3
Responses to Chemical Events at Baseline Chemical Demilitarization Facilities

Concentrating on the procedures for reporting and disclosing events and the legal processes involved, in this chapter the committee reviews onsite investigations and reports triggered by the chemical events discussed in Chapter 2 to determine if general conclusions can be drawn about whether those responses can assist in the tasks of determining the causes of events and preventing their recurrence. The committee concentrates on the two events involving release of chemical agent to the environment analyzed in detail in Chapter 2—the December 3-5, 2000, incident at Johnston Atoll Chemical Agent Disposal System (JACADS) and the May 8-9, 2000, incident at Tooele Chemical Disposal Facility (TOCDF) (see Boxes 2-1 and 2-2)—both of which triggered detailed investigations.

The committee also examines how emergency response professionals estimate the potential population exposure from a chemical event, reviews emergency response activities and public responses, and discusses how the events are communicated to local news media and interested citizens groups. These communications have important implications, since they affect how political leaders, regulators, and the general public view the chemical demilitarization program.

FORMAL EVENT REPORTING PROTOCOLS

Formal protocols for reporting a chemical event establish a communication network designed to alert the chemical demilitarization facility staff and plant workforce and the surrounding community to any imminent danger and to mobilize emergency assistance in case of a major event. Additionally, there are a variety of reporting requirements to the Army, the Environmental Protection Agency (EPA), and state and local emergency operations centers, as well as reporting protocols within the facility operating contractor’s organization and the Program Manager for Chemical Demilitarization (PMCD) organization.

Generally, the first indication of a problem is an automatic continuous air monitoring system (ACAMS) alarm, but because many interfering chemicals also cause an alarm, declaration as a chemical event requires laboratory confirmation by the more accurate depot area air monitoring system (DAAMS) analysis (which can take from 20 minutes to more than an hour).1 If an ACAMS alarm is confirmed within the chemical demilitarization facility, the installation commander must be notified. Army Regulation 50-6 requires installation commanders to notify the Army Operations Center by telephone within 3 hours of the time a chemical event is confirmed and in writing within 24 hours. A confirmed event must further be reported to EPA within 24 hours (U.S. Army, 1996b). PMCD has tailored the Army’s regulations to support its mission and requires notification within 1 hour of confirmed events.

The Army Materiel Command (AMC) has set additional guidelines for reporting incidents, including those that (1) have a potential for negative reactions from local officials or the media, (2) involve workers reporting possible exposure to agent, and (3) involve detection of agent outside primary engineering controls but within secondary engineering controls. The state and local protocols for any given plant are determined on a case-by-case basis in accordance with state and local regulations and laws.

Located on an isolated island, JACADS had only EPA Region IX to report to at the local level. Contingency procedures for dealing with agent outside engineering controls were approved in the early days of the project and included a flow chart and call-down lists. The contingency plans involved notification of on-site U.S. Army Chemical Activity

1  

Incidents triggering ACAMS alarms that are not verified by DAAMS analyses are considered to be Resource Conservation and Recovery Act (RCRA) events that require reporting within 15 days.



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3 Responses to Chemical Events at Baseline Chemical Demilitarization Facilities Concentrating on the procedures for reporting and dis- Generally, the first indication of a problem is an auto- closing events and the legal processes involved, in this chap- matic continuous air monitoring system (ACAMS) alarm, ter the committee reviews onsite investigations and reports but because many interfering chemicals also cause an alarm, triggered by the chemical events discussed in Chapter 2 to declaration as a chemical event requires laboratory confir- determine if general conclusions can be drawn about whether mation by the more accurate depot area air monitoring sys- those responses can assist in the tasks of determining the tem (DAAMS) analysis (which can take from 20 minutes to more than an hour).1 If an ACAMS alarm is confirmed causes of events and preventing their recurrence. The com- mittee concentrates on the two events involving release of within the chemical demilitarization facility, the installation chemical agent to the environment analyzed in detail in commander must be notified. Army Regulation 50-6 re- Chapter 2—the December 3-5, 2000, incident at Johnston quires installation commanders to notify the Army Opera- Atoll Chemical Agent Disposal System (JACADS) and the tions Center by telephone within 3 hours of the time a chemi- May 8-9, 2000, incident at Tooele Chemical Disposal Facil- cal event is confirmed and in writing within 24 hours. A ity (TOCDF) (see Boxes 2-1 and 2-2)—both of which trig- confirmed event must further be reported to EPA within 24 gered detailed investigations. hours (U.S. Army, 1996b). PMCD has tailored the Army’s The committee also examines how emergency response regulations to support its mission and requires notification professionals estimate the potential population exposure within 1 hour of confirmed events. from a chemical event, reviews emergency response activi- The Army Materiel Command (AMC) has set additional ties and public responses, and discusses how the events are guidelines for reporting incidents, including those that (1) communicated to local news media and interested citizens have a potential for negative reactions from local officials or groups. These communications have important implications, the media, (2) involve workers reporting possible exposure since they affect how political leaders, regulators, and the to agent, and (3) involve detection of agent outside primary general public view the chemical demilitarization program. engineering controls but within secondary engineering con- trols. The state and local protocols for any given plant are determined on a case-by-case basis in accordance with state FORMAL EVENT REPORTING PROTOCOLS and local regulations and laws. Formal protocols for reporting a chemical event estab- Located on an isolated island, JACADS had only EPA lish a communication network designed to alert the chemical Region IX to report to at the local level. Contingency proce- demilitarization facility staff and plant workforce and the dures for dealing with agent outside engineering controls surrounding community to any imminent danger and to mo- were approved in the early days of the project and included a bilize emergency assistance in case of a major event. Addi- flow chart and call-down lists. The contingency plans in- tionally, there are a variety of reporting requirements to the volved notification of on-site U.S. Army Chemical Activity Army, the Environmental Protection Agency (EPA), and state and local emergency operations centers, as well as re- porting protocols within the facility operating contractor’s 1Incidents triggering ACAMS alarms that are not verified by DAAMS organization and the Program Manager for Chemical De- analyses are considered to be Resource Conservation and Recovery Act militarization (PMCD) organization. (RCRA) events that require reporting within 15 days. 26

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27 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES Pacific (USACAP) soldiers, the Johnston Island Fire De- analyzed and reported at 0430 local time, and only then was partment, the Johnston Island airport, and resident person- action contemplated, though not yet taken. Indeed, although nel. Priority was placed on basic notification of fires, explo- the chemical event report states that the bin was placed under sions, agent releases, and serious bodily injury. There was a engineering controls as soon as the analysis was reported (at call-down list, and a written log was kept. Military officials 0220 local time), it also notes that the bin was outside engi- in Washington, D.C., were notified within 24 hours. neering controls until 0800 local time. Two Army reporting chains run in parallel. The green The Army investigation report (U.S. Army, 2001f) also suit chain culminates at the Chief of Staff of the Army and the seems to minimize the importance of the time the event be- civilian chain with the Secretary of the Army. For chemical gan. It begins: “I. Introduction. On 5 December 2000 at incident reports, both the Assistant Secretary of the Army for 0156 hours (local time), chemical agent VX was detected Installations, Logistics, and the Environment and the Chief of and confirmed in the ash from the HDC bin (BIN 135) at the Staff are notified. The desire is to get the report right, take the Deactivation Furnace System (DFS).” time necessary to be credible, and avoid putting out informa- There is no mention in that report, either in the introduc- tion or sounding alarms that later prove to be unfounded. The tion or in the Executive Summary, of the sample having been task is difficult because frequent ACAMS stack alarms are a taken on December 3. The first mention of the earlier sample common problem; most prove to be false positives rather than occurs on Page 6, under “V. Event Description.” The report chemical events (NRC, 1999a, page 29). then describes several attempts to analyze the sample on December 4, the suspicion of a false positive, and a request for a second sample. ACTUAL ON-SITE RESPONSES Had the first sample been analyzed promptly and the results believed, the release of agent to the environment and December 3-5, 2000, Event at JACADS any potential for harm could have been minimized. This After the event at JACADS on December 5, 2000, a six- incident illustrates a flaw in the reporting system, which is person investigation team was convened, with members from focused on formal declaration of an incident as a chemical PMCD, the USACAP, and the U.S. Army Pacific, as well as event. The first indication of a problem was an analysis two consultants. The team assembled on Johnston Island on showing VX at approximately 3000 times WCL at 0156 on December 13. This team reported its findings on March 15, December 5, but this is not when the “event” was defined as 2001 (U.S. Army, 2001f). In addition, EPA conducted an in- having begun. The question of when a chemical event be- vestigation on December 7-8, 2000, and issued a report on May gins is important because it is the moment beyond which 9, 2001 (EPA, 2001). The Army investigation team’s agenda workers, the public, and/or the environment are potentially was to determine the cause of the event, while the EPA team’s in harm’s way. It also determines the timing for fulfilling the aim was to determine whether or not Resource Conservation various reporting requirements. It is debatable at what point and Recovery Act (RCRA) violations had occurred. The de- the evidence was sufficient to declare this JACADS incident scription below relies heavily on the investigations’ written re- an “event,” but the potential for harm certainly began at 0806 ports (U.S. Army, 2001f; EPA, 2001). on December 3, 2000, when Bin 135 was removed from the The chemical event report submitted within 3 hours of bin enclosure. The most generous interpretation is that event the event (Appendix A of U.S. Army, 2001f) is necessarily a onset began when the site alarm sounded at 1020 on Decem- truncated version of what happened and, as a result, relates a ber 5, 2000. Even given this time of onset, the external re- sequence of events that is easily misinterpreted. It states, “At porting was tardy. In fact, the event was not reported to EPA 0156 (local) 05DEC00, a routine sample of ash from the De- Region IX until the compliance officer serendipitously called contamination Furnace (DFS) was analyzed in the site labora- at 0930 on December 6, 2000, about another matter and was tory that produced levels of VX nerve agent at approximately informed of ongoing events. A notice of violation was sub- 2000 [7000]2 times greater than Drinking Water Levels sequently issued by EPA on May 9, 2001 (EPA, 2001). In- (DWL)3 40,000 ppb vs. 20 ppb.” The report also states, “Upon ternally, there were indications of notification problems as agent detection, the HDC (heated discharge conveyor) bin was well; the notification list indicates “1039 completed call- moved to the Unpack Area (UPA) and placed under engineer- down list.” However, several lines were “busy” or resulted ing controls.” It is important to note, however, that this analy- in “no answer” or, in one case, “machine.” sis was for a sample taken from the bin 11⁄2 days earlier (the The subtitle of the Army investigative report (U.S. site’s operating procedures allow up to 4 days for samples to Army, 2001f), Report of the 3 December 2000 Chemical be analyzed). A second sample, taken at 0300 local time, was Agent Reading [emphasis added] in the Heated Discharge Conveyor (HDC) Bin rather than Report of the 3 December 2000 Chemical Agent Event [emphasis added] in the Heated 2The bracketed number is in the original document, perhaps indicating Discharge Conveyor (HDC) Bin appears to suggest a contin- confusion about what the actual handwritten entry said. ued state of denial. 3DWL is the agent waste protection limit used to assess contamination.

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28 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES From the December 2000 event at JACADS, it appears 1. The various agencies responsible for reviewing inci- that an “event” is assumed to begin when personnel confirm dents took their task very seriously. They made a agent release, as opposed to when a release may have actu- determined effort to understand the causes of the in- ally occurred. The time of onset of an event needs to be cident and to recommend changes that would pre- clarified. vent its recurrence. The problem in defining an event (both whether one 2. The multiplicity of reports is an example of overlap- has occurred and the date/time of onset) also lies partially ping investigations that create the potential for lost in the tendency of the chemical demilitarization personnel time for the mission of the program. It is also an to disregard initial indications due to frequent “false posi- indication of communication problems within the tive” readings, as discussed in Chapter 2. The required chemical demilitarization program. (This observation detection sensitivities test the limits of the technology and is elaborated below in this chapter.) lead to many readings that are not verified by subsequent 3. Incidents such as the May 8-9, 2000, stack release at analysis. Modifications, such as ACAMS employing at TOCDF need to be rare occurrences for such in-depth least two different chromatographic columns, could reduce investigations to be feasible. More frequent investi- the number of unverified alarms (false positives). Alterna- gations of this type would quickly demand more re- tive methods, potentially capable of greater specificity and/ sources than could be made available. or sensitivity, have been suggested in other reports (NRC, 4. The extensive investigation of the May 8-9, 2000, 1994). TOCDF incident as opposed to the comparatively At the sites where the committee visited there does not cursory examination of the December 3-5, 2000, seem to be a call-forwarding mechanism for getting infor- JACADS incident may be partially attributable to the mation directly to people or a hot line dedicated to notifica- fact that JACADS was in a shutdown mode while tion that an event has occurred. This problem would be am- TOCDF will continue operations for several more plified at sites where officers to be notified are not in the years. Yet dismantling a plant is not inherently less immediate vicinity. hazardous than operating a plant. The “waste” men- tality (discounting the potential for “mere waste” to result in release of agent) that may have contributed May 8-9, 2000, Event at TOCDF to the JACADS incident needs to be changed, just as After the detection of GB in the common stack at does the “crying-wolf too often” mind-set that re- TOCDF on the night of May 8-9, 2000, an investigation was sults from the frequent occurrence of and the use of undertaken by a 10-person team, which included represen- the term “false positives.” tatives from the U.S. Army Nuclear and Chemical Agency, 5. It remains to be seen if all of the recommendations in the U.S. Army Center for Explosives Safety, PMCD, the the various investigation reports are actually imple- Deseret Chemical Depot, and General Physics Corporation, mented. Incorporation of such recommendations into with partnering from two Centers for Disease Control and the programmatic lessons learned (PLL) program Prevention (CDC) scientists. The team completed its infor- (see Chapter 4) and their subsequent utilization at mation gathering on May 18, 2000, and its report on June 6, TOCDF and other sites are necessary responses, if 2000 (U.S. Army, 2000b). Separate reports were issued by the reports are to be effective. the CDC’s National Center for Environmental Health (May 18, 2000; CDC, 2000), the Utah Department of Environ- Following the May 8-9, 2000, event, the TOCDF fa- mental Quality (DEQ) (Utah DEQ, 2000a), and the contrac- cility was shut down pending the completion of the vari- tor, EG&G (June 16, 2000; EG&G, 2000). ous investigations. According to Occurrence Report No. These reports are extensive in their detail, with multiple 00-05-08-A1 Confirmed GB Agent Readings in the Com- findings and recommendations, and many addenda. The mon Stack (EG&G, 2000), 22 corrective actions were as- Army report lists 25 separate findings, 29 recommendations, signed to various individuals on June 19, 2000, at the con- and four “observations.” The CDC report lists 11 conclu- clusion of the investigative reports. According to the sions and 15 recommendations. The Utah DEQ report lists Annual Status Report on the Disposal of Chemical Weap- eight “concerns,” while the EG&G report lists several “di- ons and Materiel for Fiscal Year 2000 ( U.S. Army, rect causes,” “root causes,” “contributing causes,” 11 “find- 2000a), authorizations for operation of the liquid incin- ings,” and 22 “corrective actions.” erator and metal parts furnace were issued on July 28, 2000, and for the deactivation furnace system on Septem- ber 21, 2000. Thus, the event led to an approximately Observations 41/2-month shutdown. It is difficult to assign the exact A number of observations can be made from a review amount of time for the investigative, corrective, and ap- of the reports relating to both the December 2000 event at proval phases needed to commence facility restart because JACADS and the May 2000 event at TOCDF: of considerable overlap in phases; i.e., corrective measures

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29 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES and equipment ordering were already occurring as the inves- review of these international treaties, statutes, rules, and tigations proceeded. regulations makes it clear that the facilities for chemical de- militarization are highly regulated and can be subject to mi- croscopic oversight. This panoply of regulations befits the EXTERNAL AND REGULATORY RESPONSES TO extremely hazardous materials that are destroyed by on-site CHEMICAL EVENTS incinerators. Failure to follow the protocols called for by the statutory framework can result in facility shutdowns by the Applicable Statutes, Regulations, and Guidelines agencies that possess the authority to do so, by court orders, and by the U.S. Army. These failures can also erode public The activities of the facilities located at the Johnston trust. Enforcement of the statutes and regulations can result Island and Tooele sites were governed by multiple statutes in notices of violation for failing to operate within a given and regulatory rules and procedures, as well as permitting permit or any number of multiple permits, or for failing to requirements. The controlling federal statute, the Resource follow reporting procedures. Ultimately there is authority to Conservation and Recovery Act (RCRA; 42 U.S.C. §6901 impose remedial activity sanctions, civil fines, and in the et seq.), was enacted in 1976. RCRA contains stringent worst case, criminal fines and imprisonment. statutory requirements that control the handling and dis- Following a serious chemical event, it is typical that posal of hazardous waste. The legislation is commonly there is an investigation that can originate from multiple state referred to as the “cradle-to-grave” regulatory procedure and federal regulatory agencies. For instance, the state envi- and gives EPA’s administrator the responsibility to over- ronmental agency may assume the lead investigative posi- see the generation, transportation, treatment, storage, and tion, although the EPA always retains the authority to ini- disposal of hazardous waste. The program can be delegated tiate its own independent investigation. to the various states for primary enforcement of the statute, Time requirements for verbal reporting and follow-up although EPA continues to have a federal role of oversight written reports are not unique to chemical demilitarization of any such facilities. facilities. Furthermore, the regulatory process is not static— Additional statutes that must be considered include the it evolves. The same is true for the permitting process. Re- Toxic Substance Control Act (TSCA; 15 U.S.C. §2601 et newals are a part of the process, with a period of time built in seq.), the Emergency Planning and Community Right to prior to the expiration of permits. This provides the regu- Know Act (EPCRTKA; 42 U.S.C. §11001 et seq.), the Clean lated community with an opportunity to revisit and imple- Air Act (CAA; 42 U.S.C. §7401 et seq.), the Chemical Safety ment technological advances by the operating unit. The trend Information, Site Security and Fuels Regulatory Relief Act to tighten the regulation to a higher standard of compliance (P.L. 106-40), the Occupational Health and Safety Act affects all regulated facilities. (OSHA; 29 U.S.C. 1920.120 et seq.), and the Clean Water Each facility develops a regulatory history with the en- Act (CWA; 33 U.S.C. §1251 et seq.), in addition to any state forcement agencies with which it works. Candor and trust statutes, regulations, and local ordinances. Additionally, as are essential for these relationships to succeed. Failure to mentioned above and in Chapter 2, the chemical demilitari- follow incident reporting procedures, as agreed upon in ad- zation program is subject to U.S. Army regulations and spe- vance of an incident, erodes trust that is critical to chemical cific-site regulations, or standing orders, implemented by the demilitarization operations, wherever they are located. The post commander and/or the civilian plant manager. Finally, facilities begin operations under a cloud of suspicion, often site activities may also be subject to requirements set forth in due to public misunderstanding, lack of public education and memoranda of understanding (MOUs) entered into by gov- information, media hyperbole, and general “NIMBY” (not ernment entities and the facility. The MOUs are unique to in my back yard) sentiments. Poor communication with the the site and can address issues specific to the surrounding regulatory agencies and the public will further erode the area and nearby communities. program’s public involvement and regulatory agency trust In addition to national, state, and local regulatory re- (NRC, 2000b). view, there is also oversight required pursuant to the Chemi- cal Weapons Convention (CWC). International CWC ob- Memorandum of Understanding Between Deseret servers, commonly referred to as the Inspectorate, maintain Chemical Depot and Tooele County offices on site at JACADS and TOCDF. The Inspectorate is responsible for general oversight and for ensuring that the In the case of TOCDF, because of and subsequent to the destruction of chemicals is carried out pursuant to CWC May 8-9, 2000, incident, Tooele County entered into an MOU guidelines. (Utah DEQ, 2000b) in September 2000 (updated in Novem- These statutes, regulations, and guidelines require noti- ber 2001) with the facility that (1) defines specific event clas- fication of outside agencies when incidents affect public sifications; (2) identifies and displays hazard predictions for health, when permits require such notification, or for the chemical operations with a potential for producing agent ef- marshalling of assistance in the event of a catastrophe. A fects beyond the installation boundary; (3) provides recom-

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30 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES mendations for protective actions to be taken in advance of the proposed reporting system can be implemented effec- potential events; and (4) conducts daily activities that will tively. mimic and reinforce emergency activities, thereby enhancing the notification and response abilities of Deseret Chemical Levels of Investigation Depot (DCD) and Tooele County. Thus, the facility and Tooele County have an agreed-to daily protocol concerning The multiple investigations of the May 8-9, 2000, the tasks that will be undertaken on a particular day, the times Tooele chemical event probably prolonged operational shut- and type of agent munitions that will be processed, and the down unnecessarily. Arguably, multiple levels of review by meteorological data that will be obtained during each opera- independent agencies increase the ability to thoroughly char- tion. Under the MOU, Tooele County is required to inform the acterize an incident. There is a point, however, where the DCD of any special events, projects, or other activities occur- scale tips and accuracy and completeness give way to redun- ring in the community that could affect a quick and safe evacu- dancy and inefficiency with no added benefits. ation of DCD. Examples given were special events drawing The loss of operating time is expensive. During the unusually large crowds, road construction, bridge work, and committee’s visit to TOCDF, operating staff estimated that so on. In the event of a chemical incident, Tooele County the cost to operate the Tooele chemical demilitarization fa- must inform DCD and Utah Comprehensive Emergency Man- cility is approximately $10,000 per hour or $240,000 per day agement of the protective action decisions they have made (U.S. Army, 2001g). Long facility shutdowns also lead to a (see Appendix G). deterioration of operating skills. Facility down-time follow- The parties agreed to the following terms for classifying ing chemical events can be minimized by implementing poli- emergency events: cies that permit a coordinated review effort between mul- tiple oversight entities, in addition to the development and • Routine leaker or agent detection within containment submittal of a single comprehensive incident report. • Non-surety event Preagreement among responsible oversight agencies to estab- • Limited-area event lish a single review team with a predetermined distribution of • Post-only event representatives from various agencies and their areas of ex- • Community event. pertise would allow the rapid deployment of a single, compre- hensive event investigation. Definitions for each of these classifications, as well as the Consolidating the investigation process can still ensure body of the MOU, are reprinted in Appendix G. that the facilities are operating with the highest margin of For the last three of the five event categories listed above, safety, while at the same time ensuring that procedures are in DCD has agreed that notification shall be made to Tooele place that will minimize plant shutdown time following County within 10 minutes of when chemical agent is detected chemical events or other safety infractions. in the atmosphere, i.e., outside engineering controls, and when other unusual circumstances occur, even if a chemical event is MODELING POTENTIAL POPULATION EXPOSURE only suspected. DCD also agrees to use the dedicated “Chemi- cal Notification Hotline”4 telephone as the primary means of When chemical agents are released into the atmosphere, notification for routine leakers and other occurrences of a key challenge is to predict the affected population’s expo- chemical agent detection outlined above, as well as for events sure. This information is needed for developing effective falling into the defined chemical event classifications (Utah evacuation plans and implementing any needed mitigation DEQ, 2000b). measures. Figure 3-1 illustrates the four elements that must Had the above terms of notification and procedures now be integrated, the linkage between these components, and specified in the MOU been in place at the time of the May 8- some of the information needed to perform the calculations. 9, 2000, incident at TOCDF, the impermissible delays between As used by the Community Stockpile Emergency Pre- the time of detection and the time of reporting could have paredness Program (CSEPP), the current implementation of been avoided. The MOU between DCD and Tooele County the system shown in Figure 3-1 is called D2PC, which is used and the new reporting procedures address a number of the to calculate dosages and concentrations from accidental re- recurring reporting deficiencies that have been experienced at leases of chemical warfare agents. The model is based on a the site. Missing from the MOU, however, are specific train- Gaussian plume/puff formulation for transport and dispersion ing requirements that should be implemented to ensure that in the atmosphere (Seinfeld and Pandis, 1998). D2PC is a revision of an older dispersion model, D2, which was docu- mented in 1982. The D2PC model runs on a personal com- puter and is based on the technical paper “Methodology for 4The Chemical Notification Hotline is a dedicated phone line between Chemical Hazard Prediction” (DoD, 1980). The June 1992 DCD and Tooele County. The Chemical Notification Form (see Attach- revision of D2PC was the version originally approved by the ment A of Utah DEQ, 2000b) provides the format for any information com- Army for use by the CSEPP. Subsequently, D2PC has under- municated via the Hotline.

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31 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES Inventory of Release Atmospheric Exposure and M aterials Mechanisms Transport V erification • Meteorology • Chemical type • Fire • Monitoring • Material volumes • Explosion - Wind fields • Geographical information systems • Spatial location • Jet/plume - Turbulence • Containment type - Temperatures • Population density Release heights - Relative humidity • • Exposure models • Building distribution - Boundary layer • Risk assessment • Near source • L ong range • Chemical reactions • Removal processes Monitoring • Model verification and field experiments • System verification and uncertainty analysis • Organizational responsibility for component parts • FIGURE 3-1 Component parts of an integrated system for modeling the impact of release of chemical agents. gone at least two revisions. In June 1994, the U.S. Army dent scenarios that might occur during routine operations. Nuclear and Chemical Agency approved an October 1993 In the second mode, when emergencies occur the system is version of D2PC for all CSEPP and chemical stockpile emer- used to predict the dispersion of the agents and the likely gency planning and response actions. In March 1997, it ap- population exposure. D2-Puff includes the following new proved the Emergency Management Information System features and capabilities: (EMIS), version 3.0 (with the exception of the automated calculation of atmospheric stability), for CSEPP as well. • A Lagrangian puff model that allows concentrations D2PC was most recently upgraded in March 1998, and it is and dosages to be calculated when meteorological this version that is embedded in EMIS 3.1. conditions change in time or vary over a region The D2PC model is currently supplemented with the • The calculation of concentrations and dosages Partial Dosage (PARDOS) model, which uses the D2PC within enclosed structures, such as buildings used methodology to predict cloud arrival and departure times and as shelters dosage accumulation times. The D2PC/PARDOS models • The ability to handle multiple release locations assume flat terrain and steady-state meteorological condi- • The ability to simulate dosages received by indi- tions. Many demilitarization sites, however, are in regions viduals who are exposed to only a portion of a plume of complex terrain, and the steady-state assumption is realis- • The ability to include meteorological observations tic only for small, short-term releases. from multiple locations Gaussian puff/plume dispersion modeling techniques • The ability to include data from weather forecasting embedded in D2PC are representative of the state of the art models (assuming that a suitable meteorological in the late 1970s. Since then, there have been many technical data assimilation capability is attached to D2-Puff) advances in understanding atmospheric turbulence, bound- • The ability to model the effects of complex terrain ary layer structure, and the effects of complex terrain that on plume motion could benefit the CSEPP program. • The ability to compute dispersion based on mea- In 1996, in response to some of the limitations of D2PC, surements of the variance of wind direction the Army tasked Innovative Emergency Management, Inc., • The ability to compute for acute exposure guideline levels (AEGLs) (NRC, 2001b)5 to develop a new model called D2-Puff. D2-Puff predicts dosages and concentrations in changing meteorological con- • A graphical user interface. ditions, including wind shifts. D2-Puff uses the same meth- odology for release of agents and the same atmospheric dis- persion coefficients as D2PC. The technical basis for the 5Acute Exposure Guideline Levels (AEGLs) are a hazard communica- model and its verification are described in three comprehen- tion measure developed by the National Advisory Committee on Acute sive documents (IEM, 2001a,b; U.S. Army, 1999b). At Exposure Guideline Levels for Hazardous Substances. The committee de- present, the modeling system is used in two modes. In the veloped detailed guidelines for devising uniform, meaningful emergency first, a planning mode, the model is used to determine poten- response standards for the general public. The guidelines define three tiers tial population exposure to agent at a particular level in acci- of AEGLs as follows:

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32 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES Another important change in approach concerns the way mate transport wind speeds for all release heights at longer that the hazard is represented in D2-Puff. D2PC produces downwind distances. Thus, the toxic cloud produced by a cigar-shaped footprints for 1 percent lethality, no-deaths, and large accident will arrive in areas more than 1 to 2 km from no-effects dosages. With D2-Puff the analyst can no longer the release sooner than predicted by the models. This is think of dosages solely in terms of distances or relatively especially relevant to sites close to population centers. A simple cigar-shaped footprints. With varying meteorologi- further limitation of the Gaussian dispersion formulation is cal conditions, D2-Puff produces irregularly shaped foot- its low predictive accuracy for long-range transport (>50 prints for 1 percent lethality, no-deaths, and no-effects dos- km). If a substantial release were to occur, the current D2PC/ ages. The no-effects footprint for D2-Puff will generally not D2-Puff models are not suited for predicting the impacts on be as long as the no-effects footprint (no-effects distance) populations that might be 100 km or more downwind from for D2PC, although the D2-Puff footprint will generally be the release site. As with any model, the results produced are wider. This difference will have an impact on protective ac- limited by the accuracy of the inputs. These limitations in- tion decisions. As with D2PC, D2-Puff indicates that per- clude uncertainties about the amounts of chemical agents sons living in the downwind direction near a release will be released and about meteorological conditions. D2-Puff, like the first exposed to the hazard. However, the wind direction other models, can produce hazard estimates that are helpful may shift before populations farther away are exposed to the for emergency planning and response. hazard. This wind shift may result in exposure of a broader In light of the limitations of Gaussian dispersion models, area in the immediate vicinity of the release location—an a key part of the CSEPP should be an ongoing evaluation of area larger than the initial downwind path of the plume. In alternative approaches to modeling the release and impact of this situation, emergency managers may find that they have chemical agents. A considerable wealth of relevant modeling to change their priorities for protective actions. experience has been developed for coping with such events as The D2-Puff model, and other plume dispersion mod- fires and explosions at chemical plants, transportation spills, els, can be calibrated for the effects of complex terrain at nuclear accidents, tunnel fires, uncontrolled forest burns, vol- specific sites by experimental releases and downwind mea- canic eruptions, and oil well fires. Many different models and surements of an inert gaseous tracer under a variety of repre- methodologies are available. For example, one option would sentative meteorological conditions. These calibrations can be to supplement each stockpile site with the capabilities of significantly enhance the accuracy of dispersion calculations the National Atmospheric Release Advisory Center (NARAC)6 that is located at the University of California’s from specific fixed sites like chemical agent storage yards and demilitarization facilities. Lawrence Livermore National Laboratory. While D2-Puff represents an advance in capabilities A more accurate modeling capability is valuable only if it over D2PC, it is still based on Gaussian dispersion modeling is coupled with timely communication of results and appro- with its attendant limitations. Perhaps the most serious limi- priate responses by the stockpile site and surrounding com- tation of the D2-Puff/D2PC methodology for chemical haz- munities. In the case of sites located close to large communi- ard prediction arises from the neglect of the variation in wind ties it is particularly important to have fast communication speed with height. Because both the D2-Puff and D2PC and alert procedures. The committee found, based on several models assume that the wind speed measured at 10 m above site visits and interviews, that these procedures should be re- ground level is representative of the transport wind speed at viewed to identify bottlenecks that could be removed through all downwind distances, they tend to overestimate transport better communications technologies. speeds for low-level releases at short range and underesti- EMERGENCY RESPONSE: PREPAREDNESS, PLANS, NOTIFICATION, AND COORDINATION AT TOCDF AEGL-1: The airborne concentration of a substance above which it is This section focuses on the May 8-9, 2000, TOCDF in- predicted that the general population, including susceptible individuals, cident but also draws on the December 3-5, 2000, JACADS could experience notable discomfort, irritation, or certain asymptomatic event in discussing the importance of reporting requirements. nonsensory effects. However, the effects are not disabling and are transient The TOCDF incident is the primary focus because of that and reversible upon cessation of exposure. AEGL-2: The airborne concentration of a substance above which it is predicted that the general population, including susceptible individuals, could experience irreversible or other serious, long-lasting adverse health 6NARAC is a national emergency response service for real-time assess- effects or an impaired ability to escape. ment of incidents involving nuclear, chemical, biological, or natural haz- AEGL-3: The airborne concentration of a substance above which it is ardous material. NARAC’s primary function is to support the Department predicted that the general population, including susceptible individuals, of Energy and the Department of Defense for radiological releases. Under could experience life-threatening health effects or death. the auspices of the Federal Radiological Emergency Response Plan and the Guidelines for each of the three levels of AEGL—AEGL-1, AEGL-2, Federal Response Plan, the state-of-the-art NARAC modeling system has and AEGL-3—have been developed for each of five exposure periods: 10 the capability to perform assessments of impacts from local to global scales. minutes, 30 minutes, 1 hour, 4 hours, and 8 hours. See NRC (2001b). More information is available online at .

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33 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES event’s potential implications for the safety not only of the workers at the plant, but also for residents in the nearby com- BOX 3-1 Previous Concerns About and munity. This National Research Council (NRC) committee Recommendations for Achieving Efficient is not the first to express concern about the emergency re- CSEPP Operations sponse and management capabilities at TOCDF. Previous findings and concerns regarding the response system noted In its first systemization report produced when the plant was by other NRC committees and the General Accounting Of- about to begin operations in 1996 (NRC, 1996), and as summarized in fice (GAO) (see Box 3-1) provide some necessary context the National Research Council (NRC) report Tooele Chemical Agent for the committee’s examination. Disposal Facility—Update on National Research Council Recommen- This committee’s evaluation of the emergency response dations (NRC, 1999a), the NRC’s Stockpile Committee called on the to the two JACADS and TOCDF incidents that it examined Army and the Federal Emergency Management Agency (FEMA) where in detail focuses on how effectively the division of responsi- appropriate to: bilities between the Army and the Federal Emergency Man- agement Agency (FEMA) (see Box 3-1) actually functioned, 1. ensure that local and state Chemical Stockpile Emer- and analyzes how it is likely to continue to function in the gency Preparedness Program (CSEPP) plans for responding future. Although it is critical to have well-exercised plans, a to chemical events were complete and well exercised communication system that enables adequate warning, ef- 2. increase its efforts to work with the Utah Division of fective communication among responders, and personnel Comprehensive Emergency Management to ensure that first who are appropriately attired for the nature of the hazard, it responders were adequately trained to use personnel protec- is equally critical that the organizational structure functions tive equipment as designed, enabling an effective response. Indeed, how ef- 3. make certain that the Army/FEMA provided the neces- fectively the emergency response system is organized and sary resources for completing the planned Tooele County how capable it is of functioning in a coordinated fashion emergency communications system. have important implications for the three additional incin- erator-based chemical demilitarization sites that are close to In 1999, the NRC added another recommendation: that the Army beginning operations. One of the important components of ensure that CSEPP and FEMA officials understand how the quantita- this committee’s examination of the emergency response to tive risk assessment (QRA) and other activities might affect risk and the two JACADS and TOCDF incidents has been a review reflect this understanding in emergency planning and preparedness of the preparedness of the emergency management system activities (NRC, 1999a). The 1999 NRC report reviewed and updated when required to function during stressing events. recommendations on operations at the Tooele Chemical Agent Dis- Relevant to the examination of emergency preparedness posal Facility (TOCDF). It noted that in accordance with the formal are a recent GAO report that examined FEMA’s and the reorganization of responsibilities that had just been carried out be- Army’s efforts to prepare states for chemical weapons emer- tween the Army and FEMA, all on-site responsibilities for emergency gencies (GAO, 2001) and a CSEPP report describing CSEPP management were retained by the Army and all off-site responsibili- and Army benchmarking of the system (CSEPP, 2000). As ties for emergency management and planning were given to FEMA. pointed out in the GAO report, FEMA has adopted a series The 1999 Stockpile Committee report, noting previous General Ac- of national quantitative performance indicators that use counting Office (GAO) reports that had cited existing problems with benchmarks to evaluate the preparedness of different states the CSEPP, stated, “The Committee is also concerned about CSEPP in the program (GAO, 2001). These benchmarks are sup- and about the horizontal fragmentation of responsibility at the federal posed to focus on outcomes rather than outputs as measures level.” The report further commented (NRC, 1999a): of performance in ensuring the essentials of public safety, including warning system effectiveness, readiness of coor- Previous briefings by directors (both Army and FEMA) of the CSEPP, as well as discussions with directors of state emergency dination systems, reliability of critical communication sys- management agencies, have all stressed the importance of a well- tems, and public awareness of protective actions. FEMA is coordinated response-management capability…. The recent reor- responsible for benchmarking emergency management com- ganization will require excellent coordination and communication to pliance off-post; the Army uses a similar system at its instal- overcome the barriers of separate organizational responsibilities. lations (GAO, 2001). The 2001 GAO report also mentions that Utah is one of three states considered to be fully pre- Finally, the 1999 NRC report expressed skepticism about the pared for a chemical emergency and that an active coopera- reorganization’s impact on improving the capacity for responding to tive effort by the community is essential to the state’s cur- an emergency. rent state of preparedness. Interestingly, these three states are considered by FEMA and the Army to be fully prepared, even though both the Army and FEMA have failed to issue any site-specific planning guidance for local communities or states covering reentry into a contaminated area of a com-

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34 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES munity, or guidance on when it is appropriate to notify citi- tions concerning the credibility and functioning of the emer- zens to leave shelters following an event. gency notification and response systems have serious impli- The committee judges that the benchmarks demonstrate cations not only for communities where operating systems a significant effort by FEMA and the Army to coordinate are currently located, but also for communities where they their efforts to measure a program’s status and to guide fund- are planned, like Anniston. As pointed out above, this coop- ing. For example, these measures have been developed over eration was cited in the GAO 2001 report as being a funda- time and include the initial guidance document issued in mental condition for the three programs gaining fully pre- 1993 (FEMA, 1993), and revised in 1996 (FEMA, 1996) to pared status from FEMA and the Army. include nine benchmarks. These benchmarks were later re- During their tours of TOCDF and DCD, members of vised again in 1997, and then again in a joint policy paper the committee raised questions concerning the responsi- (FEMA, 1997) that added three additional benchmarks. The bilities of personnel as they related to the Tooele County GAO used these 12 agreed-upon benchmarks in 19 “critical EOC and Utah DEQ. In several instances personnel re- items” for its review of the program. ported that their responsibilities “ended at the fence” and The development of jointly used benchmarks does not that they were not responsible for emergency management reveal the full extent of the efforts by the Army and FEMA to operations in the community. Similar attitudes were ex- jointly coordinate the emergency response/management sys- pressed at the JACADS facility, although the lack of a com- tem for chemical incidents. On October 8, 1997, coinciding munity near the facility mitigates the impact of such views. with the formal division of the program, an MOU between the Technically, this view is correct concerning the division of Army and FEMA formally identified their respective roles responsibilities. However, for an effective response the and responsibilities and joint efforts for “ . . . emergency re- program requires a strong degree of coordination between sponse, preparedness involving the storage and ultimate dis- the DCD EOC and the Tooele County Office of Emergency posal of the U.S. stockpile of chemical warfare material” Management. (FEMA, 1997). Despite these efforts, the GAO has continued It should be remembered that at both JACADS and to find uneven performance measures being used and a lack of TOCDF the emergency response system functioned with effectiveness in providing technical assistance and guidance only a few problems (such as those at JACADS when impor- to the states and communities (GAO, 2001). tant personnel could not be notified because of communica- The performance of the emergency management system tion problems). That is, the failures of notification occurred during the TOCDF May 8-9, 2000, event is not reassuring. It in alerting the civilian authorities that are a part of CSEPP. raises questions about how to interpret the system’s perfor- Within the Army structure at JACADS, for example, the mance and what is meant by the term “fully prepared.” The personnel were assembled at checkpoint “Charlie” for pos- lack of timely notification that an event had occurred has sible evacuation once the alarm was sounded. The plant con- several important implications. First, benchmarking perfor- trol room at Tooele informed the DCD’s EOC in a timely mance evaluations aside, the real test of an emergency man- fashion of the alarms and provided it with updates on the agement and response system is how it functions during an situation. However, the DCD EOC then failed to pass on the incident rather than performance during training exercises. notice to the Tooele County EOC and relevant State of Utah What is particularly troubling is that something as simple as agencies. It is impossible to determine how the CSEPP por- notification of an alarm (even after it was confirmed) was tion of the emergency management system functioned as it not reported to the Tooele County Emergency Operating was not provided timely notification of the events. Other Center (EOC). No one disputes the fact that the Tooele communities soon to host chemical demilitarization facili- County EOC and Utah officials should have been notified of ties can learn a good deal from these two events and the the events. This notification is part of the standard operating nature of the “fix” that has been made by the Army and procedures (SOPs) and is probably the most exercised com- Tooele officials. Given this failure of communication and ponent of the system during operations testing and exercises. adequate notification, it is reasonable to assume that efforts The fact that SOPs were clearly disregarded, and the off-site to correct the problems associated with the response would community potentially put at risk because of the lack of no- focus on information exchange, such as through the MOU tification and knowledge of the event, demonstrates a clear entered into by Tooele County and the DCD (Appendix G). breakdown of the system at the most elementary level. While The lack of notification and warning between the DCD some action aimed at preventing the repeating of this se- and Tooele County and appropriate local and state agencies quence of events has been taken through a new MOU for was caused in part by a lack of coordination between com- Information Exchange (Utah DEQ, 2000b), as discussed pre- ponents of the two programs (CSEPP/FEMA and the Army), viously, the events surrounding this incident raise questions and in part because of DCD’s emergency management re- in critics of the program concerning the trustworthiness of sponsibilities that “end at the fence” (although timely com- those in charge of the emergency response and notification munication cannot). The recent GAO report (GAO, 2001) system. This trust is crucial to surrounding communities’ on FEMA and Army efforts to prepare communities for a participation and cooperation in these programs, and ques- chemical emergency is vague on how to improve what is

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35 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES being done other than suggesting that the two entities be- gram. Officials and citizens of the affected local communi- come proactive in doing so. ties, along with national officials, share the objective of de- Even if the various components of the emergency re- stroying the chemical stockpile but must rely on others to sponse system are designed to be fully coordinated, the sys- carry out that destruction in a safe and timely manner. To tem will not function well unless there is a high level of trust undertake the program, these “principals” must establish a among the personnel involved. In particular, there needs to relationship with agencies (PMCD) and contractors—or “agents”8—to carry out the mission.9 The technological re- be trust between those “inside the fence” (professional per- sonnel) and those “outside the fence” (local officials and the quirements of the process, and the magnitude of the poten- public). tial hazards, lead to barriers of complexity and security that—for practical purposes—make the program difficult for the principals to directly evaluate and monitor. The theory PUBLIC RESPONSES TO CHEMICAL EVENTS of principals and agents is discussed further in Chapter 1. A significant aspect of the responses to chemical events Effective management of the principal-agent relation- concerns when and how the event is communicated to local ship in the chemical demilitarization program in order to officials and the local public.7 While much of the focus of achieve the required level of trust appears to require (1) post-event response is necessarily on the requirements of the monitoring processes that assure principals of their role in formal regulatory process, interactions with the affected lo- effective oversight, (2) complete and timely disclosure of cal officials and public have important implications as well. events by the agents, and (3) demonstrable and timely as- From the perspectives of the public and their officials, sessments of the problems leading to chemical events and “chemical events” are largely involuntary risks that are po- their correction. tentially catastrophic and of technological origin. These The JACADS December 3-5, 2000, incident raises sev- characteristics render chemical events and incidents subject eral important issues concerning interactions with external to substantial “social amplification” in which the character- principals. First, failure to believe the first sample analysis istics of the events interact with individuals’ perceptions of and act immediately to isolate the contaminated material is the risk associated with them and the pattern of communica- troubling. Absent very careful monitoring (in the form of tion with the public and their response to both the event and investigations) by regulators, the event would have been the communication (Kasperson, 1992; Kasperson et al., misunderstood, potentially inhibiting appropriate responses. 1988). Second, tardy compliance with reporting requirements (as According to this formulation, news reporters, interest discussed above in this chapter), even when very permissive groups, and concerned citizens monitor events and select and assumptions are made about the timing of the event onset, retransmit risk signals pertinent to those events via the news may well raise significant concerns among public officials, media and informal networks, which in turn results in a ripple media, and affected citizens. Though JACADS is itself a effect of secondary impacts. These secondary impacts could geographically isolated facility, if the lapses associated with include changes in perceived levels of risk, altered trust for the December 2000 incident are repeated at other sites, resi- the organizations and officials involved, pressure for legal dents living near similar facilities might lose confidence in and institutional change, changes in property values, and a the monitoring process. Moreover, these incidents could be myriad of other effects. Thus, the pattern of communication seen as indicators of larger, unobserved problems in plant with and responsiveness to the public and their officials can operations, such as insufficient willingness to forthrightly have substantial “real” effects beyond the immediate health identify and correct conditions that could lead to chemical and environmental impacts posed by the chemical event. events. From a programmatic perspective, most importantly, these The committee’s investigation did not indicate that secondary effects can delay and further debilitate a program JACADS personnel intended to distort the December 3-5, by undercutting the credibility of the agency(ies) entrusted 2000, event or delay reporting. However, the context (the with implementing the program, reinforcing negative mes- “mere waste” mind-set versus the “agent” mind-set) and out- sages about the technology being utilized and leading the come could erode the confidence of external principals at a public to question reports and official statements about continental U.S. site in the monitoring and control processes. progress in meeting program objectives. Understanding how chemical events might initiate the “social amplification” process is facilitated by elucidating 8It is unfortunate that use of the term “agents” to indicate those who carry critical aspects of the trust relationship engendered by ac- out tasks for “principals” might in this report be a source of confusion in the context of the chemical demilitarization program (where “agent” usually tivities such as the chemical weapons demilitarization pro- refers to chemical agent). Where agent is used in the institutional sense, it is italicized to reduce the potential for confusion. 9There is a large and growing literature on what is referred to as the 7Almost by definition, the communication process includes the local principal-agent relationship. For some of the more important work, see news media and interested citizens’ groups. Wood (1992) and Scholz and Wei (1986).

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36 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES The substantial costs in terms of resources and time re- tigations both to ensure that they are competently undertaken quired for multiple investigations of chemical events involv- and to facilitate effective communication of the results. The ing environmental releases, such as those that occurred in need for such local representation is underlined by the find- the TOCDF May 8-9, 2000, event, might contribute to a de- ings of delayed reporting or failure to report, indicating the fensive mentality on the part of the operating personnel. At significant flaws in the reporting process that stimulated the the same time, it is essential that local officials and local new notification and communication MOU between the citizens have trusted representatives involved in these inves- DCD and Tooele County.