EVALUATION OF CHEMICAL EVENTS at Army Chemical Agent Disposal Facilities

Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities

Board on Army Science and Technology

Division on Engineering and Physical Sciences

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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EVALUATION OF CHEMICAL EVENTS at Army Chemical Agent Disposal Facilities Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Board on Army Science and Technology Division on Engineering and Physical Sciences THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appro- priate balance. This study was supported by Contract No. DAAD 19-01-C-0051 between the National Academy of Sci- ences and the Department of Defense. Any opinions, findings, conclusions, or recommendations ex- pressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number 0-309-08629-9 Cover: Decontaminated chemical munitions and containers at Johnston Atoll Chemical Agent Disposal System. Photographs for composite image courtesy of Colin Drury. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, D.C. 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropoli- tan area); Internet, http://www.nap.edu Copyright 2002 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES CHARLES E. KOLB, Chair, Aerodyne Research, Inc., Billerica, Massachusetts DENNIS C. BLEY, Buttonwood Consulting, Inc., Oakton, Virginia COLIN G. DRURY, University of Buffalo, New York JERRY FITZGERALD ENGLISH, Cooper, Rose and English LLP, Summit, New Jersey J. ROBERT GIBSON, Consultant, Wilmington, Delaware HANK C. JENKINS-SMITH, Texas A&M University, College Station WALTER G. MAY, NAE, University of Illinois at Urbana-Champaign GREGORY McRAE, Massachusetts Institute of Technology, Cambridge IRVING F. MILLER, Consultant, Chicago, Illinois DONALD W. MURPHY, NAE, Consultant, Davis, California ALVIN H. MUSHKATEL, Arizona State University, Tempe LEIGH SHORT, Consultant, Mount Pleasant, South Carolina LEO WEITZMAN, Consultant, West Lafayette, Indiana National Research Council Staff NANCY T. SCHULTE, Study Director (from June 2002) MARGARET N. NOVACK, Study Director (to June 2002) WILLIAM E. CAMPBELL, Administrative Officer JIM MYSKA, Research Associate PAMELA A. LEWIS, Senior Project Assistant SONNETT HOSSANAH, Senior Project Assistant CARTER W. FORD, Senior Project Assistant iv

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BOARD ON ARMY SCIENCE AND TECHNOLOGY JOHN E. MILLER, Chair, Oracle Corporation, Reston, Virginia GEORGE T. SINGLEY III, Vice Chair, Hicks and Associates, Inc., McLean, Virginia ROBERT L. CATTOI, Rockwell International (retired), Dallas, Texas RICHARD A. CONWAY, Union Carbide Corporation (retired), Charleston, West Virginia GILBERT F. DECKER, Walt Disney Imagineering (retired), Glendale, California ROBERT R. EVERETT, MITRE Corporation (retired), New Seabury, Massachusetts PATRICK F. FLYNN, Cummins Engine Company, Inc. (retired), Columbus, Indiana HENRY J. HATCH, Army Chief of Engineers (retired), Oakton, Virginia EDWARD J. HAUG, University of Iowa, Iowa City GERALD J. IAFRATE, North Carolina State University, Raleigh MIRIAM E. JOHN, California Laboratory, Sandia National Laboratories, Livermore DONALD R. KEITH, Cypress International (retired), Alexandria, Virginia CLARENCE W. KITCHENS, IIT Research Institute, Alexandria, Virginia SHIRLEY A. LIEBMAN, CECON Group (retired), Holtwood, Pennsylvania KATHRYN V. LOGAN, Georgia Institute of Technology (professor emerita), Roswell STEPHEN C. LUBARD, S-L Technology, Woodland Hills, California JOHN W. LYONS, U.S. Army Research Laboratory (retired), Ellicott City, Maryland JOHN H. MOXLEY, Korn/Ferry International, Los Angeles, California STEWART D. PERSONICK, Drexel University, Philadelphia, Pennsylvania MILLARD F. ROSE, Radiance Technologies, Huntsville, Alabama JOSEPH J. VERVIER, ENSCO, Inc., Melbourne, Florida Staff BRUCE A. BRAUN, Director MICHAEL A. CLARKE, Associate Director WILLIAM E. CAMPBELL, Administrative Officer CHRIS JONES, Financial Associate DANIEL E.J. TALMAGE, JR., Research Associate DEANNA P. SPARGER, Senior Project Assistant v

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Preface For over half a century the United States has maintained a Army Chemical Agent Disposal Facilities, convened in April stockpile of chemical weapons at Army depots distributed 2001 by the National Research Council (NRC), was charged around the country. These weapons are now obsolete, and with the following statement of task negotiated between the some have deteriorated to an alarming extent. Since 1990, Army and the NRC: in response to P.L. 99-145 and, later, P.L. 102-484, the The National Research Council will assemble a commit- Army’s Program Manager for Chemical Demilitarization tee to evaluate chemical events that have occurred at the (PMCD) has been engaged in active destruction of the Johnston Atoll Chemical Agent Disposal System (JACADS) chemical weapons stockpile. Operation of the two initial and the Tooele Chemical Agent Disposal Facility (TOCDF). chemical agent demilitarization facilities utilizing incinera- The committee will: tor technology—Johnston Atoll Chemical Agent Disposal • review process technology, operational activities (includ- System (JACADS) and Tooele Chemical Agent Disposal ing training, operations and maintenance), and management Facility (TOCDF) (see Appendix A)—has achieved destruc- by both the Army and its contractors to identify the causes of tion of more than 23 percent of the original chemical agent chemical events tonnage (U.S. Army, 2001a) but has not been without inci- • review applicable risk management and safety programs dent. A number of chemical events have resulted in various levels of chemical agent migrating at higher than anticipated • review emergency response activities that have occurred levels into areas within the plants themselves, and in a few as a result of each chemical event, including information dissemination incidents small amounts of chemical agent have been re- leased into the ambient atmosphere (see Appendix B). Al- • review actions and changes that have occurred in re- though none of these incidents resulted in agent releases sponse to each chemical event and evaluate the impact and large enough to be measured at the chemical demilitariza- adequacy of these actions and changes tion plant perimeters (U.S. Army, 2001c) and thus posed no • visit JACADS and TOCDF to review facility configura- threat to nearby communities, they did raise concern among tions and to meet with personnel involved with operational affected public officials and citizens about the fundamental activities, facility management, and emergency response safety of incineration-based chemical demilitarization facili- • make recommendations regarding improvements in op- ties, particularly the three third-generation incineration fa- erational activities, facility management, and emergency re- cilities scheduled to begin operation at depots near Anniston, sponse Alabama; Umatilla, Oregon; and Pine Bluff, Arkansas. • review and recommend the needs to enable credible and more rapid investigation and corrective actions in response STATEMENT OF TASK to future chemical events at chemical demilitarization sites, including consideration of needs of external stakeholders This report was motivated by congressional concern that (e.g., regulators and concerned public). incidents at JACADS and TOCDF might indicate systemic safety issues with either the technology or the management To ensure that new facilities for the destruction of chemi- and operational systems employed at those two initial chemi- cal agent are operated as safely as possible, the NRC was cal demilitarization facilities. further asked to recommend how lessons learned from the The Committee on Evaluation of Chemical Events at vii

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viii PREFACE events at JACADS and TOCDF should influence future op- ing this draft, including refining the report’s findings and erations, particularly at the new facilities in Alabama, Or- recommendations. egon, and Arkansas scheduled for completion and initial The committee consulted with and received input from operations in the near future. many stakeholders, both principals and agents, including personnel assigned to the office of the PMCD and its support contractors; contractor and subcontractor personnel respon- COMMITTEE COMPOSITION AND PROCESS sible for operating chemical demilitarization facilities; Committee members brought to their task extensive ex- former employees of chemical demilitarization facilities; perience in chemical process engineering, chemical plant congressional, state, and local officials; members of state operations, human factors and ergonomics, industrial engi- citizen advisory committees; members of citizen activist neering, risk assessment and management, atmospheric sci- groups; and local citizens. (See Appendixes C, D, and I.) ences, environmental chemistry, toxicology, environmental The committee has also benefited from previous NRC regulations and law, emergency management, and public reports on the chemical demilitarization program. Many of involvement and community relations (see Appendix H). In these reports were prepared by a standing NRC committee, conducting this study, committee members drew on insights the Committee on Review and Evaluation of the Army gained from their experiences in academia, chemical and Chemical Stockpile Disposal Program (the Stockpile Com- related industries, federal and state agencies, private sector mittee), which evaluates aspects of the disposal program at laboratories and consulting firms, and a law firm. the request of the Army. Several of the Stockpile Commit- The committee first met as a whole in Washington, D.C., tee reports provided background for this committee’s study. in May 2001 to hear Army briefings on JACADS and In preparing, reviewing, printing, and distributing this TOCDF general operations and chemical events. (Appendix report, the National Research Council (NRC) and this com- I lists the committee’s several meetings.) In early June many mittee are acting as an expert agent for several principals, committee members attended an informational meeting on including the U.S. Congress; the Army, which contracted Capitol Hill hosted by Congressman Bob Riley (R-Ala.), with the NRC to perform the study; and the U.S. public. who represents the region around the Anniston Chemical De- The committee’s goals for this report were to respond, as militarization Facility, which is currently undergoing sys- thoroughly as feasible in the short time allotted, to the con- temization and preoperational testing. Local government cerns stakeholders have expressed about past chemical officials, emergency management professionals, and con- events at JACADS and TOCDF, to determine the impact of cerned citizens from the area near Anniston, Alabama, shared these events on ongoing operations at TOCDF, and to assess their perspectives with the committee. Committee members the implications of these events for the safe and efficient and staff also visited PMCD and its supporting contractors operation of incineration-based chemical demilitarization located at the Aberdeen Proving Ground, Maryland. facilities scheduled to begin operation at Anniston, Umatilla, The committee made site visits to JACADS in late June and Pine Bluff. 2001 and to TOCDF in late July 2001 where it investigated The committee greatly appreciates the support and assis- the operational history, management procedures, and evalu- tance of National Research Council staff members Bruce A. ations of and responses to chemical events at these facilities Braun, Margaret Novack, Nancy Schulte, Bill Campbell, Jim and discussed these issues with contractors and PMCD per- Myska, Sonnett Hossanah, Pamela Lewis, and Carter Ford sonnel at many levels. At a meeting at Woods Hole, Massa- in the production of this report. chusetts, in October 2001 the committee completed the bulk NOTE: Following preparation of this report two chemi- of the data-gathering process as well as much of the initial cal events, one at TOCDF on July 15, 2002, and one at draft of its report. The November 2001 meeting, in Wash- JACADS on August 12, 2002, have taken place. Although ington, D.C., was dedicated to completing the initial report these incidents occurred after the committee completed its draft. A portion of the committee also visited Anniston, Ala- analysis, they are similar in nature to events analyzed by the bama, in early December 2001 to inspect a completed third- committee and reinforce the validity of the findings and the generation incineration facility and a storage depot with an utility of the recommendations presented in this report. extensive nearby population base. As a part of the visit the committee visited the County Emergency Response Facil- ity, met with County Commissioners, and participated in a Charles E. Kolb, Chair public meeting. A draft report suitable for NRC prereview Committee on Evaluation of editing was produced subsequent to the Anniston visit. A Chemical Events at Army Chemical final committee meeting in January 2002 focused on review- Agent Disposal Facilities

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Acknowledgment of Reviewers This report has been reviewed in draft form by individu- Lewis S. Nelson, New York City Poison Control Center als chosen for their diverse perspectives and technical exper- George W. Parshall, E.I. DuPont de Nemours & Co. (re- tise, in accordance with procedures approved by the National tired) Research Council’s Report Review Committee. The purpose William R. Rhyne, Informatics Corporation, and of this independent review is to provide candid and critical Palmer W. Taylor, University of California, San Diego. comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the re- Although the reviewers listed above have provided port meets institutional standards for objectivity, evidence, many constructive comments and suggestions, they were and responsiveness to the study charge. The review com- not asked to endorse the conclusions or recommendations, ments and draft manuscript remain confidential to protect nor did they see the final draft of the report before its re- the integrity of the deliberative process. We wish to thank lease. The review of this report was overseen by Royce W. the following individuals for their review of this report: Murray, University of North Carolina, Chapel Hill. Ap- pointed by the National Research Council, he was respon- Richard J. Ayen, Waste Management, Inc. (retired) sible for making certain that an independent examination Judith A. Bradbury, Battelle Patuxent River of this report was carried out in accordance with institu- Dennis R. Downs, Utah Department of Environmental tional procedures and that all review comments were care- Quality fully considered. Responsibility for the final content of this Charles A. Eckert, Georgia Institute of Technology report rests entirely with the authoring committee and the Richard S. Magee, Carmagan Engineering institution. ix

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Contents EXECUTIVE SUMMARY 1 1 THE CHEMICAL DEMILITARIZATION CHALLENGE 7 Stockpile Content, Disposal Deadline, and Disposal Technology, 7 Chemical Events, 9 Chemical Events Associated with Disposal, 9 Chemical Events Occurring During Storage, 10 Tools for Assessing Hazards in the Operation of Chemical Stockpile Disposal Facilities, 11 Prospective Risk Analysis Tools, 11 Health Risk Assessment, 11 Systems Hazard Analysis, 11 Quantitative Risk Assessment, 11 Retrospective Analysis Tools, 12 Monitoring Systems, 12 Chemical Event Investigations, 12 Putting It All Together, 12 Monitoring Methods, 14 Event Analysis and Significance, 14 Chemical Demilitarization Institutional Issues, 14 Trust and Institutional Arrangements, 14 The Institutional Setting of Chemical Demilitarization, 15 Report Roadmap, 15 2 CAUSAL FACTORS IN EVENTS AT CHEMICAL DEMILITARIZATION FACILITIES 17 Definitions, 17 Sources of Input and Selection of Events for In-depth Analysis, 17 The PMCD Incident List, 18 The Calhoun County Commissioners’ List, 18 The Chemical Weapons Working Group Incident List, 18 Notice of Violation Reports, 21 Analysis of Selected Chemical Events, 22 Causal Factors, 22 Causal Tree Analysis of Two Events, 24 General Observations, 24 Specific Observations, 25 xi

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xii CONTENTS 3 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES 26 Formal Event Reporting Protocols, 26 Actual On-Site Responses, 27 December 3-5, 2000, Event at JACADS, 27 May 8-9, 2000, Event at TOCDF, 28 Observations, 28 External and Regulatory Responses to Chemical Events, 29 Applicable Statutes, Regulations, and Guidelines, 29 Memorandum of Understanding Between Deseret Chemical Depot and Tooele County, 29 Levels of Investigation, 30 Modeling Potential Population Exposure, 30 Emergency Response: Preparedness, Plans, Notification, and Coordination at TOCDF, 32 Public Responses to Chemical Events, 35 4 IMPLICATIONS OF PAST CHEMICAL EVENTS FOR ONGOING AND FUTURE CHEMICAL DEMILITARIZATION ACTIVITIES 37 Risk and Management of Change Programs Already in Place, 37 Safety Programs, 39 Programmatic Lessons Learned Program, 40 PLL Program Database, 40 Resultant Changes, 42 5 PREPARING FOR POTENTIAL FUTURE CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES 44 Summary of Chemical Events Analyses, 44 Chemical Event Response and Review by Management, 44 Building on the Results of Risk Assessment, 45 Building a Safety Culture, 46 Operational Changes, 46 Worker Education, Training, and Involvement, 47 Desired Principal-Agent Interactions, 47 Rapid and Safe Restart Requirements, 49 Restarts After Changeovers and Maintenance, 49 Restarts After a Chemical Event, 49 6 FINDINGS AND RECOMMENDATIONS 51 REFERENCES 57 APPENDIXES A Specific Design Features of fhe Tooele Chemical Agent Disposal Facility Baseline Incineration System 61 B Chronicle of Chemical Events and Other Occurrences at TOCDF and JACADS as Identified by PMCD 71 C List of Individual Incidents from the Chemical Weapons Working Group 79 D List of Individual Incidents from Calhoun County Commission, Anniston, Alabama 90 E Additional Information Concerning Risk 97 F Causal Tree Analysis of December 3-5, 2000, Event at JACADS 103 G Memorandum of Understanding Between Deseret Chemical Depot and Tooele County for Information Exchange 106 H Biographical Sketches of Committee Members 114 I Committee Meetings 117

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Figures, Tables, and Boxes FIGURES 1-1 Location and size (percentage of original stockpile) of eight continental U.S. storage sites, 8 3-1 Component parts of an integrated system for modeling the impact of release of chemical agents, 31 4-1 TOCDF recordable injury rate 12-month rolling average, August 1996 (the start of agent operations) through December 2001, 39 A-1 Layout of the TOCDF, 62 A-2 Rocket-handling system, 63 A-3 Bulk handling system, 64 A-4 Projectile-handling system, 65 A-5 Mine-handling system, 66 A-6 Deactivation furnace system, 67 A-7 Metal parts furnace, 67 A-8 Liquid incinerator, 68 A-9 Dunnage furnace, 68 A-10 Pollution abatement system, 69 E-1 Schematic illustration of risk elements at a chemical agent and munitions storage and destruction site, 98 E-2 Contributors to the average public fatality risk from continued storage at Deseret Chemical Depot, 99 E-3 Comparison of risks to the public during processing at Deseret Chemical Depot and the Tooele Chemical Agent Disposal Facility, 100 E-4 Contributors to the average public fatality risk from disposal operations at DCD and TOCDF, 100 E-5 Contributors to the average risk of fatality for disposal-related workers at DCD and TOCDF, 101 F-1 Causal tree for December 3-5, 2000, JACADS event, 104-105 TABLES 2-1 Events on the PMCD List That Were Examined by the Committee, 19 2-2 Events on the PMCD List That Were Chosen by the Committee for Detailed Analysis, 19 xiii

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xiv FIGURES, TABLES, AND BOXES 2-3 Committee’s Classification of 69 Items Cited in Notice of Violation Reports, 22 2-4 Frequency of Causal Factors in the Seven Incidents Analyzed by the Committee, 23 4-1 Issues and Factors in Assessing the Value of Change Options, 38 BOXES 1-1 Details on Airborne Chemical Agent Monitoring Methods and Standards at Chemical Demilitarization Facilities, 13 2-1 December 3-5, 2000, JACADS Event, 20 2-2 May 8-9, 2000, TOCDF Event, 21 2-3 An Example of Negative Effects of Mind-set, 25 3-1 Previous Concerns About and Recommendations for Achieving Efficient CSEPP Operations, 33 4-1 Additional PLL Program Components, 41 5-1 Examples of Observations That the Committee Concluded Were Uninformed, 48

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Acronyms and Abbreviations ACAMS automatic continuous air monitoring system AEGL Acute Exposure Guideline Level AMC Army Materiel Command ASC allowable stack concentration CAC Citizens Advisory Commission CAMDS Chemical Agent Munitions Disposal System CDC Centers for Disease Control and Prevention Chem demil chemical demilitarization CSDP U.S. Chemical Stockpile Disposal Program CSEPP Chemical Stockpile Emergency Preparedness Program CWC Chemical Weapons Convention CWWG Chemical Weapons Working Group DAAMS depot area air monitoring system DCD Deseret Chemical Depot DEQ (Utah) Department of Environment Quality DFS deactivation furnace system DoD Department of Defense DSHW (Utah) Division of Solid and Hazardous Waste DWL drinking water level ECP engineering change proposal ECR explosive containment room EG&G Edgerton, Germerhausen and Grier (a contracting company) EMIS Emergency Management Information System EOC emergency operations center EPA Environmental Protection Agency FEMA Federal Emergency Management Agency FPD flame photometric detector GAO General Accounting Office GB sarin (a nerve agent) GC gas chromatograph, gas chromatography GPL general population limit xv

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xvi ACRONYMS AND ABBREVIATIONS H sulfur mustard HAZMAT hazardous material HAZOP hazardous operation HD sulfur mustard (distilled) HDC heated discharge conveyor HRA health risk assessment HT vesicant mixture: 60 percent agent H and 40 percent bis[2(2-chloro- ethylthio)ethyl] ether HVAC heating, ventilation, and air conditioning JACADS Johnston Atoll Chemical Agent Disposal System LIC liquid incinerator MDB munitions demilitarization building MOU memorandum of understanding MPF metal parts furnace MSD mass spectrometric detector NARAC National Atmospheric Release Advisory Center NRC National Research Council OSHA Occupational Safety and Health Administration PARDOS partial dosage PAS pollution abatement system P.L. public law PLL programmatic lessons learned (program and database) PMACWA Program Manager for Assembled Chemical Weapons Assessment PMATA Product Manager for Alternative Technologies and Approaches PMCD Program Manager for Chemical Demilitarization PMCSD Project Manager for Chemical Stockpile Disposal QA quality assurance QC quality control QRA quantitative risk assessment RCRA Resource Conservation and Recovery Act RIR recordable injury rate SAIC Science Applications International Corporation SBCCOM U.S. Army Soldier and Biological Chemical Command SHA systems hazard analysis SOP standard operating procedure TOCDF Tooele Chemical Agent Disposal Facility TWA time-weighted average UPA unpack area USACAP U.S. Army Chemical Activity Pacific USACHPPM U.S. Army Center for Health Promotion and Preventive Medicine U.S.C. United States Code VX a nerve agent WCL waste control limit WPL worker population limit 5X level of decontamination (suitable for commercial release)