at the mall Full Scale Exercise October 18, 2017 AFTER ACTION REPORT/ IMPROVEMENT PLAN November 14, 2017 Handling Instructions 1 Cochise County
HANDLING INSTRUCTIONS 1. The title of this document is at the mall...fse 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. Reproduction of this document, in whole or in part, without prior approval from AGENCY is prohibited. 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: Exercise Director Norman Sturm Emergency Services Coordinator Cochise County Office of Emergency Services 1415 Melody Lane, Building A Bisbee, AZ 85603 520-432-9220 (office) 520-559-2147 (cell) nsturm@cochise.az.gov Exercise Planner Gregory McQuaide Public Health Emergency Preparedness Coordinator Cochise Health & Social Services 1415 Melody Lane, Building A Bisbee, AZ 85603 520-432-9437 (office) 520-255-9176 (cell) gmcquaide@cochise.az.gov Handling Instructions 2 Cochise County
CONTENTS Administrative Handling Instructions...2 Contents...3 Executive Summary...4 Section 1: Planning Summary...6 Section 2: Exercise Evaluation...7 Section 3: Exercise Overview... 12 Event Details Scenario Participating Organizations Exercise Sequence of Events Section 4: Lessons Learned... 15 Section 5: Improvement Plan... 16 Section 6: Conclusion... 18 Section 3: Analysis of Capabilities 3 Cochise County
EXECUTIVE SUMMARY at the mall was a full-scale exercise designed to evaluate the readiness of first responders and healthcare facilities in Cochise County to respond to a hazardous materials incident involving a suspicious white powder. In the scenario, a white powder is maliciously disbursed in a shopping mall movie theater, contaminating approximately 50+ patrons. Concurrently, a major terrorist event had occurred in Tucson, stressing regional resources and providing a high index of suspicion regarding the seriousness of the local event. First responders were challenged with on-scene health, safety and evidence preservation issues. Healthcare providers throughout the county were challenged with both patients transported from the scene, contaminated walk-in patients who had left the scene prior to the arrival of first responders, having to decompress their hospitals and provide surge availability in non-hospital healthcare settings. During the exercise, players were challenged: Dispatch and communications Initial scene control Incident management needs and objectives Mutual aid resources Public information and warning Hospital notification Decontamination procedures & capabilities Hospital surge and decompression Hospital Communication Patient Tracking Section 3: Analysis of Capabilities 4 Cochise County
Major Strengths The major strengths identified during this exercise are as follows: Good scene control at the mall site. Unified command established Proper tactics and strategies were employed by first responders for hazmat response and incident command Backup communications via RACES amateur radio was successful, especially communicating between EOC and 6 hospitals. Primary Areas for Improvement Throughout the event, several opportunities for improvement in Cochise County s ability to respond to the incident were identified. The primary areas for improvement, including recommendations, are as follows: Radio communications for both healthcare providers (HAM Radio) and first responders (SVFD2) presented technical challenges that should be addressed. Cross training on hazmat detection equipment among various fire agencies. Continued decontamination training by hospitals to ensure technical proficiency. Section 3: Analysis of Capabilities 5 Cochise County
SECTION 1: PLANNING SUMMARY Planning for the at the mall full scale exercise began immediately upon the completion of the at the mall tabletop exercise that took place on July 18, 2017. The scenario used in the tabletop exercise was adopted for use as the full-scale exercise scenario. 17 August 2017: The full-scale exercise initial planning meeting was conducted with representation from Cochise County Emergency Services, Health & Social Services, RACES, Douglas Fire Department, Fry Fire District, Sierra Vista Fire & Medical Services, the Southern Arizona Health Care Coalition and The Mall at Sierra Vista. The exercise date was set as October 18, 2017 and exercise planning tasks and responsibilities were delegated and assigned. 24 August 2017: A full-scale exercise planning meeting was held as an in-progress review. A draft of an exercise plan (EXPLAN) was presented for planning team members to review and to reference for the assigned tasks. A draft copy of the exercise Master Scenario Event List (MSEL) was presented for review and a meeting set for first responders to build their specific MSEL items. 1 September 2017: A first responder MSEL development meeting was held and the first responder specific sector events were developed. 28 September 2017: An all partners exercise planning meeting was held with invited representation from all first responder organizations and health care agencies for final review of the exercise documentation to include the EXPLAN, MSEL, Exercise Controller Evaluator Handbook, Exercise Player Handbook, and all Exercise Evaluation Guides. 16 October 2017: The exercise communications guide was completed and disseminated to exercise participants. Section 3: Analysis of Capabilities 6 Cochise County
SECTION 2: EXERCISE EVALUATION The following are comments made by exercise evaluators regarding operations during the exercise: Exercise Design & Control: It would have been a good idea after the exercise was explained to pull the fire responder players aside and brief them about what units would be real and what would be imaginary. It would have been good to brief the fire responders that PT card colors were for hospital staff and not for their triage. Exercise called complete early despite the identifier with the positive indicator for ricin still inside the theater along with the equipment wagon and other field test kits. Exercise moved fast as indicated due to the drill time limit. It was made known that a terrorism incident would fall under the jurisdiction of LE including FBI, and fire department hazmat teams would serve a support function. Good job to all involved and filling the gaps as best they could in the absence of LE players. Simulating the LE portion seemed challenging and an obvious missing component in the exercise Having CCSO and SVPD radio operators handling communications and dispatch with the first responders was extremely helpful for all participants. Make sure to involve PSAPs early in all exercise planning. Incident Command Unified command established early as well as command post location Unified Command was established however the communication between Fire and LE within the unified ICP could have been improved. Good early notification of hospitals to prepare for influx of patients contaminated with suspicious unknown white powder. The initial IC sent two FFs to do reconnaissance into the theater. Again, focus was on the hazmat rather than the patients waiting for medical attention. Despite knowledge of the theater being cleared by security, the FF s made entry into an unknown hazmat environment without any air monitoring or chemical detector equipment. Again, the absence of LE made this scenario challenging for the Fire IC and the engine company officer. With the suspicion of terrorism, the CO did radio the IC about having LE clear for secondary IED. Section 3: Analysis of Capabilities 7 Cochise County
Scene size-up was good. Early recognition of a hazmat incident with possible terrorism nexus. Early recognition of an MCI. Early request for additional resources and upgraded hazmat. Early contact with mall security. Initial IC should address the Mass Casualty Incident (MCI) as first responders and leave the Hazmat stuff to the Hazmat teams. They delayed patient care to address reconnaissance. This would be a significant problem in a real situation. Hazmat On-scene Operations First arriving fire crews made early contact with victims, however, the focus turned to setting up for hazmat rather than emergency treatment of patients. Victims were waiting around for over 20 min and some wandered off into the mall, complicating the incident. Emergency decontamination Too timely a set-up, especially given that some patients were displaying severe health symptoms. One suggestion is to perform emergency gross decon using either the decon buckets and garden hoses housed on the fire apparatus, or use of fire hose with low pressure flows, with the goal to reduce the time the victims are exposed to the hazmat and expedite medical treatment. Recommend leaving the systematic decon set-up to the hazmat team. Quick hazmat team response and early hazmat team leader designation. Good communications between the IC and hazmat team lead. IC called for Level A hazmat deployment and the hazmat team committed to that order rather than making their own determination of PPE selection as subject matter specialists. Team deployment location Suggest deploying strategically. The location selected seemed far and out of sight of the incident, behind the fire crews and close to the IC post. This created confusion for both the hazmat crews and fire crews. Team deployment With the luxury of so many hazmat team members present, recommend designating teams with team supervisors (Decon Team, Entry & Back-up Team, Research Team, Medical Team). Suggest that the research team decipher all known facts about the hazmat and determines the appropriate PPE selection. There was miscommunication of victim symptoms to the hazmat team which the research team could have used to narrow down their product identification. All teams must be in place prior to entry, including systematic decon, and entry teams briefed of all known hazards and hand signals. No need to rush hazmat, especially after the immediate life threat scenario has been mitigated. 1 st Entry Team Mission unclear. They did make entry the short way, but began performing the same sample collecting and field testing as the first crew. The field test kit with the positive identifier of Ricin was left behind by both entry teams. 2 nd Entry Team Deployment The team of two deployed quickly with sampling equipment, however they were not briefed on where they were going, nor was it clear where the decontamination station was. The team ended up making entry into the mall, Section 3: Analysis of Capabilities 8 Cochise County
rather than the Cinemark, and walked the long way around the main hall of the mall and into the main entrance of the Cinemark, and finally into the hot zone (all while in Level A). Again, the hazmat team set-up location was far away and not in direct sight of the incident area. No communications were ever made to re-direct the entry team, nor did the entry team clarify on their way in. Entry Team Decon Miscommunication between the hazmat team lead and the fire crews. At some point it was decided to keep the emergency decontamination corridor initially set up by the fire crews and use it for the hazmat systematic decon. When the 1st entry team exited the hot-zone they did not know where to go for decon. Fire crews seemed confused about what to do. Water was simulated despite the presence of two fire apparatus. Entry team had to walk all the way back to the hazmat trailer to have hazmat crews doff their suits. Recommend that the hazmat team be the ones to perform systematic decontamination. Decon team members wear the PPE recommended by the Research Team. Set up decon corridor with tool drop-off, sample decon & collection, runoff containment, all under the supervision of a Decon Supervisor whom also keeps an eye on the Decon Team members (rehab). Bench seats for suit doffing (systematic as well). Sample collection 1st entry team successfully collected samples, then went a step further and performed field tests on site. Impressive that they could do so while in Level A. Recommend, however, to have the research team perform the field tests in a more controlled environment outside of the immediate hazard area. Doing so will limit the amount of contamination of the 1st entry team as well as shorten the time on air, keeping in mind the time it takes for a systematic decon. Samples left in an uncontrolled location Communications: Benson Community The older Motorola Spectra installed at the hospital developed an erratic transmit problem that RACES operators were able to work around to communicate during the exercise Bisbee Copper Queen A change of the PL tone configuration on Mule Mountain 147.02 repeater (We dropped passing the PL tone through the repeater) and did not get the Yaesu FT 2600 reset. Unfortunately, this meant they could transmit, but not receive on the designated frequency. RACES operators were able to work around to communicate during the exercise Sierra Vista Canyon Vista The crew at Canyon Vista were new and not familiar with the radio in place. Although it has been tested in the past, there were some over the air complaints of weak signals into the repeater. Section 3: Analysis of Capabilities 9 Cochise County
Sim Cell - Unfortunately, the radio we were using was not programmed with the correct PL tone for transmit. The problem was verified when the radio was put on the bench after the exercise. RACES operators were able to work around to communicate during the exercise In spite of technical glitches, contact with 100% of participating hospitals was achieved. Public Safety Radio Issues with weak signals most likely caused by the Mule Mountain antenna. Sufficient coverage to complete the exercise. Healthcare: RACES (Amateur Radio) communications was reliable and an excellent resource, need to incorporate more into planning, exercises and real events Several phone numbers on the Communication Guide were incorrect, need to ensure correct people listed under key positions and EOC numbers correct. Electronic medical record challenges during mass casualty paper charting best option especially with patient tracking Ensure access to EM Track and train with it Tent set up, donning/doffing PPE and actual decon procedures and processes went well but need even more consistent training Inventory and set up of equipment to ensure serviceability More training for clinicians and staff and scheduled regularly More IC training with plans and job action sheets and HICS Home health, long term care and ambulatory surgery incorporated into exercise but not fully tested develop scenario to ensure full participation Bed availability for transfers accomplished and new patient assessments conducted without issue Ensure reliable volunteers to serve as patients/actors numbers issue at onset of exercise Sector specific training for mass casualty, decon operations where decompression and surge apply so other healthcare entities better understand their roles and responsibilities. Improve ESF 8 communication to partners, develop and implement means other than AZ Han AZHAN worked to provide messages to players Continue to develop AZ Han across the healthcare spectrum and break out groups by healthcare type As most hospitals are TJC accredited, consider ensuring exercise planning is conducted around TJC 6 critical areas and MSEL includes actions for all Need training with hospitals to set up funnel for patients to decon tent and ways for Security to avoid contact with patients and address patient movement All Ambulatory, Long Term Care and Home Health had objectives and ways to play Section 3: Analysis of Capabilities 10 Cochise County
Need to work on paper tracking form education and way to submit them to EOC There was no amateur radio support at Carondelet St. Mary s Hospital Section 3: Analysis of Capabilities 11 Cochise County
Event Details Event Name SECTION 3: EXERCISE OVERVIEW Type of Event Suspected terrorist attack using a white powder Event Start Date October 18, 2017, 0800hours Event End Date October 18, 2017, 1200hours Duration 4 hours Scenario Location The Mall at Sierra Vista, 2200 El Mercado Loop, Sierra Vista AZ 85635 Capabilities Operational Coordination Operational Communications Scene Security and Protection Emergency Medical Services Treatment & Transportation Threat & Hazard Identification Healthcare Notification Hospital Decontamination Operations Hospital Decompression Hospital Communications Healthcare Surge Operations Patient Tracking On the morning of October 18, 2017, there are an estimated 50 people in attendance at a screening of the classic Shirley Temple movie Curly Top at the Cinemark Theater, Theater #6, at the Mall at Sierra Vista. As the final movie trailer ends and feature begins, a patron sitting in the last row of the theater jumps to his feet and screams: LOOSERS Unite! Death to all who do not join us! and proceeds to run down the aisle throwing handfuls of powder onto Section 3: Analysis of Capabilities 12 Cochise County
stunned moviegoers. After leaving the approximately 50 patrons covered in a cloud of white powder, the LOOSER runs out of the theater using the emergency exit. At approximately the same time, an explosion occurred at the University of Arizona Stadium during a football game. Numerous casualties are reported at the stadium as public safety agencies and healthcare facilities throughout the Tucson metro area become committed to the response. The LOOSER organization claims responsibility for both incidents. Participating Organizations Emergency Management Cochise County Office of Emergency Services Cochise County Radio Amateur Civil Emergency Service (RACES) Santa Cruz County OEM Law Enforcement Cochise County Sheriff s Office & Dispatch National Park Service Sierra Vista Police Department & Dispatch US Border Patrol Fire & Rescue Cochise County Regional HAZMAT Team Douglas Fire Department Ft. Huachuca Fire Department Fry Fire District Healthcare Innovations (HCI) Sierra Vista Fire & Medical Services Sunsites-Pearce Fire District Tucson Fire Department Health Departments Cochise County Health & Social Services (PHEP) Graham County Health Department Greenlee County Health Department Santa Cruz County Health Department Southern Arizona Health Care Coalition Section 3: Analysis of Capabilities 13 Cochise County
Hospitals & Medical Centers Benson Hospital Canyon Vista Medical Center Carondelet / Holy Cross Hospital Carondelet / St. Mary s Hospital Copper Queen Community Hospital Green Valley Hospital Mt. Graham Regional Medical Center Northern Cochise Community Hospital Long-term Care Providers & Clinics Bayada Home Health Care Casa Del Luz Hospice Cenpatico Integrated Care Cochise Eye and Laser Copper Queen Long Term Care Dependable Home Health Inc. (Nogales) Douglas Dialysis Kindred Hacienda Legacy Home Health United Community Health Center Community Partners Cinemark Theaters Cochise College Sierra Vista Mall, Security Department Section 3: Analysis of Capabilities 14 Cochise County
SECTION 4: LESSONS LEARNED Engage all possible stakeholders early in the exercise planning cycle. Ask for input regarding what capabilities they want to test and adjust scenario to meet multiple needs. Have PSAP dispatchers involved Use Cochise College for obtaining volunteer victims Consider a longer time-period for an FSE. Allow for sufficient time to perform all handson tactics and skills Hospitals should train together on decontamination operations to continue to improve capabilities. Hospitals should develop protocols for RACES (amateur radio) operators in regards to emergency support. Section 3: Analysis of Capabilities 15 Cochise County
SECTION 5: IMPROVEMENT PLAN Recommendations: The following recommendations are made to address issues identified during the exercise: Exercise Design and Control Ensure future exercises include operational participation from all affected stakeholder agencies (i.e.: LE, Federal, State, PSAPs, etc.) Allow sufficient time for the exercise participants to sufficiently test their capabilities. Limit the simulation of operational components as much as possible during the exercise (i.e.: decontamination; LE operations, Federal participation) Incident Command Review & emphasis during training on command priorities: Life Safety, Incident Stabilization, Property Preservation Review Unified Command operations during ongoing training. Healthcare All Cochise County hospitals should arrange for and participate in joint decontamination training on a regular basis. First responder agencies should develop a common protocol to alert local healthcare facilities of ongoing emergencies that could impact the operations of those facilities. Additionally, healthcare facilities need to be able to alert one another of events that could impact area patient care operations. County PHEP should evaluate current inter-hospital communications capabilities and develop a communications plan that best meets County needs. Hospitals should develop protocols for RACES (amateur radio) operators in regard to emergency support. Hazardous Materials Team Operations Review pre-entry procedures Review decon procedures for victims and hazmat entry teams Section 3: Analysis of Capabilities 16 Cochise County
Miscellaneous Operations County OES should work with agency PIOs to develop a county-wide interagency PIO communications system. Communications Investigate options for boosting coverage of the SVFD Channel 2 Conduct more frequent testing of the hospital equipment in the future. Prepare a recommendation for replacement of the radio that failed in Benson. Troubleshoot the Benson Spectra radio to determine if the failure is due to older components (foil capacitors) or just beyond its normal service life. Prepare a recommendation for Douglas Medical Center, they currently have no amateur equipment on site and staff has requested information to equip that site in the future. Local amateur radio groups (RACES) should attempt to develop an amateur radio backup communications capability with their local hospitals. Section 3: Analysis of Capabilities 17 Cochise County
SECTION 6: CONCLUSION Just another day at the mall Just Another Day at the Mall was a full-scale exercise designed to 1) test response capabilities of the Cochise County Hazardous Materials Team; 2) test the capabilities of local healthcare providers to respond to patients exposed to a hazardous material; and 3) test incident management capabilities for a multi-jurisdictional emergency. Participants were challenged to respond to issues posed by the dispersion of an unknown hazardous agent (white powder) at a local cinema. The incident had a strong terrorism nexus and required close coordination between first responders and healthcare facilities throughout the county. In general, on-scene operations went well considering the artificialities inherent to an exercise. Due to the terrorism/law enforcement nexus, a more prominent hands-on role of local law enforcement agencies would have significantly enhanced the exercise. For future exercises, more effort will be put into engaging law enforcement and public safety dispatchers. However, there was for this exercise law enforcement subject matter experts who helped with needed LE input during the exercise. Chief challenges for the exercise included technical problems that affected radio communications, on-scene coordination/communications between fire and hazmat crews, and patient decontamination and assessment at receiving healthcare facilities. Throughout the exercise there was good participation among the players who demonstrated good competency in dealing with the operational challenges presented by the scenario. The opportunities for improvement and recommended actions listed in this document were highlighted in the after-action hot wash. It is anticipated that the recommendations will be addressed in the months to come. It was also clear from post-incident feedback that future, possibly annual, full-scale exercises are a priority for the first responder and healthcare providers in Cochise County. Conclusion 18 Cochise County