After Action Report Improvement Plan September 10, 2013 City of West Fargo 1 Page
ADMINISTRATIVE HANDLING INSTRUCTIONS 1. The title of this document is The "" After Action Report. 2. The information gathered in this AAR/IP is classified as For Official Use Only (FOUO) and should be handled as sensitive information not to be disclosed. This document should be safeguarded, handled, transmitted, and stored in accordance with appropriate security directives. 3. At a minimum, the attached materials will be disseminated only on a need-to-know basis and when unattended, will be stored in a locked container or area offering sufficient protection against theft, compromise, inadvertent access, and unauthorized disclosure. 4. Points of Contact: City of West Fargo: Mike Reitan City of West Fargo Police Department (Office) 701-433-5500 (E-Mail) mike.reitan@westfargond.gov Exercise Director: Ginny Schwartzer All Clear Emergency Management Group LLC (Office) 919-323-9995 (E-Mail) ginnys@allclearemg.com 2 Page
CONTENTS ADMINISTRATIVE HANDLING INSTRUCTIONS... 2 CONTENTS... 3 EXECUTIVE SUMMARY... 4 SECTION 1: EXERCISE OVERVIEW... 5 Exercise Details... 5 Participant Information... 5 SECTION 2: EXERCISE DESIGN SUMMARY... 6 Exercise Purpose and Design... 6 Exercise Objectives, Capabilities and Activities... 6 Scenario Summary... 7 SECTION 3: ANALYSIS OF CAPABILITIES... 7 SECTION 4: CONCLUSION... 21 APPENDIX A: IMPROVEMENT PLAN... 23 APPENDIX B: PARTICIPANT FEEDBACK (Strengths Areas for Improvement)... 23 APPENDIX C: ACRONYMS... 25 3 Page
EXECUTIVE SUMMARY was designed and facilitated to validate plans, policies and procedures, as well as an opportunity to for response agencies to coordinate activities to a realistic hazardous materials incident scenario. The purpose of this report is to analyze exercise results, identify strengths to be maintained and built upon, identify potential areas for further improvement, and support development of corrective actions. Incorporated in Section 3: Analysis of Capabilities of this After Action Report is a comprehensive listing of each with its associated Major Strengths, Primary Areas for Improvement and Improvement 4 Page
Exercise Details SECTION 1: EXERCISE OVERVIEW Exercise Name: Type of Exercise: Functional Exercise Start Date: September 10, 2013 Duration: Location: Sponsor: Four Hours West Fargo, North Dakota City of West Fargo Program: The exercise was designed and facilitated to measure the effectiveness of the coordinated aspects of a hazardous materials response in the City of West Fargo. Purpose: The purpose of the exercise was to validate plans, policies and procedures, as well as provide an opportunity to for response agencies to coordinate activities to a realistic hazardous materials incident scenario. Mission: The mission of the exercise was to provide a mechanism to measure the effectiveness of the coordinated aspects of the hazardous materials response program for the City of West Fargo. Scenario Type: Hazardous Materials Incident Participant Information Participant Location Emergency Operations Center HazMat Response Incident Investigation On-Scene Incident Command Red River Regional Dispatch Center Number of Participants 36 5 Page
SECTION 2: EXERCISE DESIGN SUMMARY Exercise Purpose and Design The purpose of the exercise was to validate plans, policies and procedures, as well as provide an opportunity to for response agencies to coordinate activities to a realistic hazardous materials incident scenario. Exercise Objectives, Capabilities and Activities Capabilities-based planning allows for the exercise planning team to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Target Capabilities List (TCL). The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail. Based upon the identified exercise objectives below, the exercise planning team decided to demonstrate the following capabilities during this exercise: Communications Activity # 1 Alert and Dispatch Emergency Operations Center Management Activity # 1 Activate EOC # 2 Direct EOC Tactical Operations # 3 Gather and Provide Information # 4 Prioritize and Provide Resources # 5 Provide EOC Connectivity Law Enforcement Investigation Activity # 1 Conduct Investigations of Criminal Activity # 2 Share Information to Aid in Investigations 6 Page
Onsite Incident Management Activity # 1 Implement On-Site Incident Management # 2 Establish Full On-Site Incident Command # 3 Resource Management # 4 Develop Incident Action Plan (IAP) Scenario Summary An eastbound train of 125 tank cars traveling 45 mph derails near the Magellan Pipeline Terminal in West Fargo. The train is transporting sweet crude oil. The three lead engines leave the tracks as well as the next eighteen cars immediately behind the engines. Several tank cars are leaking from their fittings or are punctured. A fire has broken out in the engines and is quickly spreading to the first set of tank cars. 7 Page
SECTION 3: ANALYSIS OF CAPABILITIES Communications Performance Strong Activity # 1: Alert and Dispatch Associated Critical Tasks Task # 1.1: Communicate incident response information per agency protocols. Strong Evaluator # 1 Stacy followed all protocols and guidelines as per RRRDC Policy. All requests for additional personnel or notifications were made in a timely and professional manner. Task # 1.2: Communicate incident response information per agency protocols. Strong Evaluator # 1 Task # 1.3: Communications is established with appropriate agencies as dictated by situation. Strong Evaluator # 1 All radio traffic on Fire and Police channels was clear. Metro channel communications were clear. Task # 1.4: Support of incident objectives through communication with outside agencies. Strong Evaluator # 1 8 Page
All requests made to dispatch were clear from command and personnel in the field. Emergency Operations Center Management Performance Adequate Activity # 1: Activate EOC Associated Critical Tasks Task # 1.1: Activate, alert and request response from EOC personnel. City Manager was guided to call only minimal amount of staffing to do a phased start of EOC. Phased start worked effectively for IT and others. Could have expanded to include others as the exercise developed. Make sure clear guidelines and checklists are available to assist members in roles and responsibilities. Task # 1.2: Brief incoming personnel. Briefing given of what was reported up to that time. As staff arrived with additional information that was relayed to staff. Need to ensure verbal briefings and messages are followed with written message for record keeping and later clarification of information. Task # 1.3: Activate EOC. Strong Evaluator # 1 IT brought a phased EOC on-line quickly. Requested personnel appeared when called and brought 9 Page
resources with them. Need to build on staff when it is determined there needs to be additional staff. Performance Adequate Activity # 2: Direct EOC Tactical Operations Associated Critical Tasks Task # 2.1: Ensure that all emergency support functions (ESFs) are staffed. The initial staff positions were staffed with at least one person. Each staffed position should have a primary and an assistant to facilitate movement of information and assist with clerical duties. Task # 2.2: Coordinate management of EOC with other ICS operations. Weak Evaluator # 1 There was not a consistent flow of information from the scene to Unified Command to EOC. Need to establish a scheduled update of information and information update following a major change in the incident. Task # 2.3: Arrange for shelter, housing, and feeding for responders and personnel supporting the operation per the emergency plan, as applicable. Strong Evaluator # 1 Request for feeding and support was up channeled and acted on quickly. Need to review contact information on a six month schedule to make sure information is as current as possible. Performance 10 Page
Adequate Activity # 3: Gather and Provide Information Associated Critical Tasks Task # 3.1: Verify that all participating public safety-related Communication Centers, serving the EOC directly or indirectly, have established communication links with the EOC. Weak Evaluator # 1 Radio was not immediately available in the EOC. Telephone numbers and other listings were available for telephone contact. Computer access was available early on to make contact with local and state resources. Radio should be part of activation checklist. Task # 3.2: Ensure appropriate notifications are made. Code RED was used to contact staff and conduct a recall of personnel. Need to develop coordinated system that establishes roles and responsibilities of Code RED use. Develop a checklist and fillable form for preparation of the Code RED messages. Task # 3.3: Collect, analyze and disseminate information and intelligence. As information became available the information was briefed to staff. Performance Adequate Activity # 4: Prioritize and Provide Resources 11 Page
Associated Critical Tasks Task # 4.1: Facilitate resolution to legal, policy, political, social, and economic sensitivities of the affected jurisdiction as they impact response and recovery operations. Incident was coordinated with BNSF Railway and responders. Contact with public health for environmental services. Performance Adequate Activity # 5: Provide EOC Connectivity Associated Critical Tasks Task # 5.1: Communicate internal incident response information. Information was relayed to all persons present in the EOC and reported to the State using the WebEOC, Need to ensure verbal reporting is accompanied with written documentation of report to allow for record keeping and later message clarification. Task # 5.2: Provide direction, information and/or support as appropriate to IC/UC and/or EOC. There were adequate systems available to allow for the timely exchange of information and direction. Task # 5.3: Maintain a common operating picture (COP) for real time sharing of information with all the participating entities at all levels to ensure all responder agencies are working from the same information. Weak Evaluator # 1 12 Page
There was some lack of information sharing and decision making resulting in decisions being made at multiple levels that were sometimes in conflict. Need to provide for a formal information up flow to make sure all are aware of what is occurring. Task # 5.4: Report and document the incident by completing and submitting required forms, reports, documentation, and follow-up notations. Strong Evaluator # 1 Use of local forms and systems were utilized as well as use of WebEOC. Law Enforcement Investigation Performance Adequate Activity # 1: Conduct Investigations of Criminal Activity Associated Critical Tasks Task # 1.1: Respond to initial reports of potential threats/suspicious behavior from the community, other agencies, or the subject. Weak Evaluator # 1 Initial information was not shared with others. First threat was disregarded and nearly discarded. Later threats were shared within the investigations group, with BNSF Railways and with FBI. A theft report should have been tied into threats. Need to develop a system to screen, review and route electronic messages that are sent to the city. Need to provide information to all staff to allow for more eyes on a potential problem. Task # 1.2: Initiate investigation of a suspect. Strong Evaluator # 1 13 Page
Case file was opened and investigative staff met with BNSF Railways and FBI to coordinate investigation. Evaluation of potential targets was identified and electronic surveillance was set up to monitor the areas. Physical observation of the areas resulted in people and vehicles being identified. Task # 1.3: Gather, catalogue and preserve evidence for prosecutorial purposes and attribution. Strong Evaluator # 1 Electronic recordings of potential targets were gathered as well as information on people seen in the area. A case file was developed to track and record activities associated with the investigation. Task # 1.4: Interview witnesses to criminal and/or suspicious activity. Did interview employees of one of the locations from where a threatening message was sent. Performance Adequate Activity # 2: Share Information to Aid in Investigations Associated Critical Tasks Task # 2.1: Share investigation-related information across jurisdictions and among law enforcement and other appropriate agencies as appropriate. Shared information with BNSF Railways and FBI. Unsure if information was shared with other local agencies. 14 Page
Task # 2.2: Conduct targeted outreach with private industries, businesses, and facilities to assist in investigation. Made contact with BNSF Railways and Magellan Pipeline. Onsite Incident Management Performance Adequate Activity # 1: Implement On-Site Incident Management Associated Critical Tasks Task # 1.1: First arriving unit provides initial on-scene report. Basic description of incident and approximate location given by Central Dispatch to responding units. First arriving units reported thick black smoke with flames showing and train cars derailed. First Responders were notified by Magellan Pipeline the overturned and leaking tanker cars contained sweet crude oil. BNSF Railways representation indicated each tanker car carried about 30,000 gallons. First Responders saw an immediate need for the HazMat Team and made that request through the on scene command for HazMat and Fargo Fire mutual aid. The police department notified their chain of command. Law Enforcement saw a need for traffic control on a large scale basis and did a code red callback to their off-duty officers to come in and assist. Task # 1.2: Initiate and implement Incident Command System (ICS). 15 Page
Some of the players who would later become part of the Unified Command initially were involved with the Incident Management at the beginning. Dell Sprecher, Ken Zetocha from the West Fargo Fire Department and Duane Sall from the West Fargo Police Department, we're initially involved in information being pushed to them and they were calling in resources and starting with planning. Dell had Ken as an assistant, so they were able to effectively manage the situation / issues pushed at them. Duane did not have an assistant and at times was overwhelmed with phone calls, radio traffic and people talking to him. He needed a second in command to delegate some things to in order for him to be more effective. Even if you don't have another supervisor immediately available, grab onto an officer or someone you can temporarily make your assistant until other supervisors arrive. Task # 1.3: First arriving unit initiates site management and control. Not Applicable Evaluator # 1 Performance Adequate Activity # 2: Establish Full On-Site Incident Command Associated Critical Tasks Task # 2.1: Transition from IC to Unified Command (UC) for incidents involving multiple jurisdictions, a single jurisdiction with multi-agency involvement, or multiple jurisdictions with multi-agency involvement. A request was made to set up Unified Command at the Fargo Fire Hall on 1st St and for department representatives to report to that location for the Unified Command. 16 Page
A request was also made to set up an EOC for the City Manager and department heads. The unified commander was Dell Sprecher and his assistant was Ken Zetocha. Duane Sall represented the Police Department, Grant the Health Department, Derrick for BNSF Railways, Chris Rasmussen for HazMat, Ken Kupich for FM Ambulance. An announcement was given over the radio indicating who the unified commander was. This is when it's important for everyone in the Unified Command to understand the role of being in a Unified Command position. You are the thinkers, decision makers, strategists and planners... You are not the doers. You have to be comfortable with making a decision and then delegating the responsibility and authority to someone in operations to get it done. You can't get sucked into the details of how to carry out that operation. Let the operations people worry about that. The Unified Command people have to be a cohesive group that sits close together to talk things through. You can't be constantly pulled away from the table of decision makers. That's what your assistant is for. Task # 2.2: Establish communications with emergency operations center multiagency coordinating center (EOC/MACC), dispatch center and responding units. Every agency / department involved switched over to the Metro Channel once Unified Command was established. The announcement to switch to Metro was well done and clear. So radio communication was good. I would suggest turning off the ringers on everyone s cell phones in the Unified Command and just having them on vibrate. It seemed like everyone's phone was ringing and it made it distracting and difficult to hear conversations. Task # 2.3: Establish communications and coordinate operations with emergency response specialty teams (e.g. SWAT/tactical, Bomb Squad/Explosives, HAZMAT, urban SAR). As teams arrived they were to report to the designated staging 17 Page
area. Their arrival was announced and received in the Unified Command. Direction / deployment were done through operations to the onsite staging manager. Performance Adequate Activity # 3: Resource Management Associated Critical Tasks Task # 3.1: Establish processes to order, track, assign, and release incident resources. Ken Zetocha in Unified Command did a good job of tracking all of the resources that arrived on scene and were then deployed. The tracking was done on a handwritten notebook. It would be better to have a large white board or big screen so everyone could see what resources were being utilized and what was still in staging. Task # 3.2: Monitor/measure performance of assigned resources and request additional resources as needed. Unsure Evaluator # 1 Unified Command had an understanding of what was available. They also received a lot of help from Derrick with BNSF Railways on a multitude of resources for fire suppression, environmental protection and salvage. Task # 3.3: Request mutual aid through the dispatch center, EOC/MACC ordering process. 18 Page
The appropriate requests for mutual aid were made over the radio and the telephone. The EOC may not have been established yet for some of these requests. Duane Sall was able to get the WEBEOC up after he caught up with managing his people. Task # 3.4: Coordinate with arriving regional, State, and Federal responders. Most of the coordination was done with local and regional resources and BNSF Railways resources. The Unified Command did communicate with other entities, but the exercise probably didn't go long enough to get all of them involved. The EOC may have communicated with state and Federal resources. Performance Adequate Activity # 4: Develop Incident Action Plan (IAP) Associated Critical Tasks Task # 4.1: Establish incident objectives, priorities and operational periods. Weak Evaluator # 1 At first the Unified Command was disjointed and not acting as a Unified Command. Chris Rasmussen recognized this and got Dell to call everyone around the table together for a briefing on what the Unified Command is supposed to do. This got everyone on the same page and they established a list of priorities that needed to get done. This probably took a little too long to get done, but once everyone understood what the Unified Command actually does, the ship was quickly up righted and the planning started to happen. 19 Page
Task # 4.2: Develop written IAP to establish priorities, procedures, and actions to be accomplished to meet the Incident Objectives for each operational period. IAP is approved by IC/UC. Priorities were established by the Unified Command but they didn't have enough time to establish operational periods. 1. Fire suppression. 2. Run-off and diking and damming the HazMat runoff. 3. HazMat coordinating response with BNSF Railways fire suppression and environmental crews. 4. Patient I.D. and decontamination before transport to hospital. 5. Evacuation plan communication - ask for cameo model which would determine scope of evacuation or shelter in place. 6. EOC notified of priorities and changes. 20 Page
SECTION 4: CONCLUSION Exercises such as this one allow personnel to validate training and practice strategic and tactical prevention, protection, response and recovery capabilities in a risk-reduced environment. Exercises are the primary tool for assessing preparedness and identifying areas for improvement, while demonstrating community resolve to prepare for major incidents. Exercises aim to help entities within the community gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are addressed prior to a real incident. Exercises are the most effective (and safer) means to: Assess and validate policies, plans, procedures, training, equipment, assumptions, and interagency agreements; Clarify roles and responsibilities; Improve interagency coordination and communications; Identify gaps in resources; Measure performance; and Identify opportunities for improvement. This exercise succeeded in addressing all of the above as it provided examples of good to excellent participant knowledge, teamwork, communication and use of plans and procedures while pointing out areas in need of improvement and clarification. Listed below is a summary of the level of performance the Target Capabilities and Tasks evaluated during the exercise. This summary outlines the areas in which the City of West Fargo is strong as well as identifying areas that the departments should invest future planning, training and exercise funds on. Communications Activity Performance # 1 Alert and Dispatch Strong Emergency Operations Center Management Activity Performance # 1 Activate EOC Adequate # 2 Direct EOC Tactical Operations Adequate # 3 Gather and Provide Information Adequate 21 Page
# 4 Prioritize and Provide Resources Adequate # 5 Provide EOC Connectivity Adequate Law Enforcement Investigation Activity Performance # 1 Conduct Investigations of Criminal Activity Adequate # 2 Share Information to Aid in Investigations Adequate Onsite Incident Management Activity Performance # 1 Implement On-Site Incident Management Adequate # 2 Establish Full On-Site Incident Command Adequate # 3 Resource Management Adequate # 4 Develop Incident Action Plan (IAP) Adequate 22 Page
APPENDIX A: IMPROVEMENT PLAN This Improvement Plan has been developed specifically for the City of West Fargo based on the results of West Fargo HazMat Incident Functional Exercise conducted on September 10, 2013. These recommendations draw on both the After Action Report and the After Action Conference. Capability Observation Recommendation Responsible Agency Completion Date Communications Emergency Operations Center Management Law Enforcement Investigation Onsite Incident Management 23 Page
Set up went well. APPENDIX B: PARTICIPANT FEEDBACK (Strengths Areas for Improvement) Strengths EOC staggered start allowed IT to prioritize installation of needed systems. Personnel reported with resources necessary to conduct business. Shared information that was available as it became available. Communication. Areas for Improvement Need to add staff to allow for a primary and assistant for each staffed position. Need to follow verbal communication with written documentation to allow for record keeping and message clarification. Need to further develop response plans and resources available to conduct business. 24 Page
APPENDIX C: ACRONYMS Acronym Meaning COMM CONOPS EOC ESF IAP IC ICS IMT JIC LOFR MOA MOU NIMS OPS PIO RRRDC SitRep SOG SOP UC Communications Concept of Operations Emergency Operations Center Emergency Support Function Incident Action Plan Incident Command Incident Command System Incident Management Team Joint Information Center Liaison Officer Memorandum of Agreement Memorandum of Understanding National Incident Management System Operations Public Information Officer Red River Regional Dispatch Center Situation Report Standard Operating Guideline Standard Operating Procedure Unified Command 25 Page