FEMA Region II Neptune System Full-Scale Exercise. After-Action Report/ Improvement Plan

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FEMA Region II Neptune System Full-Scale Exercise October 17, 2015.

The aligns exercise objectives with preparedness doctrine to include the National Preparedness Goal and related frameworks and guidance. Exercise information required for preparedness reporting and trend analysis is included; users are encouraged to add additional sections as needed to support their own organizational needs.

CONTENTS Exercise Overview...1 Executive Summary...3 Exercise Objectives and Core Capabilities...3 Exercise Summary...4 Exercise Evaluation...5 Strengths and Areas for Improvement...6 Major Strengths... 6 Areas for Improvement... 6 Analysis of Core Capabilities...7 Environmental Response/Health and Safety... 9 Fire Management and Suppression... 11 Fire Management and Suppression... 13 Intelligence and Information Sharing... 14 Intelligence and Information Sharing... 14 Operational Communications... 15 Operational Communications... 15 Public Health, Healthcare, and Emergency Medical Services... 16 Situational Assessment... 17 Appendix A:... A-1 Appendix B: Exercise Participants...B-1 Appendix C: Participant Feedback...C-1 Contents i FEMA Region II

This page is intentionally blank. Contents ii FEMA Region II

EXERCISE OVERVIEW Exercise Name Federal Emergency Management Agency Region II Neptune System Exercise Series Full-Scale Exercise Exercise Date October 17, 2015 Scope Mission Area Core Capabilities Threat or Hazard Scenario Sponsors Points of Contact This was a full-scale exercise, planned for six hours at the International- Matex Tank Terminal Bayonne at 250 East 22nd Street, Bayonne, New Jersey 07002. Exercise play was limited to 9:00 am 3:00 pm Eastern Time. Response Environmental Response/Health and Safety Fire Management and Suppression Intelligence and Information Sharing Operational Communications Operational Coordination Public Health, Healthcare, and Emergency Medical Services Situational Assessment A fuel tank fire with exposure to other tanks within the terminal and product leakage into a major waterway. Lightning strikes a fuel tank at the International-Matex Tank Terminal in Bayonne, New Jersey. Fuel inside the tank is ignited and burns freely, resulting in exposure to adjacent tanks and fuel leakage into the Hudson Bay. Federal Emergency Management Agency Region II U.S. Department of Homeland Security/Federal Emergency Management Agency/National Exercise Division Jordan Blasi Chief, International-Matex Tank Terminal Fire Brigade Phone: 201-232-0085 Email: JordanBlasi@IMTT.com Carl Heitmeyer Deputy Chief, Elizabeth (New Jersey) Fire Department Phone: 908-420-4969 Exercise Overview 1 FEMA Region II

Email: cavercarl@aol.com Stephen Peterson Battalion Chief, Bayonne (New Jersey) Fire Department Phone: 201-858-6968 Email: chiefpetersonbfd@gmail.com Kelly Casas Exercise Program Support Federal Emergency Management Agency/National Exercise Division Phone 202-733-7864 E-mail: kelly.casas@fema.dhs.gov Exercise Overview 2 FEMA Region II

EXECUTIVE SUMMARY EXERCISE OBJECTIVES AND CORE CAPABILITIES The following exercise objectives in Tables 1 and 2 describe the expected outcomes for the exercise. The objectives are linked to core capabilities, which are distinct critical elements necessary to achieve the specific mission area. The objectives and aligned core capabilities were guided by elected and appointed officials and selected by the exercise planning team. Exercise Objective The Incident Command System team will conduct health and safety assessments and provide guidance and resources to support environmental health and safety actions for the affected area within 30 minutes of arrival. The Incident Command System team will ensure and maintain assured communications with necessary internal and external partners for the duration of the incident. The Incident Command System team will develop and provide an incident briefing that includes incident overview, situation status update, incident objectives, resources, tasking and an organizational chart by the end of the incident. The Incident Command System team will ensure emergency response apparatus is deployed and positioned as identified by all applicable plans, policies, and procedures within one hour of the incident notification. Core Capability Environmental Response/ Health and Safety Operational Communications Situational Assessment Fire Management and Suppression Table 1. General Exercise Objectives and Associated Core Capabilities Exercise Objective Elizabeth City (New Jersey) Fire Department/Neptune System: The Incident Command System team will ensure the required information is provided to the Union County Neptune System Task Force Team Leaders following the notification of this resource. Elizabeth City (New Jersey) Fire Department/Neptune System: The Union County Neptune Task Force Team Leaders will ensure they have the necessary information required to deploy and establish their resources within 20 minutes of arriving at the incident site. City of Bayonne (New Jersey) Fire Department: The Bayonne Fire Department, working in coordination with the McCabe Ambulance Service, will triage, treat, and transport injured facility employees in accordance with applicable medical directives within 15 minutes of arrival. New Jersey Office of Homeland Security and Preparedness: The State of New Jersey Office of Homeland Security and Preparedness, through the Emergency Support Function #2 (Communications), will provide for the coordination with telecommunications and information technology industries utilizing the JerseyNet system within the timeframe of the exercise. Core Capability Intelligence and Information Sharing Intelligence and Information Sharing Public Health, Healthcare, and Emergency Medical Services Operational Communications Table 2. Agency-Specific Exercise Objectives and Associated Core Capabilities Analysis of Core Capabilities 3 FEMA Region II

Due to unforeseen circumstances outside the control of the exercise planning team and participating organizations, the following objectives were not fully achievable and therefore were only partially evaluated, or not evaluated, during the exercise. Exercise Objective The Incident Command System team will assess, monitor, and perform cleanup actions to assist in mitigating the event before operations cease. Core Capability Environmental Response/ Health and Safety This objective was not evaluated during the exercise due to an International-Matex Tank Terminal water system issue. During water flow operations, all runoff must be reclaimed in an on-site storage system. Prior to the start of the exercise, facility maintenance had taken one of the two reclamation and storage systems out of service for cleaning. This left only one system in place which had to remain operational in the event of a real-world incident. Without the ability to reclaim the runoff from fire suppression activities, exposure protection and decontamination tasks had to be partially simulated which eliminated additional water usage and flow and any subsequent contaminated runoff from fire suppression efforts. It was determined by the exercise directors to eliminate this objective. The Incident Command System team will ensure the desired water flow capacity of 8,000 gallons per minute be attained within four hours of incident notification and that this capacity will be exercised for a minimum duration of ten minutes. Fire Management and Suppression This objective was modified due to an International-Matex Tank Terminal water system issue prior to the start of the exercise. During the week prior to the exercise, the fire system pump that supports and augments the Neptune pump system was taken out of service for repairs and was still out of service at the start of the exercise. Without this critical piece of terminal equipment in service, it would not be possible for the Union County Task Force assets to reach the 8,000 gallons per minute flow rate with the resources that were scheduled for exercise participation. The exercise directors determined that a more realistic target matrix would be 4,000 5,000 gallons per minute given the circumstances presented. International-Matex Tank Terminal Fire Brigade: The International- Matex Tank Terminal will utilize the man-down feature of its communications network to identify that there is a terminal employee in need of immediate assistance and identify the location of said employee within five (5) minutes of activation of this feature. Operational Communications Due to technical difficulties with the man-down system, it was not operational to its full capabilities at the start of the exercise. The reporting and GPS systems were not available in all locations of the International-Matex Tank Terminal facility. This resulted in the inability to receive notifications or distress calls in all required locations at the facility. The exercise directors determined the evaluation of the system when it was not fully operational was inappropriate. EXERCISE SUMMARY Table 3. Objectives Not Evaluated, or Partially Evaluated The purpose of this exercise was to evaluate the command, coordination, and communications interoperability between participating agencies and organizations in response to an incident at the International-Matex Tank Terminal. This exercise was used to enhance general awareness; validate plans and procedures; and assess the types of systems needed to guide response during a storage tank fire incident affecting the International-Matex Tank Terminal Bayonne facility. It was Analysis of Core Capabilities 4 FEMA Region II

aimed at facilitating the concept of understanding and identifying strengths and areas for improvement. The Federal Emergency Management Agency Region II Neptune Series Full-Scale Exercise planning team consisted of representatives from all participating facilities and agencies working together to develop the exercise Core Capabilities, objectives, scenario, and evaluation criteria over an eight-month planning process. The full-scale exercise was preceded by a successful tabletop exercise in which agencies came together to identify planning and training needs for local participants responsible for incident management and stabilization at the International-Matex Tank Terminal facility. In total over 125 individuals from the International-Matex Tank Terminal, Union County Neptune Task Force, and other local and state response and support agencies participated in the exercise. Players received notification of a lightning strike at a fuel tank at the International-Matex Tank Terminal with possible injuries to facility workers. International-Matex Tank Terminal Fire Brigade personnel assembled and deployed to the incident scene. Once on the scene, fire brigade personnel established incident command and requested the aid of the Union County Neptune Task Force and Bayonne Fire Department. As mutual aid support arrived a Unified Command team was established and resources were deployed as needed to complete identified rescue and fire suppression tasks and objectives. EXERCISE EVALUATION Evaluation of the exercise was based on the exercise objectives and aligned capabilities, capability targets, and critical tasks, which were documented in Exercise Evaluation Guides. Evaluators were provided Exercise Evaluation Guides for each of their assigned areas. Additionally, players completed Participant Feedback Forms and provided input during the hot wash. These documents were used to evaluate the exercise and compile the After Action Report. Analysis of Core Capabilities 5 FEMA Region II

STRENGTHS AND AREAS FOR IMPROVEMENT Major Strengths The major strengths identified by participants during this exercise are as follows: The JerseyNet communications system proved to be a robust and versatile component of incident communications interoperability providing voice, video, and internet accessibility to all participating agencies throughout the exercise. When firefighters are given a task they will find a way to accomplish it even with minimal training. When the situation becomes difficult, their remarkable tenacity plays a big part in overcoming any obstacle. Large-scale exercises such as this allow the firefighters to work in real-world surroundings and overcome hindrances not normally found in the pristine training environment. It also allows the officers and firefighters to work to their full potential. The information gleaned from this type of an exercise is invaluable. The exercise gave members of the private and public sectors an opportunity to come together for a large and robust event to work through many challenges that they could possible face during a real world incident at the International-Matex Tank Terminal. Many of the participants had not been exposed to the terminal prior to the exercise and received first-hand experience in operating in an environment that is substantially different than what they are used to during structural firefighting assignments. Areas for Improvement The major areas for improvement identified by participants during this exercise are as follows: There were challenges when the Neptune task force leader assigned personnel with specific titles. Additional Neptune Task Force Leaders with the rank of Chief Officer need to be recruited. Additional training funds should be devoted to this area. A current and up-todate task force leader program should be developed to include all of the case histories now available. In addition, an expanding incident command chart should be developed with each position clearly delineated along with its responsibilities. Additional training on the various components of the Neptune System and the standard operating guide should be conducted in order to adequately prepare all personnel assigned to the Neptune Task Force. Many of the participants had no training or had not received training updates which caused a delay in operational status of the Neptune System or inability to meet some of the defined exercise objectives. There should be at least one person who is intimately familiar with his or her component of the Neptune System to operate as a mentor or team leader for that particular group s assignment. Analysis of Core Capabilities 6 FEMA Region II

ANALYSIS OF CORE CAPABILITIES Aligning exercise objectives and core capabilities provides a consistent taxonomy for evaluation that transcends individual exercises to support preparedness reporting and trend analysis. Table 4 explains the ratings used. Table 5 includes the exercise objectives, aligned core capabilities, and performance ratings for each core capability as observed during the exercise and determined by the evaluation team. Performed without Challenges (P) Performed with Some Challenges (S) Performed with Major Challenges (M) Unable to be Performed (U) The targets and critical tasks associated with the core capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. The targets and critical tasks associated with the core capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. However, opportunities to enhance effectiveness and/or efficiency were identified. The targets and critical tasks associated with the core capability were completed in a manner that achieved the objective(s), but some or all of the following were observed: demonstrated performance had a negative impact on the performance of other activities; contributed to additional health and/or safety risks for the public or for emergency workers; and/or was not conducted in accordance with applicable plans, policies, procedures, regulations, and laws. The targets and critical tasks associated with the core capability were not performed in a manner that achieved the objective(s). Table 4. Explanation of Ratings Objective Core Capability Rating The Incident Command System team will conduct health and safety assessments and provide guidance and resources to support environmental health and safety actions for the affected area within 30 minutes of arrival. The Incident Command System team will ensure emergency response apparatus is deployed and positioned as identified by all applicable plans, policies, and procedures within one hour of the incident notification. The Incident Command System team will ensure the desired water flow capacity of 8,000 gallons per minute be attained within four hours of incident notification and that this capacity will be exercised for a minimum duration of ten minutes. Environmental Response/ Health and Safety Fire Management and Suppression Fire Management and Suppression S S U Analysis of Core Capabilities 7 FEMA Region II

Objective Core Capability Rating The Incident Command System team will ensure the required information is provided to the Union County Neptune System Task Force Team Leaders following the notification of this resource. The Union County Neptune Task Force Team Leaders will ensure they have the necessary information required to deploy and establish their resources within 20 minutes of arriving at the incident site. The Incident Command System team will ensure and maintain assured communications with necessary internal and external partners for the duration of the incident. The State of New Jersey Office of Homeland Security and Preparedness, through the Emergency Support Function #2 (Communications), will provide for the coordination with telecommunications and information technology industries utilizing the JerseyNet system within the timeframe of the exercise. The Bayonne Fire Department, working in coordination with the McCabe Ambulance Service, will triage, treat, and transport injured facility employees in accordance with applicable medical directives within 15 minutes of arrival. The Incident Command System team will develop and provide an incident briefing that includes incident overview, situation status update, incident objectives, resources, tasking and an organizational chart by the end of the incident. Table 5. Summary of Core Capability Performance Intelligence and Information Sharing Intelligence and Information Sharing Operational Communications Operational Communications Public Health, Healthcare, and Emergency Medical Services Situational Assessment The following sections provide an overview of the performance related to each exercise objective and associated core capability, highlighting strengths and areas for improvement. P P P S P U Analysis of Core Capabilities 8 FEMA Region II

OBJECTIVE: The Incident Command System team will conduct health and safety assessments and provide guidance and resources to support environmental health and safety actions for the affected area within 30 minutes of arrival. The strengths and areas for improvement for the core capability aligned to this objective are described in this section. Environmental Response/Health and Safety Strengths The partial capability level can be attributed to the following strengths: Strength 1: Within 10 minutes after arrival on the scene and establishing an incident command post, the Incident Commander directed units to establish decontamination for responders and victims as needed. Less than one hour after given the direction, the responding crews were able to identify a site and establish the support, such as water supply for the system. A full decontamination system was established including a tent and facility to shower those potentially contaminated. Strength 2: Within 10 minutes after establishing command, the Incident Commander directed the hazardous materials crews to provide environmental monitoring and modeling to determine the areas potentially affected by the combustion products. A full weather station was set up quickly and modeling begun as soon as the equipment was in place. This information was considered in the application of the pre-plans for the affected tank and the direction of the tactical approach to suppression activities. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: The use of personal protective equipment by Neptune Task Force personnel was inappropriate or absent. Reference: Operational Guide-Union County Fire Mutual Aid-Neptune Response System Responses-Revision Date 5-5-15; National Fire Protection Association 471-Recommended Practice for Responding to Hazardous Materials Incidents-2002 Edition Analysis: The Neptune Task Force Leader reassigned the Staging Area Manager to the position of Safety Officer; this was due to a limited availability of chief officers. Several serious safety violations occurred early on and had to be corrected by the evaluation staff. For example, a number Analysis of Core Capabilities 9 FEMA Region II

of members were working near the water, but were not wearing personal flotation devices. In addition, many of the members working in the area of overhead obstructions did not have helmets in place. And finally, in most cases, safety gloves were nonexistent. Recommended Corrective Action 1: Ensure the appointment of an Incident Safety Officer and Assistant Safety Officers, as needed, at the onset of all incidents as identified in the Incident Command System. Area for Improvement 2: Although some measures were used to address safety and provide guidance, no specific assessment team or process was ever identified. Reference: Operational Guide-Union County Fire Mutual Aid-Neptune Response System Responses-Revision Date 5-5-15; National Fire Protection Association 471-Recommended Practice for Responding to Hazardous Materials Incidents-2002 Edition Analysis: Although certain measures, such as weather monitoring and decontamination were in place shortly after arrival on the scene, no specific plan or process to monitor environmental health and safety was initiated. The Incident Commander was aware of and discussed the potential concerns but no plan was developed and disseminated to the responders or overall incident management. The Incident Commander was focused on the tactics of the operations rather than the management of the process which left gaps in planning process. If Incident Command System forms, such as the ICS 208-Safety Message/Plan had been utilized, the environmental and safety needs might have been specifically addressed. Without developing of a specific plan and ensuring that all responders are briefed on the plan, potential dangers such as exposure to hazardous products, fire, and improper use of personal protective equipment could result. Recommended Corrective Action 1: Ensure the adoption of the National Incident Management System and use of Incident Command System forms to prompt command to initiate required safety components and goals of the operations. Recommended Corrective Action 2: Include the requirement of an environmental and health assessment as a tactical component and a specific process to ensure it is addressed in all International-Matex Tank Terminal response plans. Recommended Corrective Action 3: Ensure that all applicable requirements outlined in the Occupational Safety and Health Administration 29 CFR-1910/Occupational Safety and Health Standards are incorporated into applicable International-Matex Tank Terminal response plans. Analysis of Core Capabilities 10 FEMA Region II

OBJECTIVE: The Incident Command System team will ensure emergency response apparatus is deployed and positioned as identified by all applicable plans, policies, and procedures within one hour of the incident notification. The strengths and areas for improvement for the core capability aligned to this objective are described in this section. Fire Management and Suppression Strength The partial capability level can be attributed to the following strength: Strength 1: The initial arriving companies were positioned uphill and up wind. The incident command post was set up on arrival. Companies from International-Matex Tank Terminal and the Bayonne Fire Department were positioned for exposure protection and civilian rescue. Immediately upon establishment of command, the incident commander directed International- Matex Tank Terminal units to begin cooling tanks that would have been exposed to the fire. This pro-active tactic followed a tactical priority established in facility pre-plans. The crews were able to quickly establish positions as directed and establish water supplies. Unfortunately constraints in the use of on-site water supplies negated the actual flowing of water, but it appeared that the units were in effective position to meet the tactical objectives. Area for Improvement The following area requires improvement to achieve the full capability level: Area for Improvement 1: Neptune Task Force assets were not fully operational within one hour of notification. Reference: Operational Guide-Union County Fire Mutual Aid-Neptune Response System Responses-Revision Date 5-5-15 Analysis: Neptune pump set up began at 10:53 am. The Roselle Fire Department tower ladder was put into position and both satellite pumps were lowered into the water using Hall systems. The 8 hose was hooked up to the satellite pumps and the Neptune System. At 11:28 am the Neptune pump was completely set up and ready to supply water. It should be noted that most firefighters and officers assigned to the Neptune pump set up had been properly trained. Analysis of Core Capabilities 11 FEMA Region II

At 11:35 am, the Neptune Hose Group began laying the 12ʺ hose. It should be noted that the hose group should have started deploying the 12ʺ hose at the same time that the Neptune pump was being set up. In addition, there was confusion regarding the set up and the 12ʺ manifold was not initially installed. At 12:00 pm, the group began installing the 12 manifold after they realized it had not been installed. It should be documented that the Neptune Hose Group was advised to try and keep the roadway open. The 12 hose was placed close to the edge of the roadway and the roadway siding dropped down 8 10 feet into the tank dike areas. This proved to be catastrophic during the charging and shut down phase as the hose rolled down into the diked area. There was confusion regarding the foam station set up. At one point, the Neptune Pump Group Supervisor reported to the Neptune Task Force Leader that the system was up and ready to go. However, the Neptune Pump Group Supervisor failed to realize the foam station had never been set up. The foam station set up began at approximately 12:30 pm and was not completed until 1:17 pm. Foam station set up should have been completed within 15 20 minutes. It was noted that many of the personnel assigned to foam station set up had been involved in operations in the past but had no specific foam station training. In addition they were having trouble matching the required flow with the available jet pumps. There was also confusion regarding the proper operational pressure for the jet pumps. In addition the large 3,000 gallon-per-minute jet pumps were set up with only one pickup tube when they clearly required two. It should be noted that the foam station needs to be set in an area where foam tenders have easy access to discharge their contents, leave the scene, and allow additional units to dump their contents. The Iron Man nozzle placement was also initially wrong. It was 80 too close and had to be moved. This required the ballast tanks to be emptied and refilled a second time once it was placed in the proper location. A major cause of the delay in reaching operational status was that the Neptune Task Force standard operating guide, Operational Guide-Union County Fire Mutual Aid-Neptune Response System Responses-Revision Date 5-5-15, was not followed. Assignments were made and tactics executed in a linear fashion instead of being carried out simultaneously. Secondly, almost half of those that where at the exercise had no training in the Neptune System. Several had not worked or trained with the system in years. The Neptune Pump Group, for example, usually has 8-10 highly trained personnel setting it up. At this exercise there were only two trained operators present. Recommended Corrective Action 1: Ensure all personnel assigned to the Neptune Task Force receive training in the Operational Guide-Union County Fire Mutual Aid-Neptune Response Analysis of Core Capabilities 12 FEMA Region II

System Responses-Revision Date 5-5-15 as well as the various tasks associated with each fire company s responsibilities. Recommended Corrective Action 2: When future exercises are conducted, clear guidelines must be established to identify and define the personnel acceptable to participate in the exercise. Members participating must meet all of the training requirements for their assigned area. OBJECTIVE: The Incident Command System team will ensure the desired water flow capacity of 8,000 gallons per minute be attained within four hours of incident notification and that this capacity will be exercised for a minimum duration of 10 minutes. The area for improvement for this core capability aligned to this objective are described in this section. Fire Management and Suppression Area for Improvement The following area requires improvement to achieve the full capability level: Area for Improvement 1: The target water flow of 8,000 gallons per minute was not met. Reference: Operational Guide-Union County Fire Mutual Aid-Neptune Response System Responses-Revision Date 5-5-15; International-Matex Tank Terminal Fire Pre-plan Analysis: The target flow of 8,000 gallons per minute was never reached. It was identified prior to the exercise that onsite facility fire pumps were inoperable and would be required to augment the Neptune System to reach the desired water flow goal. It was noted however, that supplementing the system with fire pumpers operating in tandem with the Neptune System would be put in place in an actual incident to reach the target water flow. If pumpers assigned to the exercise were reassigned to water supply operations, this objective may have been reached. It is unclear why, given the compromise of the onsite pumping systems, that exercise apparatus was not utilized to reach the objective. Pressure measured at the Ironman nozzle indicated an estimated flow total of 4,000 gallons per minute. Other notable influencing factors include the fact that many of the firefighters participating in the exercise had either no training on the Neptune System or had not undergone refresher training in many years. This stretched the abilities of the on-hand firefighters that were trained far beyond an effective level. Recommended Corrective Action 1: Once the on-site fire pumps are operational, conduct a drill involving the Neptune Task Force and the International-Matex Tank Terminal to duplicate the exercise parameters to evaluate if the required water flow of 8,000 gallons per minute can be met. Recommended Corrective Action 2: Conduct a drill that duplicates the exercise parameters including the on-site fire pump compromise but utilize fire department pumpers to determine what flow can be achieved. Recommended Corrective Action 3: Ensure Neptune Task Force personnel have the requisite training for their job assignments in order to effectively establish the required water flow. Analysis of Core Capabilities 13 FEMA Region II

OBJECTIVE: The Incident Command System team will ensure the required information is provided to the Union County Neptune System Task Force Team Leaders following the notification of this resource. The strength for the core capability aligned to this objective is described in this section. Intelligence and Information Sharing Strength The full capability level can be attributed to the following strength: Strength 1: Through monitoring of radio communications, it was determined that the Neptune Task Force Leader began his site reconnaissance at 10:12 am as requested by the Incident Commander. This task was completed by 10:35 am at which time the Task Force Leader met with the Incident Commander at the incident command post. The proper incident information was exchanged as well as fire suppression information for foam and water flow calculations. OBJECTIVE: The Union County Neptune Task Force Team Leaders will ensure they have the necessary information required to deploy and establish their resources within 20 minutes of arriving at the incident site. The strengths and areas for improvement for each core capability aligned to this objective are described in this section. Intelligence and Information Sharing Strength The full capability level can be attributed to the following strength: Strength 1: After receiving an initial scene report from the Incident Commander, Neptune Task Force leadership was able to determine the necessary personnel and equipment needed for the response. Task force components were provided with assignments and began establishing operations. Analysis of Core Capabilities 14 FEMA Region II

OBJECTIVE: The Incident Command System team will ensure and maintain assured communications with necessary internal and external partners for the duration of the incident. The strength for the core capability aligned to this objective is described in this section. Operational Communications Strength The full capability level can be attributed to the following strength: Strength 1: Communications at the incident command post appeared to be effective with no constraints or issues. Information was shared within expected timelines with no problems noted. The Incident Commander was able to effectively communicate with exercise participants as needed. Although some communications were not always conducted through radio, face-to-face discussions with representatives of other agencies were facilitated and updates were provided as needed. No issues were identified with communications that would affect the strategic or tactical elements of the response. OBJECTIVE: The State of New Jersey Office of Homeland Security and Preparedness, through the Emergency Support Function #2 (Communications), will provide for the coordination with telecommunications and information technology industries utilizing the JerseyNet system within the timeframe of the exercise. The strength for the core capability aligned to this objective is described in this section. Operational Communications Strength The full capability level can be attributed to the following strength: Strength 1: Prior to the start of the exercise, there was a real world event in progress that diverted communications equipment essential for exercise communication to the real incident. Despite the interruption, all components of the communications system were successfully utilized. Through JerseyNet, participants were able to establish video, voice and text over commodity internet Band 14, and satellite. Nine phones and five radio connections were maintained on-site. Communications personnel were successful in establishing interoperability with all seven playing agencies, but limited just-in-time training and operator Analysis of Core Capabilities 15 FEMA Region II

socialization with equipment/devices prior to the start of the exercise caused interruptions in maintaining established communications. There were also some individual devices that had technical issues that were replaced or taken out of service during the exercise. However, communications personnel were still able to verify and complete critical communications links. The JerseyNet system was used to connect International-Matex Tank Terminal in-house closedcircuit television cameras to the command center via Mutualink. Communications were also established with International-Matex Tank Terminal Radio, Newark Real Time Crime Center, the New Jersey Regional Operations Intelligence Center, and the Jersey City Office of Emergency Management. OBJECTIVE: The Bayonne Fire Department, working in coordination with the McCabe Ambulance Service, will triage, treat, and transport injured facility employees in accordance with applicable medical directives within 15 minutes of arrival. The strength for the core capability aligned to this objective is described in this section. Public Health, Healthcare, and Emergency Medical Services Strength The full capability level can be attributed to the following strength: Strength 1: Upon arrival at the scene, the International-Matex Tank Terminal Fire Brigade initiated search and rescue for missing maintenance personnel near the incident site. All personnel were wearing proper personal protective equipment, including self-contained breathing apparatus while executing the task. After locating one injured patient, fire brigade members provided a situation report to the Incident Commander, extricated the patient to a safe location, and transferred patient care to awaiting McCabe Ambulance Service personnel. Fire brigade personnel provided pertinent scene and patient information to emergency medical services personnel. Emergency medical services personnel then determined the most suitable receiving hospital based on patient injuries and determined an additional emergency medical services unit would be called to the scene to provide transport for any remaining patients. Bayonne Fire Department arrived on scene and formed a rescue team with International-Matex Tank Terminal Fire Brigade personnel and initiated a search for the second missing maintenance crew member. Again, all personnel were wearing proper personal protective equipment during the search. The joint rescue team located the second patient, provided a situation report to the Incident Commander, and transported the second patient to McCabe Ambulance Service personnel. Patient care was transferred to the emergency medical services transport unit with a scene and patient report. Fire personnel confirmed that, if indicated, both patients would have been decontaminated prior to releasing the patients to emergency medical services. Patient removal from the immediate area was rapid and appropriate given the scene conditions and scenario. Analysis of Core Capabilities 16 FEMA Region II

OBJECTIVE: The Incident Command System team will develop and provide an incident briefing that includes incident overview, situation status update, incident objectives, resources, tasking and an organizational chart by the end of the incident. The area for improvement for the core capability aligned to this objective is described in this section. Situational Assessment Area for Improvement The following area requires improvement to achieve the full capability level: Area for Improvement 1: Although the artificiality of the exercise did not lend itself to facilitating an incident briefing to a simulated on-coming shift at the incident command post, key components to the incident management process were not addressed. Reference: Federal Emergency Management Agency Incident Action Planning Guide Analysis: The artificiality of the timeline did not lend itself to prompting the Incident Commander to develop a full incident briefing. It did not appear that the Incident Commander was following a formal planning process that would have concluded with providing a briefing at the end of the operational period. It could not be determined whether a briefing would have been developed if the incident would have continued through a second operational period. Some critical components to the planning process and the ability to transfer operations to another shift were not addressed or developed. Among the key components that were not developed (that should have been completed well within the exercise timeline) was the development of an organizational chart and incident objectives. No Incident Command System forms were utilized in the process, which would have prompted the development of this information. Not incorporating a process to plan for the current operational period and the next operational period could leave large gaps in the response, mitigation, and recovery phases. Without specific objectives developed, the resources required for effective response may not be identified. If followed, the planning process, specifically the Planning P process, outlines the specific steps needed to effectively manage the incident, keep critical stakeholders up to date on progress, and to ensure effective transfer of the incident management component. Recommended Corrective Action 1: Ensure that all members of the Incident Management team are trained in the Incident Command System 201 forms used for the development of the Incident Action Plan. Recommended Corrective Action 2: Ensure that all members of the Incident Management Team complete training in ICS 300-Intermediate ICS for Expanding Incidents and ICS 400-Advanced ICS. Recommended Corrective Action 3: Ensure that personnel expected to fill specific positions within the incident management team complete training applicable to those positions: Analysis of Core Capabilities 17 FEMA Region II

E/L 950: NIMS ICS All-Hazards Position Specific Incident Commander E/L 954: NIMS ICS All-Hazards Position Specific Safety Officer E/L 958: All-Hazards Position Specific Operations Section Chief E/L 962: All-Hazards Position Specific Planning Section Chief E/L 967: All-Hazards Position Specific Logistics Section Chief Recommended Corrective Action 4: Conduct functional training on the incident management process on a minimum of a bi-annual basis and include this in the training plan. Analysis of Core Capabilities 18 FEMA Region II

APPENDIX A: IMPROVEMENT PLAN This has been developed specifically for International-Matex Tank Terminal and Union County Fire Mutual Aid as a result of the Federal Emergency Management Agency Region II Neptune Series Full-Scale Exercise conducted on October 17, 2015. A capability may be delivered during an emergency with any combination of elements that achieves the desired outcome, namely properly planned, organized, equipped, trained, and exercised personnel. Therefore, all recommendations are linked to the capability element in need of improvement: Planning; Organization and Leadership; Equipment and Systems; Training; and Exercises, Evaluations, and Corrective Actions. Capability elements are further defined in the following table. Planning Organization and Leadership Equipment and Systems Training Exercises, Evaluations, and Corrective Actions Collection and analysis of intelligence and information, and development of policies, plans, procedures, mutual aid agreements, strategies, and other publications that comply with relevant laws, regulations, and guidance necessary to perform assigned missions and tasks. Individual teams, an overall organizational structure, and leadership at each level in the structure that comply with relevant laws, regulations, and guidance necessary to perform assigned missions and tasks. Major items of equipment, supplies, facilities, and systems that comply with relevant standards necessary to perform assigned missions and tasks. Content and methods of delivery that comply with relevant training standards necessary to perform assigned missions and tasks. Exercises, self-assessments, peer assessments, outside review, compliance monitoring, and actual major events that provide opportunities to demonstrate, evaluate, and improve the combined capability and interoperability of the other elements to perform assigned missions and tasks to standards necessary to achieve successful outcomes. Table 6. Capability Elements Core Capability Issue/Area for Improvement Corrective Action Capability Element Primary Responsible Organization Organization Point of Contact Start Date Completion Date Environmental Response/Health and Safety 1. The use of personal protective equipment by Neptune Task Force personnel was inappropriate or absent. 1.1 Ensure the appointment of an Incident Safety Officer and Assistant Safety Officers, as needed, at the onset of all Organization and Leadership Appendix A: A-1 FEMA Region II

Core Capability Issue/Area for Improvement Corrective Action incidents as identified in the Incident Command System. Capability Element Primary Responsible Organization Organization Point of Contact Start Date Completion Date 2. Although some measures were used to address safety and provide guidance, no specific assessment team or process was ever identified. 2.1 Ensure the adoption of the National Incident Management System and use of Incident Command System forms to prompt command to initiate required safety components and goals of the operations. Planning 2.2 Include the requirement of an environmental and health assessment as a tactical component and a specific process to ensure it is addressed in all International- Matex Tank Terminal response plans. Planning 2.3 Ensure that all applicable requirements outlined in the Occupational Safety and Health Administration 29 CFR- Planning Appendix A: A-2 FEMA Region II

Core Capability Issue/Area for Improvement Corrective Action Capability Element Primary Responsible Organization Organization Point of Contact Start Date Completion Date 1910/Occupational Safety and Health Standards are incorporated into applicable International- Matex Tank Terminal response plans. Fire Management and Suppression 1. Neptune Task Force assets were not fully operational within one hour of notification. 1.1 Ensure all personnel assigned to the Neptune Task Force receive training in the Operational Guide-Union County Fire Mutual Aid- Neptune Response System Responses- Revision Date 5-5- 15 as well as the various tasks associated with each fire company s responsibilities. Training 1.2 When future exercises are conducted, clear guidelines must be established to identify and define the personnel acceptable to participate in the exercise. Members participating must Exercises, Evaluations, and Corrective Actions Appendix A: A-3 FEMA Region II

Core Capability Issue/Area for Improvement Corrective Action Capability Element Primary Responsible Organization Organization Point of Contact Start Date Completion Date meet all of the training requirements for their assigned area. 2. The target water flow of 8,000 gallons per minute was not met. 2.1 Once the on-site fire pumps are operational, conduct a drill involving the Neptune Task Force and the International- Matex Tank Terminal to duplicate the exercise parameters to evaluate if the required water flow of 8,000 gallons per minute can be met. Exercises, Evaluations, and Corrective Actions 2.2 Conduct a drill that duplicates the exercise parameters including the onsite fire pump compromise but utilize fire department pumpers to determine what flow can be achieved. Exercises, Evaluations, and Corrective Actions 2.3 Ensure Neptune Task Force personnel have the requisite Training Appendix A: A-4 FEMA Region II

Core Capability Issue/Area for Improvement Corrective Action Capability Element Primary Responsible Organization Organization Point of Contact Start Date Completion Date training for their job assignments in order to effectively establish the required water flow. Situational Assessment 1. Although the artificiality of the exercise did not lend itself to facilitating an incident briefing to a simulated on-coming shift at the incident command post, key components to the incident management process were not addressed. 1.1 Ensure that all members of the Incident Management team are trained in the Incident Command System 201 forms used for the development of the Incident Action Plan. Training 1.2 Ensure that all members of the Incident Management Team complete training in ICS 300-Intermediate ICS for Expanding Incidents and ICS 400-Advanced ICS. Training 1.3 Ensure that personnel expected to fill specific positions within the incident management team complete training applicable to those positions: E/L 950: NIMS ICS All-Hazards Training Appendix A: A-5 FEMA Region II

Core Capability Issue/Area for Improvement Corrective Action Position Specific Incident Commander E/L 954: NIMS ICS All-Hazards Position Specific Safety Officer E/L 958: All- Hazards Position Specific Operations Section Chief E/L 962: All- Hazards Position Specific Planning Section Chief E/L 967: All- Hazards Position Specific Logistics Section Chief Capability Element Primary Responsible Organization Organization Point of Contact Start Date Completion Date 1.4 Conduct functional training on the incident management process on a minimum of a biannual basis and include this in the training plan. Training Table 7. Core Capabilities and Areas for Improvement Appendix A: A-6 FEMA Region II

APPENDIX B: EXERCISE PARTICIPANTS Participating Organizations Private Sector International-Matex Tank Terminal Bayonne McCabe Ambulance Service Local Government- New Jersey City of Bayonne Fire Department City of Bayonne Office of Emergency Management City of Bayonne Police Department City of Passaic Fire Department Elizabeth City Fire Department Garfield Fire Department Jersey City Police Department Rahway Fire Department Schooley s Mountain Fire Department Springfield Fire Department Teaneck Fire Department Town of Kearny Fire Department Union Fire Department State Government New Jersey Division of Fire Safety New Jersey Office of Homeland Security and Preparedness Appendix B: Exercise Participants B-1 FEMA Region II

APPENDIX C: PARTICIPANT FEEDBACK Part I: General Information (10 completed forms) 1. Agency/Organization Affiliation Position Title New Jersey Office of Homeland Security and Preparedness Exercise Support Team Fire Department Captain Roselle Fire Department Captain Bayonne Fire Department Captain Bayonne Fire Department Acting Captain Bayonne Fire Department Captain Bayonne Fire Department Captain International-Matex Tank Terminal International-Matex Tank Terminal Acting Captain/Firefighter Jersey City Police Department Emergency Services Unit Sergeant 2. Years of experience in present position. 3. Number of exercises previously participated in. 3 (43%) 1 (14%) 2 (29%) 1 (14%) 2 (22%) 1 (11%) 1 (11%) 5 (56%) 15 or more 10 15 5 10 1 5 0 4. Exercise role. 1 (10%) 9 (30%) Player Evaluator Appendix C: Participant Feedback C-1 FEMA Region II

Part II: Exercise Design 1. Pre-exercise briefings were informative and provided the necessary information for my role in the exercise. 2. The exercise scenario was plausible and realistic. 4 (33%) 3 (25%) 2 (20%) 3 (30%) 5 (42%) 5 (50%) Strongly Agree Agree Neutral Disagree Strongly Disagree 3. Exercise participants included the right people in terms of level and mix of disciplines. 4. Participants were actively involved in the exercise. 2 (20%) 2 (20%) 2 (20%) 2 (20%) 6 (60%) 6 (60%) Strongly Agree Agree Neutral Disagree Strongly Disagree 5. Exercise participation was appropriate for someone in my field with my level of experience/training. 4 (40%) 2 (20%) 6. The exercise increased my understanding about and familiarity with the capabilities and resources of other participating organizations. 3 (30%) 1 (10%) 4 (40%) 6 (60%) Strongly Agree Agree Neutral Disagree Strongly Disagree Appendix C: Participant Feedback C-2 FEMA Region II

7. The exercise provided the opportunity to address significant decisions in support of critical mission areas. 8. After this exercise, I am better prepared to deal with the capabilities and hazards addressed. 2 (20%) 3 (30%) 1 (10%) 1 (10%) 5 (50%) 8 (80%) Strongly Agree Agree Neutral Disagree Strongly Disagree Part III: Participant Feedback Overview Strengths Observed 7 (15%) 7 (15%) 5 (10%) 10 (21%) 9 (19%) 4 (8%) 6 (12%) Environmental Response/Health and Safety 1 2 3 4 Fire Management and Suppression Intelligence and Information Sharing Operational Communications 5 6 7 Operational Coordination Public Health, Healthcare, and Situational Assessment Emergency Medical Services 1. I observed the following strengths during this exercise (please select the corresponding capability and applicable element related to the strength): Need additional training in Sonim JerseyNet systems. o Core Capability Intelligence and Information Sharing Capability Element Training Appendix C: Participant Feedback C-3 FEMA Region II

Accomplished a piece of each operation: interop radio communications, video feeds from multiple scenes (and International-Matex Tank Terminal CCTV), voice/intercom between agencies. Not enough training time, no unified command structure. o Core Capability Operational Communications Capability Element Planning Capability Element Equipment Capability Element Training Capability Element Exercise Provided situational awareness from both motor vehicle accident scene and the fire scene. Video feed from both telephone/sonim and International-Matex Tank Terminal internal cameras were able to be linked. o Core Capability Situational Assessment Capability Element Exercise Safety. o Core Capability Health and Safety Capability Element Organization Capability Element Training Staging. o Core Capability Fire Management and Suppression Capability Element Equipment Safety issues addressed. o Core Capability Environmental Response/Health and Safety Capability Element Organization Capability Element Exercise Search and investigation of contamination, finding a safe zone. o Core Capability Environmental Response/Health and Safety Capability Element Training Appendix C: Participant Feedback C-4 FEMA Region II

Overview Areas for Improvement 2 (25%) 2 (25%) 1 (13%) 1 (12%) 2 (25%) 1 2 3 4 Environmental Response/Health Safety and Fire Management and Suppression Intelligence and Information Sharing 5 6 7 Operational Coordination Public Health, Healthcare, and Emergency Medical Services Operational Communications Situational Assessment 2. I observed the following areas for improvement during this exercise (please select the corresponding capability and applicable element related to the strength): Radio/Sonim phone equipment needed additional time to socialize the players. Practice with the phone systems was not complete due to time constraints. o Core Capability Operational Communications Capability Element Training Should have environmental co. involved. o Core Capability Environmental Response/Health and Safety Should have flowed water and foam. o Core Capability Fire Management and Suppression Unified command did not take place. International-Matex Tank Terminal established command and both Bayonne Fire Department and Union County Neptune Task Force came in and began set up without even conferring with Incident Commander. It was 45 minutes before Bayonne Fire Department came to the command post. The Neptune Task Force leader arrived at the command post 55 minutes into the incident. o Core Capability Operational Coordination Many significant areas that required senior Neptune Task Force leaders were staffed with junior officers. (Neptune Pump, & Foam Station Set up). This caused several set up and operations issues. Iron Man nozzle placement was wrong; it was 80 feet too close and had to be moved. Neptune Pump ladder tower operations where approaching unsafe load limits. Appendix C: Participant Feedback C-5 FEMA Region II