FOR CORRECTION COMPLETION DATE PU01A01.1 CLOSED Inaccurate Emergency Notification Level to HQ CSEPP Division 31 July 2001 CORRECTIVE ACTION/COMMENT: OC staff will be trained to verify chemical event notification level upon their arrival at the OC. To ensure there is no doubt as to the correct event classification, the current event classification level will be posted on large yellow signs with red letters. The sign will be hung on the front wall of the OC to the left side of the projection screen. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing Procedures FINDING NUMBER SHORT TITLE RESPONSIBLE FOR CORRECTION COMPLETION DATE PU01A04.1 CLOSED EPDS and MPDS Location Setup All Directors and other key staff. 30 June 2001 CORRECTIVE ACTION/COMMENT: A working group will be formed to address establishment of four permanent PDS setup locations. Setup procedures, including proper methods for setting up the PDS trailer, will be addressed in a SOP for the PDS trailer. Upon completion of the PDS SOP, the capability will be demonstrated during a quarterly CAIRA exercise. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing X Procedures 4-8

71 FINDING NUMBER SHORT TITLE RESPONSIBLE FOR CORRECTION COMPLETION DATE PU01A05.1 CLOSED No Repeat Siren Sounding Chief, CSEPP Division 30 Sept 01 CORRECTIVE ACTION/COMMENT: The CSEPP outdoor warning system installed by Pueblo County does not have the capability to automatically sound the system at the intervals it must be activated manually each time. PCD does not have the resources to assign a person to repeatedly activate the on-post portion. During the current review of the Initial Notification MOA with Pueblo County we will look at the possibility of having them do the follow on activation of the depot sirens. The following areas need to be addressed to correct this finding: Training Facilities X Plan(s) Other Equipment Staffing X Procedures FINDING NUMBER SHORT TITLE RESPONSIBLE FOR CORRECTION COMPLETION DATE PU01A12.1 CLOSED Lack of Narcotic Medications IMA, OHC Staff and Security 30 June 2001 CORRECTIVE ACTION/COMMENT: A safe, suitable for securely storing narcotic medications, will be installed in the OHC. Working with Security personnel, the IMA and OHC staff will develop appropriate procedures to ensure proper storage and handling of narcotic medications. The IMA will determine which medications should be available for treatment of potential occupational injuries and will initiate medication procurement actions to, once again, acquire and store narcotic medications in the OHC. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other X Equipment Staffing X Procedures 4-9

72 FINDING NUMBER PU01A13.1 CLOSED RESPONSIBLE FOR CORRECTION Operations Directorate (QASAS) COMPLETION DATE 30 Sep 2001 SHORT TITLE Non-availability of Mobile Personnel Decontamination Station CORRECTIVE ACTION/COMMENT: A SOP is currently under development. A working group will be established to address various technical and operational issues prior to finalization of the new SOP. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other Equipment Staffing X Procedures FINDING NUMBER PU01A13.2 CLOSED SHORT TITLE Chemical Agent Monitor (CAM) Battery Low Indicator RESPONSIBLE FOR COMPLETION CORRECTION DATE Risk Management 30 June 2001 CORRECTIVE ACTION/COMMENT: Due to the gross detection level by the CAM, the utility of the device for detecting mustard contamination on personnel is, at best, questionable. As a result of their limited utility, CAMS will be removed from service and no longer used by PCD staff. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other X Equipment Staffing X Procedures 4-10

73 FINDING RESPONSIBLE FOR COMPLETION SHORT TITLE NUMBER CORRECTION DATE PU01A13.3 CLOSED Mask Control Inside the Limited Area Risk Management Directorate 30 June 2001 CORRECTIVE ACTION/COMMENT: An instructional memo will be issued to all staff assigned masks reminding them of the proper protocol for wearing and retaining control of masks when within the Chemical Limited Area. The following areas need to be addressed to correct this finding: X Training Facilities Plan(s) Other Equipment Staffing Procedures FINDING RESPONSIBLE FOR COMPLETION SHORT TITLE NUMBER CORRECTION DATE PU01A13.4 Escape Mask Risk Management 30 June 2001 CLOSED Availability CORRECTIVE ACTION/COMMENT: A supply of M 40 Masks will be stored in the MPDS Trailer for use of personnel exiting the chemical storage area. Will assess number of masks required, determine funding required to procure masks and identify this issue as an unfunded requirement. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) X Other X Equipment Staffing Procedures 4-11

74 FINDING NUMBER PU01A13.5 CLOSED SHORT TITLE Security Policemen Drive through Hazardous Area RESPONSIBLE FOR COMPLETION CORRECTION DATE CSEPP Division 30 June 2001 CORRECTIVE ACTION/COMMENT: Hazard Analyst checklist will be revised to require faxing of initial plume plot to the Site Security Control Center (Post 5). Subsequent plots will be faxed only when there has been a significant change in the plot (i.e., plume changes size, shape or direction). Supervisor at the SSCC will then direct Security units movement around hazard area. The following areas need to be addressed to correct this finding: Training Facilities Plan(s) Other Equipment Staffing X Procedures 4-12

75 ACTION PLANS FOR PUEBLO COUNTY Pueblo Community CSEPP Exercise 2002 (20 March 2002) FINDING NUMBER PC01CV.1 CLOSED SHORT TITLE Proper Triage RESPONSIBLE FOR CORRECTION Pueblo West Fire Department COMPLETION DATE 28 Feb 02 CORRECTIVE ACTION/COMMENT: The following areas need to be addressed to correct this finding: X Training Facilities X Plan(s) Other Equipment Staffing X Procedures 4-13

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77 SECTION 5. COMMUNITY MASS CASUALTY EXERCISE Colorado State Fairgrounds The Pueblo Community, Colorado State Fairgrounds mass casualty exercise was held on March 20, 2002 and included the following facilities and jurisdictions: Pueblo City Fire Department (PCFD), Pueblo West Fire Department (PWFD), Pueblo Rural Fire Department (PRFD), American Medical Response (AMR), Pueblo County Sheriff s Office (PCSO), Pueblo City Police Department (PCPD), Parkview Medical Center (PMC), and St. Mary Corwin Regional Medical Center (SMC). The scenario involved an intentional release of anhydrous ammonia with multiple explosions and a shooter in the event center at the Colorado State Fairgrounds, with multiple victims, requiring a large-scale community response. The objective of the exercise was for the responders and supporting community resources to appropriately mitigate the situation with as little morbidity and mortality possible, using existing standard operating procedures (SOPs) and emergency response plans (ERPs). VICTIM CARE The exercise began at 0945 with a simulated notification to the 911-dispatch system reporting a tanker truck being driven into the event center causing multiple explosions. Officers from the PCSO arrived on the scene at 0950, and staged on the southeast corner of the building, where they were met by approximately thirty victims displaying multiple signs of trauma and exposure to hazardous material. The victims were notified through a public address system to evacuate the scene if possible. When several victims collapsed enroute to the decontamination staging area firefighters from E-1 carried these victims to their apparatus, placed them inside of the rear of the cab, and transported them to the decontamination staging area. This could have potentially contaminated the interior of the apparatus, however this action was highly effective for removing the patients out of the hazard area. A gross decontamination area was set-up for the initial reception of patients. At 1002, PCFD Haz-Mat 1 arrived at the decontamination staging area and parked directly in front of the patient staging area acting as a cover for that area. The driver of the vehicle assisted in the direction of patients to the proper staging area, designated by scene tape. Within seventeen minutes of dispatch, a rudimentary triage facility was operational. At the decontamination staging area, PCSO was able to interview several victims regarding the events that had occurred. PCSO made a significant effort to provide victim care prior to decontamination by having walking wounded patients assist the more seriously injured patients. This included calming those personnel who were hysterical and providing general assistance to the more seriously injured. Several victims attempted to escape the decontamination staging area and were quickly redirected back to that area. This situation identified the need for an increase in security for the 5-1

78 decontamination staging area, which would require additional law enforcement resources. The HazMat crew set up the gross decontamination area within seven minutes of arrival. At 1012, the PCSO mobilized its Special Tactics and Rescue (STAR) team personnel who were dressed in Battle Dress Overgarments (BDOs) and powered air-purifying respirators (PAPRs). A single officer conducted a reconnaissance mission approximately one hundred-fifty feet from the event center, and then quickly returned to his team. The secondary decontamination area was set-up 200 yards south of the gross decontamination connected to an uninterrupted water source. The gross decontamination area began to utilize a 1-inch hose line for processing personnel. Six patients were actually processed using ambient water, and the remaining patients were simulated due to environmental conditions and water temperature. Fire personnel who had assisted were also processed through gross decontamination. Support personnel donned OSHA Level B for gross decontamination. It was observed that the personnel in the gross decontamination area failed to establish an uninterrupted water source, which limited them to the five hundred gallons of water. This could have caused delays in the gross decontamination process if the water source had been exhausted in the gross decontamination process. Medical command assigned a triage officer for initial patient reception accompanied by a firefighter in structural firefighting (turnout) gear and SCBA. The triage officer explained to the victims that a hazardous material had been released, that each person would have to be decontaminated, and that the process would be as rapid and thorough as possible. Another triage officer was assigned at the secondary triage site to monitor any change in patient condition after gross decontamination. A safety officer was assigned by the PCSO to continually assess the scene. Several PCSO and fire department personnel performed crowd control for those people in the decontamination staging area and were in very close proximity to potentially contaminated victims with limited personal protective equipment (PPE). Medical transport resources from AMR arrived forty-five minutes into the incident, with additional resources enroute, to include transport units and multiple casualty supplies. The command staff requested mass transport resources, such as transit buses. Estimations of total patients were not available at this time due to the lack of information from inside the event center. Two mock media teams breeched the hotline and were able to interview victims at the decontamination staging area prior to decontamination. Although, operations officer had defined the hot zone, response personnel failed to clearly mark it resulting in both response personnel and civilians entering the hot zone inappropriately throughout the incident. After approximately ten minutes inside the perimeter, the mock media teams were asked to leave. Before leaving they were decontaminated and their equipment was quarantined (simulated). Their presence may have been due to an exercise artificiality that had real media inside the perimeter covering the exercise and mock media on the outside requesting entry. When the mock media teams were leaving the exercise at the fairgrounds, a Pueblo Police Department Officer stopped each car to ensure that the occupants had been decontaminated. He radioed the command post and verified 5-2

79 that it was appropriate to exit the premises. This was evidence of effective internal communication and coordination. Several patients arrived at the decontamination site with gunshot wounds and several additional personnel corroborated the fact that a shooter remained in the building. At 1021 a fourteenmember team from the PCSO STAR began to prepare for an entry into the facility. The STAR personnel were dressed in BDOs and PAPRs. At 1031 the STAR team entered the building by the south entrance stepping over an unconscious patient. No notification to the command staff regarding this patient was observed nor was any care rendered by the team. The STAR team proceeded to investigate the building for the next thirty-two minutes attempting to find the shooter. At 1103 the shooter was located and subdued; the building was then deemed clear for Haz-Mat entry. At 1026 a secondary decontamination area was established as operational with the ability to provide privacy and hot water. The secondary decontamination area consisted of two decontamination trailers for processing ambulatory patients as well as a portable shower to be utilized for the non-ambulatory patients. The trailers were positioned parallel to each other with the non-ambulatory shower between them. Personnel staffing the secondary decontamination area were dressed in OSHA Level C PPE consisting of a PAPR, splash suit, boots and gloves. There were no response personnel available initially to direct patients to the appropriate decontamination line. This caused a delay for patients to receive secondary decontamination and left patients unattended after left the gross decontamination area. The personnel in the decontamination staging area requested permission to remove their PAPR face pieces keeping the unit with them. This request was denied due to the unknown concentration of material not only in the area, but also on the patients. Triage began at 1031, which included victims being identified by color-coded surveyors tape. The decontamination teams failure to establish a corridor from the decontamination staging area to the hot side of the gross decontamination area resulting in confusion as to the actual entry/exit at the gross decontamination area. Patients would enter the gross decontamination area from opposing ends, complicating the process. As the patients exited gross decontamination they were interviewed by the PCSO. One patient was identified as retaining vital information regarding the events and was detained. The initial five patients were processed through gross decontamination; they proceeded to the secondary decontamination area, where they had to wait several minutes before being processed through the trailer. Fire personnel transported nonambulatory patients to the secondary decontamination area by personnel dressed in only turnout pants. At 1045 the first non-ambulatory patient with an open wound entered secondary decontamination and was appropriately processed and decontaminated with soap and water. No particular treatment was given to the wound at this stage. At 1048 the first ambulatory patient entered the decontamination trailer #1. At 1049 initial triage in the decontamination staging area was completed. The non-ambulatory patient completed decontamination and arrived in the EMS transport area at All patients were processed through gross decontamination then escorted to a secondary decontamination site. 5-3

80 At the medical receiving and treatment area patients were again triaged and placed in defined staging areas according to their need for medical treatment. Patients with minimal injuries were initially interviewed by law enforcement in an area adjacent to the medical treatment area. Patients who were identified as suspects were detained by law enforcement. The transport of injured suspects to appropriate medical facilities was stimulated. The transport team confirmed the decontamination status of each patient although colored bands that indicated status were present on each patient after processing through decontamination. The transport team noted the severity of the first non-ambulatory patient s wound and confirmed the need to be transported to the closest hospital. This process was delayed by the transport sector; a second patient was already enroute to this specific unit for transport. During this time, the initial patient received appropriate Advanced Life Supportive (ALS) care. Four minutes later the second patient (also deemed critical) arrived for transport. This unit was initially staffed with a single paramedic, however due to the severity of these patients, a second paramedic joined the staff. Definitive care for the first patient was delayed while waiting for the second patient. However placing two patients in one transport unit demonstrated effective transport resource utilization. As the unit left the scene, the hospital was notified of the incoming patient status. At the secondary decontamination site, several ambulatory patients repeatedly entered the nonambulatory corridor, necessitating the addition of several personnel to assist in patient processing. The management of patient s personal effects was simulated. In the transition area from secondary decontamination and transport, a non-ambulatory patient was presented to the transport area after decontamination; however no transport resources were immediately available. There appeared to be a miscommunication between the transport area and the resource staging area. This situation delayed patient transport for several minutes. However, the issue was resolved, which resulted in a more expeditious delivery of transport resources to the transport staging area. The secondary decontamination site became overwhelmed, with 15 patients waiting at decontamination trailer #2 and no patients waiting at decontamination trailer #1. At this time, the transport staging area was also expanded due to the number of patients enroute to their location from the secondary decontamination area. This expedited the process, however trailer #2 remained backlogged with ambulatory patients. As non-ambulatory patients were processed, they were transported in an efficient and organized manner from the transport sector to appropriate facilities. Significant transport assets were present at this point, rectifying the earlier situation that potentially delayed patient transport. By 1120, all but five ambulatory and five non-ambulatory patients had been processed through secondary decontamination. EMS personnel identified a conflict in priorities between medical treatment and law enforcement interviews. This conflict potentially compromized the ability of EMS to assess and assign transport priorities. The EMS triage team leader corrected this problem once it was identified. 5-4

81 At 1125, a Haz-Mat entry/assessment team was enroute to the event center to perform monitoring and assess any remaining patients in the facility. The team identified that readings inside the building were minimal five parts per million and entered the building dressed in OSHA Level C PPE, which was appropriate based on air monitoring. They immediately identified one unconscious casualty inside the entrance and called for the appropriate resources. Unable to provide any medical care at this point, the entry/assessment team continued through the facility to identify any additional hazards and patients. They found two victims outside the door where the anhydrous ammonia truck had entered the building called for additional resources. As they were being notified that a small all-terrain vehicle (ATV) capable of transporting three patients was enroute to their location, the team relayed that two additional victims had been found, bringing the total to five. The ATV transport vehicle arrived with three personnel dressed in structural firefighting gear and SCBA. These personnel proceeded to place three victims on backboards and load them onto the ATV and trailer. No specific type of triage was completed to identify which patients were more severe; the most accessible patients were transported first. Patients were simply placed on the backboards and not secured with the available straps. For patient safety the practice of securing patients is encouraged in both exercises and real life. Two additional firefighters were sent to the event center in structural firefighting gear and SCBA to assist with patient care and transport. At 1140, the hot zone was clearly demarcated by the HazMat command. He declared personnel that entered the area would have to be decontaminated. This included all personnel transporting the patients from the event center, as well as the patients and the Haz-Mat entry/assessment team. Inside the event center, the remaining two victims were formally triaged, and provided basic care until resources became available for their removal. They were subsequently decontaminated, treated, and transported in a quick and efficient manner. At the transport area multiple ambulatory patients were transported to local hospitals in a mass transit bus (simulated). Also, simulated was seven non-critical, non-ambulatory victims were transported by ambulance and wheelchair van to facilities in Colorado Springs. This was an excellent demonstration of utilizing resources and communicating with EOC personnel as to the availability of hospital resources. With the removal of the last victim from the event center, the HazMat entry/assessment team and the firefighters returned to the warm zone for decontamination, leaving the scene for the appropriate cleanup operations. The exercise was officially ended at Observation Description: Communications Impeded Between Processes Discussion: In several different aspects of the exercise communications were unclear or completely lacking between key functional areas. This created several different challenges, resources were not effectively transferred from one staging area to another in a timely manner; patients were located inside of the event center however the information was not relayed; specific zones were not clearly delineated; and patient processing was interrupted by personnel performing non-vital actions. As an example, when patients 5-5

82 proceeded from gross decontamination to secondary decontamination, there were few personnel to guide the process along. This was also manifested after secondary decontamination when law enforcement personnel entered the patient care process prior to the approval of medical personnel. Recommendation: Clarify communication and coordination procedures between functional areas and agencies. Exercise and evaluate revised communications and coordinator procedures in future exercises. Observation Description: Delay in Decontamination of Victims Discussion: During the exercise two decontamination trailers were set up for use, only one was primarily utilized for victims at the scene. The second trailer was staffed and operational but victims were not directed to it resulting in ineffective use of both these trailers. This caused a backup of victims in the secondary decontamination area, delaying not only decontamination but also patient care. Utilizing the secondary trailer would have reduced the patient exposure time by almost half. Recommendation: Ensure that victims receive clear guidance and directions. Ensure that resources are efficiently utilized. Command & Control This exercise tested all aspects of emergency response, including fire, police and emergency medical services. The first unit to arrive at the scene was Pueblo County Sheriff s Office who set up an inner perimeter using two patrol vehicles. Several victims began to exit the events center under the control of local law enforcement units; these units immediately began to don personnel protective equipment. Local fire units arrived and began to set up zones of control in an effort to treat the injured victims. Several emergency units began to stage and individual departments started incident command; however, it wasn t until much later into the exercise that unified command was established. The fire chief from Pueblo Rural Fire Department informed dispatch to perform an all page to get as many responders to the scene as possible. The Assistant Sheriff from the Pueblo County Sheriff s Office informed all arriving units to check in with the staging officer. The fire units identified the leaking tanker trucks contents as being anhydrous ammonia, and after informing all other responders of this information, they decided to move the staging area back 75 feet from the original location. 5-6

83 PCSO Special Tactics and Rescue (STAR) team was mobilized and was able to apprehend the shooter. After interviewing the suspects, the Sheriff called the Federal Bureau of Investigations to report the incident (simulated). One hour into the exercise, the Sheriff held a briefing involving department heads from the various emergency response agencies and at this point a unified command structure was established. Mock media was on scene and began asking questions. They conducted an interview with the Sheriff and various fire chiefs. There was a Public Information Officer appointed who lead the media around the scene. The Sheriff advised support personnel to establish a staging area for parents in preparation for their arrival at the scene. The Chief (Pueblo Rural Fire) confirmed with St. Mary-Corwin Regional Medical Center that 30 victims were on scene and had been decontaminated. The Sheriff was informed that a third suspect was in custody. The operations deputy stimulated contacting the coroner, requesting a refrigeration truck, and requesting an air space restriction by the Federal Aviation Administration. The Sheriff gathered all media and conducted a brief interview updating them on the events that took place and the progress made by emergency responders. All units were advised that the events center was secure and medical personnel were requested for several injured victims that remained in the building. After the remaining victims were treated for injuries and processed through the decontamination trailer, the STAR team was told to stand down. Numerous hazard mitigation actions were identified and simulated. Observation Description: The incident command post was not adequate for an event of this magnitude. Discussion: The incident command post did not afford sufficient space for representation from each agency involved in the incident. The ability of the responders to establish a unified command was hindered by the size of the incident post, this cause communication and coordination issues for the responders. Recommendations: The Pueblo County Sheriff s Office needs to review options to expand the size of the command post to allow sufficient space for representation from each agency involved in a given incident. Hazard Mitigation Evacuated victims reported there were multiple active shooters still inside the events center. Deputies on scene notified their commanders who activated the Pueblo County Sheriff s Office Special Tactics and Rescue (STAR) team. Notification was made by radio and pager. 5-7

84 STAR communications broke down due to the incompatibility of their communication gear and the PAPR s. The STAR members were unable to communicate with other team members in the building because the type of microphone they were using caused radio transmissions to be garbled and unclear. Observation Description: PCSO Radios and PAPRs Compatibility Discussion: In this event, the primary threat was an active shooter, and the secondary threat was a known chemical. It was necessary for STAR to wear Personal Protective Equipment (PPE) (Mission Oriented Protective Posture (MOPP) suits and Powered Air Purifying Respirators (PAPR)) during their response to the events center. It became evident that STAR communications broke down due to the incompatibility of their communication gear and the PAPR s. The STAR members were unable to communicate with other team members in the building because the type of microphone they were using caused radio transmissions to be garbled and unclear. Reference: Police Officer Standards & Training Procedures Recommendation: Find a compatible communication gear to interface with the use of PAPR s and or SCBA equipment. Observation Description: PCSO Air Monitoring Capability Discussion: Due to the type of scenario driven environment and the type of PPE equipment available to STAR / Law Enforcement (MOPP-4 suits and PAPR s), concerns for general safety arose due to the lack of active air monitoring. Appropriate HazMat resources for air monitoring and pre/post PPE medical screening must support Law Enforcement personnel using this level of PPE. Reference: OSHA 29 CFR & 29 CFR Recommendation: The community needs to establish procedures to ensure Law Enforcement pre/post PPE health screening and air monitoring support. One possible option for the pre-screening is to provide this support to appropriate personnel at the beginning of their shift. 5-8

85 Observation Description: Priority Established for Victim Care Discussion: In this scenario, the STAR team members were searching for a specific suspect, bypassing downed conscious victims and/or other possible suspects. During the initial entry through door one the STAR entry team bypassed a female that was conscious laying to the left of their point of entry. There was no attention given to this person. No search for weapons was done nor was victim care was provided. Recommendation: Modify procedure to include having a STAR paramedic to evaluate and treat injured team members and victims they encounter during the course of any incident. Victims should be searched for weapons, etc. Observation Description: Personal protective equipment not appropriate for a Haz-Mat incident with unknowns. Discussion: The Pueblo County Sheriff s Office Special Tactics and Rescue (STAR) team entered the convention center wearing PAPRs. This level of protection is not appropriate for initial entry into an unknown environment. Responders entering an environment with an unknown hazardous material must enter wearing OSHA level A, until the hazards have been identified & monitored. The initial entry into the convention center would have placed responders in harms way, especially if the hazardous material release displaced oxygen. Recommendation: The Pueblo County Sheriff s Office Special Tactics and Rescue (STAR) team needs to implement one of the following options: 1. The STAR team obtains training and equipment to permit them to make initial entry into an environment containing hazardous materials. 2. The STAR team coordinates efforts with the local fire department hazardous material team to provide equipment and PPE needed to make entry into a hazardous material environment, which also contains a human threat (active shooter). Reference: OSHA

86 Hazard Assessment As police and fire department units arrived at the reported incident location, they began their initial assessment of physical and chemical hazards. They were approached by a number of injured victims (figure 2). Figure 1. Sheriff s Office arrives on the scene Figure 2. Victims approach responders While police escorted victims to safety, the first-arriving engine company determined that a chemical hazard potential existed. A tank truck partially inside the building on the east side (figure 3) was judged to be leaking based on a white vapor that appeared to be coming from the truck. A firefighter observed the vehicle using binoculars and determined the tank contained anhydrous ammonia. The identification was made using markings on the tank and placard information. The firefighters also observed that the vapor color was consistent with a leak of this product. The PCFD appropriately called for a hazardous materials response based on his size-up and input from his crew. The officer and his crew worked together to ensure complete and accurate information was relayed to a command officer who had arrived in the interim and assumed command. Fire units, after briefly assisting with the rescue of some non-ambulatory patients, retreated to a safer location based on the potential chemical hazard and physical hazard information obtained by the police Figure 3. Leaking truck. (Note: this vehicle was used for simulation purposes; it does not meet the specification for the transport of anhydrous ammonia.)

87 Based on victim reports, police determined potential shooters with weapons were still in the area. The initial engine company and the arriving hazardous materials unit positioned at a distance from the events center. As the incident progressed, firefighters realized that their positioning did not afford sufficient protection from gunfire that might come from the events center. At this point, firefighters re-positioned apparatus to provide additional cover. Firefighters used the references carried on their hazardous materials unit to determine the course of action they would take and the equipment they would require once the physical hazard was mitigated by law enforcement agencies. Figure 4. Sheriff s Deputy monitors patients prior to assessment and decontamination. Law enforcement personnel and fire department personnel cooperated to control the movement of victims until they had been assessed and decontaminated (figure 4). Fire department personnel triaging patients were aware of the possibility that potential perpetrators might mingle with victims and coordinated with law enforcement personnel to manage the threat. As victims pointed out potential perpetrators, law enforcement personnel separated them from the crowd and immediately secured them (figure 5,6). Figure 5, 6. Suspects identified by other victims. 5-11

88 Once law enforcement personnel reported the events center secure, hazardous materials technicians were able to take further action to assess the chemical hazard. The fire department s entry team used colorimetric tubes to assess the chemical hazard during a reconnaissance of the building (figure 7). Entry personnel were able to correctly interpret readings on the tubes to determine whether further action was possible. The entry team was also able to correctly assess and mitigate the remaining chemical hazard, a leaking hose on the tank truck. Once the leak was terminated, they communicated with their command to advise that the hazard had been mitigated, enabling firefighters and medical personnel to enter the area and treat victims that had not previously been accessible to rescuers. Figure 7. Entry team with colorimetric tube for monitoring. Use of OSHA level A PPE was simulated. Responders went on air prior to entering structure. Hospital Victim Care Parkview Medical Center Three injured teenage victims arrived at 1004 from the Colorado State Fairgrounds following some unknown accident. There was no prior communication to ED staff regarding anticipated victims of any community disaster. Although it was later determined that the Hospital EOC had received notification at 0948 of an explosion at the event s center involving one hundred victims. Patient reception was conducted without universal precautions, such as gloves, goggles, and masks. At 1010 the first victim was triaged and tagged. In the absence of prior notification from the scene or clear exercise simulations to indicate potential HazMat presence, no decontamination was conducted. The hospital demonstrated a clear readiness to perform decontamination. At 1015 the ED staff suspected that the arriving patients were contaminated. One of the ED nurses questioned the fact that the victim was not wearing a pink decontamination bracelet and at that time considered the patient contaminated. The disaster coordinator declared the emergency department was contaminated as were the hospital personnel working inside the ED. (NOTE: for the sake of continued participation in the exercise and a continued opportunity to practice emergency procedures, the hospital disaster coordinator made the decision to 5-12

89 continue to use the ED as if contamination had not occurred.) Initial contaminated victims entering the ED were directed to return to the decontamination trailer for proper decontamination. The hot zone coordinator had difficulty during the initial exercise determining if the victims were contaminated, due to the lack of clear exercise indications. At 1022 the decontamination team arrived at the staging area where they recorded vital signs and made other preparations. Five decontamination team members were properly donned in an Occupational Safety and Health Administration (OSHA) Level C consisting of a Kappler responder suits with a tight fitting powered air-purifying respirator (PAPR) with hood at Contaminated victims continue to arrive and were unattended in the hot zone without instruction. The ED director was informed at 1034 by the hospital EOC that the event center had over one thousand - casualties some with gunshot wounds. At 1036 the hot zone coordinator receives notice from the ED that a bus was en-route from the fairgrounds with an unknown number of victims. The first decontamination team deployed at 1040 to the decontamination trailer. Due to the number of victims that had arrived at PMC from the fairground, the hot zone coordinator requested community assistance by personnel trained in decontamination procedures via hospital EOC. At 1042 American Medical Response (AMR) ambulance communication center advises the ED that thirty patients were exposed to anhydrous ammonia at the events center. The decontamination trailer was operational at 1034 and victim decontamination began. The decontamination process was exceptional once operational. At this time, the decontamination coordinator announced that the victims were having difficulty hearing instructions from decontamination team. The decontamination team had difficulty communicating with the patients due to the restrictions of the personal protective equipment. Use of a public address system or bullhorn may help address this problem. The use of liquid detergent and plastic wrap to treat burn victims was observed. This is inconsistent with established medical protocols and indicates a degree of miscommunication in either training of exercise preparation. Additional actions (real and simulated) effectively performed included locking down the hospital, logging and admitting twenty-eight patients, determination of bed availability, spiritual support to patients and families, and the decontamination and relief of the hospital decontamination team. 5-13

90 Observation Description: Ineffective Communication During Victim Transfers. Discussion: There was little or no exchange of important and pertinent clinical information between caregivers as victims were processed through decontamination, triage, emergency department (ED) and eventual hospital admission processes. Recommendation: Proper patient transfer techniques and pertinent information communication between caregivers should be emphasized and practiced when conducting in-house exercises and training. Documentation or the use of clinical personnel to verbally communicate this information could improve this process. Observation Description: Improper Burn Treatment Discussion: When burn victims from the fairground explosion site arrived at Parkview Medical Center, decontamination personnel poured liquid dish washing detergent on burns then wrapped the burn sites with plastic wrap. Victims then proceeded through the decontamination process. Reference: American Burn Association Standard of Practice Recommendation: Verify that medical personnel receive appropriate training that is consistent with standard treatment protocols. Observation Description: Hot Zone Access Control Discussion: The evaluation team observed numerous hospital personnel and civilians passing through the hot zone without proper personal protective equipment. This breech indicates a lack of appropriate access control in the hot zone placing personnel at risk. Reference: 29 CFR Recommendation: Provide training and opportunities for demonstration of competency on proper contamination control procedures. 5-14

91 Observation Description: Documentation of PPE Work/Rest Times Discussion: Personal protective equipment (PPE) entry and exit times were not documented thus subjecting personnel to unnecessary health risks. Reference: OSHA / American Conference of Industrial Hygienist (ACGIH) Guidelines Recommendation: Document work/rest cycles Observation Description: Decontamination Trailer Malfunction Discussion: The decontamination trailer had an active leak in the gray-water tank s overflow. Recommendation: Caution should be observed in not overfilling the tank. Saint Mary-Corwin Regional Medical Center At 0902, the emergency department (ED) received a telephone call from Pueblo Chemical Depot stating that there had been an unspecified accident at the depot and the hospital should stand-by. Accordingly, at 0904 the ED charge nurse promptly notified the hospital administrator on call of the depot notification. Shortly thereafter, at 0912 the hospital issued an overhead page Standby Disaster Drill. At 0913, a hospital disaster cart arrived at the ED and various response support supplies such as identification vests were distributed. Hospital security staff also arrived in the ED, reported that they and assigned maintenance staff simulate lock down of facility, and established perimeter control. At 0915 hospital administrators, nurses, and other assigned staff began to set-up the hospital Emergency Operations Center (EOC) in a pre-designated room in the basement not far from the ED. The EOC had adequate telecommunications setup with several telephones, numerous radios, and community emergency response maps on the wall. In addition, well-organized task assignment booklets containing checklists and job actions sheets were distributed to EOC staff. Several whiteboards were available but not used. The EOC did not demonstrate connectivity to the hospital s networked computer system or associated software applications for patient tracking, logistics management, and alternative communications channels such as and Internet fax. EOC staff wore yellow-green vests without position indicators to facilitate quick identification of roles. However, the ED and security personnel did have labels on the vest. The hospital chief financial officer (CFO) was the hospital incident commander and initially was in 5-15

92 the EOC. At 0923, the hospital EOC staff requested and received a status update from the ED demonstrating functioning communication systems and information sharing. Meanwhile, at 0928 outside the ED in the decontamination preparation area assignments were made to the decontamination team members. The decontamination team members were medically screened, per Occupational Safety and Health Administration (OSHA) requirements, with vital signs and recorded on a Personal Protective Equipment (PPE) status board. The board was also used to track time the decontamination team was in PPE during the exercise. The Safety Officer later indicated that work-rest times would be followed using the American Conference of Governmental Industrial Hygienist (ACGIH) guidelines based on ambient conditions, level of PPE, and estimated work intensity. At 0930 two decontamination team, members completed donning OSHA level C PPE. Two more members began the level C donning process with two additional members on standby as back ups. The PPE consisted of blue Kappler over-garment (splash gear), rubber boots, and gloves taped at ankles and wrist, respectively, full-face tight-fitting powered air purifying respirators (PAPR) respirator and hood with filter canisters. The PAPRs worked properly and facemasks appeared to fit well with no reported hot spots or face-piece fogging noted. The participants demonstrated competence in donning and wearing the PPE. Several members of the decontamination team were from the Pueblo City Fire Department, again indicating the excellent support provided by that Department to the hospital. One of the fire chiefs was present supervising their personnel and general situation in the decontamination area. The decontamination area was located immediately outside the ED and consisted of a decontamination supply and PPE storage room, a large, well-equipped decontamination trailer, decontamination water run-off storage tank, and pre-decontamination areas were surrounded with clearly a visible marker tape and orange street cones. However, there was not clear delineation of an actual hot line. This was later a problem and led to violation of the hot zone by several staff including the Safety Officer and Hospital Incident Commander. At 0930 the ED obtained operating room (OR) critical care bed status, and current inpatient census. A Level I disaster drill notification was declared utilizing the overhead paging system. At 0931 the ED charge nurse called the EOC to clarify the basis for the change in disaster level. At 0935 the hospital EOC was operational. This was a result of an enthusiastic, efficient, and capable EOC staff. At 0938 the PPE status board in the decontamination support area indicated that eight team members had completed and passed medical screening. The hospital incident commander was observed roving between the ED and decontamination area reporting that status back to the EOC over handheld radio. His effort to personally assess the progress of various areas and departments in the response was certainly commendable. However, communications seemed sufficient to suggest that he might have actually had a better situation awareness if he had stayed in the EOC where he could also have exerted his stature and authority in facilitating communications with external agencies, authorizing critical resource allocations and other decisions requiring his level of clearance. 5-16

93 At 1000 several groups of ambulatory simulated casualties arrived and were escorted by the safety officer (SO) without PPE to the back of the decontamination trailer. The SO acknowledged her potential exposure and was decontaminated. This was a potentially serious mistake due to lack of recognition of the potential hazard of rushing to assist victims without consideration of adequate PPE protection to avoid becoming a victim herself. At that time, the EOC was also receiving victim status reports and incident information from the hospital incident commander (IC) who in attempting to visually appraise the victims also crossed the hotline without any PPE. The IC should not have placed himself at such risk. (Note: The SO s and IC s assessment of the need for PPE and decontamination may have been compromised by the lack of exercise injects to support their situational awareness and assessment.) At 1004 the first decontamination team entered the decontamination trailer and at 1006 the EOC was aware that SMC had received nine patients with numerous injuries from an explosion that involved anhydrous ammonia at the Colorado State Fair Grounds. All patients presenting to SMC were assumed to be exposed and decontaminated. At 1010 the decontamination team, following prompting, recognized unmanageable congestion of non-triaged patients in the decontamination trailer undress area. The victims were then moved out into a predecontamination staging area and assessed for evidence of contamination, patient injury, and administration of life saving measures. Additionally, communications from decontamination personnel to victims was difficult. The team members were very difficult to understand while speaking through the PAPR masks compromising command and control of victims in the decontamination staging area. Use of a public address system or bullhorn could enhance communication between victims and hospital personnel. At 1012 the EOC attempted to ascertain more information regarding the incident but was unable to glean much information from the incident site. At 1014 hospital response posture was upgraded to a Level II. By 1030, twenty-four ambulatory victims had been processed through decontamination and internal triage areas. Four emergent victims had been triaged to the ED, eight potential surgical victims to the Post Anesthesia Care Unit (PACU), and twelve minimal victims to the Family Practice (FP) holding area. An experienced ED nurse, having radio communications with the EOC as well as the FP chief resident, manned the internal triage station. The triage station was well organized and staffed with admissions personnel who logged in the patients. Victims had additional triage tags applied with green indicating minimal, yellow delayed, and red immediate. Previously applied triage and treatment tags and clinical notes were not always noted or incorporated into the clinical assessment process. At 1031 the ED received information that 30 more victims were in route to the hospitals from the incident site. At 1038 they were communicating with Pueblo City County Health Department (PCCHD) and Pueblo City Fire Department (PCFD) attempting to confirm the reported number of additional victims. Simultaneously, the EOC logistics officer was providing other EOC staff with information regarding available critical supplies, e.g., that the hospital had sufficient supplies for up to 700 gravity-fed intravenous setups. By 1055, victims who had previously been decontaminated in the field began arriving via EMS. Some of the victims had multiple decontamination bands and triage tags, which was potentially 5-17

94 confusing to triaging staff. Decontamination and triage staff is commended for identifying which victims had or had not received prior field decontamination. A pink wristband applied by field decontamination staff indicated prior field decontamination. At 1105 the SO was overheard verifying PPE stay times for decontamination team members and indicating the times would be checked against American Conference of Governmental Industrial Hygienist (ACGIH) work rest cycle times. At 1145 the evaluation team, posing as concerned family, queried the EOC staff regarding the location of three patients randomly selected from rosters at the internal triage point. Victim information was not readily available in the EOC because the information was not being transmitted from the triage area to the EOC as outlined in their plan. This demonstrated a lack of patient tracking which complicated the process when incoming calls from relatives, media, and coordinating agencies requested victim information. At 1202 the last six victims arrived and were triaged appropriately. A review of the tracking logs at the triage point revealed that they had processed a total of thirty-five victims (eight acute triaged to the ER, fifteen possible surgical victims to PACU, and twelve relatively stable nonsurgical victims to the FP holding area. At 1206 the EOC indicated the end of exercise after appropriate coordination with external EOCs. Observation Description: Hotline Demarcation Discussion: The safety officer and hospital incident commander inadvertently crossed the hotline because it was not visibly marked. These individuals could have become affected either by liquid contamination or vapor exposure and thereby have become ineffective and required diversion of decontamination resources. Reference: Hospital emergency response plan and accepted standards of decontamination systems. Recommendation: Clearly demarcate the hotline. Consider signage to warn participants and inform regarding PPE requirements on the hot side. Hotline indicator could include physical barriers or other measures that do not impede victim flow or pose trip hazards. 5-18

95 Observation Description: Hospital EOC Patient Tracking Discussion: The EOC staff was not able to quickly determine location or disposition of three randomly selected victims. Although they explained a procedure for doing so, it was not utilized in this exercise. The triage point provided the number of victims to the EOC via radio. Internal triage did not completely fill out victim triage tags, which included patient information that is to be relayed to the EOC as per their plan. Recommendation: Follow the procedure outlined in their plan. Conclusion Overall, the scenario was handled properly by all of the jurisdictions involved, and the morbidity and mortality were limited to those directly involved in the initial incident. The first responders showed good judgment in their initial evaluation of the scene. Several issues were identified in regards to communications and protocols between different agencies, which impacted patient care. However, this would not have directly resulted in the patient succumbing to their injuries. At the fairground scene, a lack of zone delineation could have resulted in several unprotected personnel being potentially exposed to any hazardous materials in the area. Overall, the decontamination process (although simulated in some areas) was thorough and appropriate. Care was delayed for the victims that remained in the event center. This could have been minimized with the addition of medically trained personnel entering with law enforcement (specifically STAR team). Unique, multiple-patient transport options were available once remaining victims were identified, and were quickly implemented once requested. The responding agencies managed to treat in excess of forty patients from a large-scale intentional hazardous materials release in a fairly short period of time (less than three hours). Such preparations, planning and inter-agency cooperation should be commended. The multi-agency teamwork proved highly effective in meeting the challenges of this exercise. The medical centers demonstrated a mature emergency response capability with excellent and timely mobilization of personnel and resources. Strengths included managerial support, staff enthusiasm and participation, dedication by all participants to making the exercise a worthwhile learning experience, and impressive ability of the emergency department staff to deal with simulated and real patients simultaneously without compromising quality care. Safety staff was pre-eminent in organizing and assisting in the response and conveyed professionalism and care that helped make the exercise a success. 5-19

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97 SECTION 6. TABLE TOP RECOVERY EXERCISE Introduction The Pueblo County Chemical Stockpile Emergency Preparedness Program (CSEPP) scheduled a Recovery Tabletop Exercise for March 21, 2002 from 0800 to 1200 hrs at the Pueblo Convention Center. The Recovery Tabletop Exercise focused on hypothetical re-entry and restoration challenges that would require resolution in the event of an accident or incident at the Pueblo Chemical Depot (PCD) that resulted in the possibility of off-post contamination. Participating agencies were organized into eight functional areas: Environmental, Fire/HAZMAT, Law Enforcement, Medical, Public Information Officers, Schools, Volunteer Organizations and Policy. The problem or challenge, along with a standard answer format, was provided to participants prior to the tabletop exercise. Each group was requested to present its solution during the exercise. The format was designed to stimulate interaction between other working groups/tables as solutions were presented to better identify cross-cutting issues that could affect the community as a whole in the case of an emergency situation as outlined in the scenario. Scenario On the morning of March 20, 2002, at approximately 0700 a commercial jet airliner departed the Colorado Springs Airport for a non-stop flight to Dallas/Fort Worth. The plane held 160 passengers and a crew of six. At approximately 0710 the airliner reported severe control problems and that they were going to attempt an emergency landing at the Pueblo Airport. The airliner was on a southeasterly course at approximately 15,000 feet. In an apparent attempt to lose altitude the plane made a wide sweeping descending turn to the south and west. The last radar contact placed the plane in a steep decent about two miles east of PCD. There was no further communication from the aircraft. At 0720 the airliner crashed into the PCD chemical storage area. The crash ruptured a storage igloo and resulted in a large fire. All on board were presumed dead. There were no casualties on the ground. The fire burned for several hours and resulted in a long sustained release of mustard agent in a slow moving smoke plume. In accordance with established procedures, PCD immediately notified the Pueblo County Sheriff s Communications Center of the community level emergency. Based on PCD s protective action recommendation the county recommended the evacuation of areas south and southwest of the Depot. This included zones S1, S2, SW1 and SW2. The evacuation of these zones took two to three hours and may have resulted in some people being exposed to a mustard agent vapor hazard. 6-1

98 What we know at this point: It is now There were approximately 8,000 people evacuated. Traditionally 20 percent will require shelter. All inbound roads to those zones are closed. All schools were successfully evacuated. The Airport Industrial Park was successfully evacuated. All fire department assets in the zones were successfully evacuated and two field decontamination stations are set up in the city of Pueblo. Hundreds of people are requesting decontamination. There are over 1000 people who self transported to area hospitals, 20 percent of those who have been decontaminated and evaluated so far have mild mustard agent exposure symptoms. The extent of contamination, if any is not known. The sampling and testing for contamination in those zones may take weeks to complete. The following map provides an overview of the hazard area with zones. 6-2