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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities 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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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Pacific (USACAP) soldiers, the Johnston Island Fire Department, the Johnston Island airport, and resident personnel. Priority was placed on basic notification of fires, explosions, agent releases, and serious bodily injury. There was a call-down list, and a written log was kept. Military officials in Washington, D.C., were notified within 24 hours. Two Army reporting chains run in parallel. The green suit chain culminates at the Chief of Staff of the Army and the civilian chain with the Secretary of the Army. For chemical incident reports, both the Assistant Secretary of the Army for Installations, Logistics, and the Environment and the Chief of Staff are notified. The desire is to get the report right, take the time necessary to be credible, and avoid putting out information or sounding alarms that later prove to be unfounded. The task is difficult because frequent ACAMS stack alarms are a common problem; most prove to be false positives rather than chemical events (NRC, 1999a, page 29). ACTUAL ON-SITE RESPONSES December 3-5, 2000, Event at JACADS After the event at JACADS on December 5, 2000, a sixperson investigation team was convened, with members from PMCD, the USACAP, and the U.S. Army Pacific, as well as two consultants. The team assembled on Johnston Island on December 13. This team reported its findings on March 15, 2001 (U.S. Army, 2001f). In addition, EPA conducted an investigation on December 7-8, 2000, and issued a report on May 9, 2001 (EPA, 2001). The Army investigation team’s agenda was to determine the cause of the event, while the EPA team’s aim was to determine whether or not Resource Conservation and Recovery Act (RCRA) violations had occurred. The description below relies heavily on the investigations’ written reports (U.S. Army, 2001f; EPA, 2001). The chemical event report submitted within 3 hours of the event (Appendix A of U.S. Army, 2001f) is necessarily a truncated version of what happened and, as a result, relates a sequence of events that is easily misinterpreted. It states, “At 0156 (local) 05DEC00, a routine sample of ash from the Decontamination Furnace (DFS) was analyzed in the site laboratory that produced levels of VX nerve agent at approximately 2000 2 times greater than Drinking Water Levels (DWL)3 40,000 ppb vs. 20 ppb.” The report also states, “Upon agent detection, the HDC (heated discharge conveyor) bin was moved to the Unpack Area (UPA) and placed under engineering controls.” It is important to note, however, that this analysis was for a sample taken from the bin 1½ days earlier (the site’s operating procedures allow up to 4 days for samples to be analyzed). A second sample, taken at 0300 local time, was analyzed and reported at 0430 local time, and only then was action contemplated, though not yet taken. Indeed, although the chemical event report states that the bin was placed under engineering controls as soon as the analysis was reported (at 0220 local time), it also notes that the bin was outside engineering controls until 0800 local time. The Army investigation report (U.S. Army, 2001f) also seems to minimize the importance of the time the event began. It begins: “I. Introduction. On 5 December 2000 at 0156 hours (local time), chemical agent VX was detected and confirmed in the ash from the HDC bin (BIN 135) at the Deactivation Furnace System (DFS).” There is no mention in that report, either in the introduction or in the Executive Summary, of the sample having been taken on December 3. The first mention of the earlier sample occurs on Page 6, under “V. Event Description.” The report then describes several attempts to analyze the sample on December 4, the suspicion of a false positive, and a request for a second sample. Had the first sample been analyzed promptly and the results believed, the release of agent to the environment and any potential for harm could have been minimized. This incident illustrates a flaw in the reporting system, which is focused on formal declaration of an incident as a chemical event. The first indication of a problem was an analysis showing VX at approximately 3000 times WCL at 0156 on December 5, but this is not when the “event” was defined as having begun. The question of when a chemical event begins is important because it is the moment beyond which workers, the public, and/or the environment are potentially in harm’s way. It also determines the timing for fulfilling the various reporting requirements. It is debatable at what point the evidence was sufficient to declare this JACADS incident an “event,” but the potential for harm certainly began at 0806 on December 3, 2000, when Bin 135 was removed from the bin enclosure. The most generous interpretation is that event onset began when the site alarm sounded at 1020 on December 5, 2000. Even given this time of onset, the external reporting was tardy. In fact, the event was not reported to EPA Region IX until the compliance officer serendipitously called at 0930 on December 6, 2000, about another matter and was informed of ongoing events. A notice of violation was subsequently issued by EPA on May 9, 2001 (EPA, 2001). Internally, there were indications of notification problems as well; the notification list indicates “1039 completed calldown list.” However, several lines were “busy” or resulted in “no answer” or, in one case, “machine.” The subtitle of the Army investigative report (U.S. Army, 2001f), Report of the 3 December 2000 Chemical 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 Discharge Conveyor (HDC) Bin appears to suggest a continued state of denial. 2 The bracketed number is in the original document, perhaps indicating confusion about what the actual handwritten entry said. 3 DWL is the agent waste protection limit used to assess contamination.
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities From the December 2000 event at JACADS, it appears that an “event” is assumed to begin when personnel confirm agent release, as opposed to when a release may have actually occurred. The time of onset of an event needs to be clarified. The problem in defining an event (both whether one has occurred and the date/time of onset) also lies partially in the tendency of the chemical demilitarization personnel to disregard initial indications due to frequent “false positive” readings, as discussed in Chapter 2. The required detection sensitivities test the limits of the technology and lead to many readings that are not verified by subsequent analysis. Modifications, such as ACAMS employing at least two different chromatographic columns, could reduce the number of unverified alarms (false positives). Alternative methods, potentially capable of greater specificity and/ or sensitivity, have been suggested in other reports (NRC, 1994). At the sites where the committee visited there does not seem to be a call-forwarding mechanism for getting information directly to people or a hot line dedicated to notification that an event has occurred. This problem would be amplified at sites where officers to be notified are not in the immediate vicinity. May 8-9, 2000, Event at TOCDF After the detection of GB in the common stack at TOCDF on the night of May 8-9, 2000, an investigation was undertaken by a 10-person team, which included representatives from the U.S. Army Nuclear and Chemical Agency, the U.S. Army Center for Explosives Safety, PMCD, the Deseret Chemical Depot, and General Physics Corporation, with partnering from two Centers for Disease Control and Prevention (CDC) scientists. The team completed its information gathering on May 18, 2000, and its report on June 6, 2000 (U.S. Army, 2000b). Separate reports were issued by the CDC’s National Center for Environmental Health (May 18, 2000; CDC, 2000), the Utah Department of Environmental Quality (DEQ) (Utah DEQ, 2000a), and the contractor, EG&G (June 16, 2000; EG&G, 2000). These reports are extensive in their detail, with multiple findings and recommendations, and many addenda. The Army report lists 25 separate findings, 29 recommendations, and four “observations.” The CDC report lists 11 conclusions and 15 recommendations. The Utah DEQ report lists eight “concerns,” while the EG&G report lists several “direct causes,” “root causes,” “contributing causes,” 11 “findings,” and 22 “corrective actions.” Observations A number of observations can be made from a review of the reports relating to both the December 2000 event at JACADS and the May 2000 event at TOCDF: The various agencies responsible for reviewing incidents took their task very seriously. They made a determined effort to understand the causes of the incident and to recommend changes that would prevent its recurrence. The multiplicity of reports is an example of overlapping investigations that create the potential for lost time for the mission of the program. It is also an indication of communication problems within the chemical demilitarization program. (This observation is elaborated below in this chapter.) Incidents such as the May 8-9, 2000, stack release at TOCDF need to be rare occurrences for such in-depth investigations to be feasible. More frequent investigations of this type would quickly demand more resources than could be made available. The extensive investigation of the May 8-9, 2000, TOCDF incident as opposed to the comparatively cursory examination of the December 3-5, 2000, JACADS incident may be partially attributable to the fact that JACADS was in a shutdown mode while TOCDF will continue operations for several more years. Yet dismantling a plant is not inherently less hazardous than operating a plant. The “waste” mentality (discounting the potential for “mere waste” to result in release of agent) that may have contributed to the JACADS incident needs to be changed, just as does the “crying-wolf too often” mind-set that results from the frequent occurrence of and the use of the term “false positives.” It remains to be seen if all of the recommendations in the various investigation reports are actually implemented. Incorporation of such recommendations into the programmatic lessons learned (PLL) program (see Chapter 4) and their subsequent utilization at TOCDF and other sites are necessary responses, if the reports are to be effective. Following the May 8-9, 2000, event, the TOCDF facility was shut down pending the completion of the various investigations. According to Occurrence Report No. 00-05-08-A1 Confirmed GB Agent Readings in the Common Stack (EG&G, 2000), 22 corrective actions were assigned to various individuals on June 19, 2000, at the conclusion of the investigative reports. According to the Annual Status Report on the Disposal of Chemical Weapons and Materiel for Fiscal Year 2000 (U.S. Army, 2000a), authorizations for operation of the liquid incinerator and metal parts furnace were issued on July 28, 2000, and for the deactivation furnace system on September 21, 2000. Thus, the event led to an approximately 41/2-month shutdown. It is difficult to assign the exact amount of time for the investigative, corrective, and approval phases needed to commence facility restart because of considerable overlap in phases; i.e., corrective measures
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities and equipment ordering were already occurring as the investigations proceeded. EXTERNAL AND REGULATORY RESPONSES TO CHEMICAL EVENTS Applicable Statutes, Regulations, and Guidelines The activities of the facilities located at the Johnston Island and Tooele sites were governed by multiple statutes and regulatory rules and procedures, as well as permitting requirements. The controlling federal statute, the Resource Conservation and Recovery Act (RCRA; 42 U.S.C. §6901 et seq.), was enacted in 1976. RCRA contains stringent statutory requirements that control the handling and disposal of hazardous waste. The legislation is commonly referred to as the “cradle-to-grave” regulatory procedure and gives EPA’s administrator the responsibility to oversee the generation, transportation, treatment, storage, and disposal of hazardous waste. The program can be delegated to the various states for primary enforcement of the statute, although EPA continues to have a federal role of oversight of any such facilities. Additional statutes that must be considered include the Toxic Substance Control Act (TSCA; 15 U.S.C. §2601 et seq.), the Emergency Planning and Community Right to Know Act (EPCRTKA; 42 U.S.C. §11001 et seq.), the Clean Air Act (CAA; 42 U.S.C. §7401 et seq.), the Chemical Safety Information, Site Security and Fuels Regulatory Relief Act (P.L. 106-40), the Occupational Health and Safety Act (OSHA; 29 U.S.C. 1920.120 et seq.), and the Clean Water Act (CWA; 33 U.S.C. §1251 et seq.), in addition to any state statutes, regulations, and local ordinances. Additionally, as mentioned above and in Chapter 2, the chemical demilitarization program is subject to U.S. Army regulations and specific-site regulations, or standing orders, implemented by the post commander and/or the civilian plant manager. Finally, site activities may also be subject to requirements set forth in memoranda of understanding (MOUs) entered into by government entities and the facility. The MOUs are unique to the site and can address issues specific to the surrounding area and nearby communities. In addition to national, state, and local regulatory review, there is also oversight required pursuant to the Chemical Weapons Convention (CWC). International CWC observers, commonly referred to as the Inspectorate, maintain offices on site at JACADS and TOCDF. The Inspectorate is responsible for general oversight and for ensuring that the destruction of chemicals is carried out pursuant to CWC guidelines. These statutes, regulations, and guidelines require notification of outside agencies when incidents affect public health, when permits require such notification, or for the marshalling of assistance in the event of a catastrophe. A review of these international treaties, statutes, rules, and regulations makes it clear that the facilities for chemical demilitarization are highly regulated and can be subject to microscopic oversight. This panoply of regulations befits the extremely hazardous materials that are destroyed by on-site incinerators. Failure to follow the protocols called for by the statutory framework can result in facility shutdowns by the agencies that possess the authority to do so, by court orders, and by the U.S. Army. These failures can also erode public trust. Enforcement of the statutes and regulations can result in notices of violation for failing to operate within a given permit or any number of multiple permits, or for failing to follow reporting procedures. Ultimately there is authority to impose remedial activity sanctions, civil fines, and in the worst case, criminal fines and imprisonment. Following a serious chemical event, it is typical that there is an investigation that can originate from multiple state and federal regulatory agencies. For instance, the state environmental agency may assume the lead investigative position, although the EPA always retains the authority to initiate its own independent investigation. Time requirements for verbal reporting and follow-up written reports are not unique to chemical demilitarization facilities. Furthermore, the regulatory process is not static— it evolves. The same is true for the permitting process. Renewals are a part of the process, with a period of time built in prior to the expiration of permits. This provides the regulated community with an opportunity to revisit and implement technological advances by the operating unit. The trend to tighten the regulation to a higher standard of compliance affects all regulated facilities. Each facility develops a regulatory history with the enforcement agencies with which it works. Candor and trust are essential for these relationships to succeed. Failure to follow incident reporting procedures, as agreed upon in advance of an incident, erodes trust that is critical to chemical demilitarization operations, wherever they are located. The facilities begin operations under a cloud of suspicion, often due to public misunderstanding, lack of public education and information, media hyperbole, and general “NIMBY” (not in my back yard) sentiments. Poor communication with the regulatory agencies and the public will further erode the program’s public involvement and regulatory agency trust (NRC, 2000b). Memorandum of Understanding Between Deseret Chemical Depot and Tooele County In the case of TOCDF, because of and subsequent to the May 8-9, 2000, incident, Tooele County entered into an MOU (Utah DEQ, 2000b) in September 2000 (updated in November 2001) with the facility that (1) defines specific event classifications; (2) identifies and displays hazard predictions for chemical operations with a potential for producing agent effects beyond the installation boundary; (3) provides recom-
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities mendations for protective actions to be taken in advance of potential events; and (4) conducts daily activities that will mimic and reinforce emergency activities, thereby enhancing the notification and response abilities of Deseret Chemical Depot (DCD) and Tooele County. Thus, the facility and Tooele County have an agreed-to daily protocol concerning the tasks that will be undertaken on a particular day, the times and type of agent munitions that will be processed, and the meteorological data that will be obtained during each operation. Under the MOU, Tooele County is required to inform the DCD of any special events, projects, or other activities occurring in the community that could affect a quick and safe evacuation of DCD. Examples given were special events drawing unusually large crowds, road construction, bridge work, and so on. In the event of a chemical incident, Tooele County must inform DCD and Utah Comprehensive Emergency Management of the protective action decisions they have made (see Appendix G). The parties agreed to the following terms for classifying emergency events: Routine leaker or agent detection within containment Non-surety event Limited-area event Post-only event Community event. Definitions for each of these classifications, as well as the body of the MOU, are reprinted in Appendix G. For the last three of the five event categories listed above, DCD has agreed that notification shall be made to Tooele County within 10 minutes of when chemical agent is detected in the atmosphere, i.e., outside engineering controls, and when other unusual circumstances occur, even if a chemical event is only suspected. DCD also agrees to use the dedicated “Chemical Notification Hotline”4 telephone as the primary means of notification for routine leakers and other occurrences of chemical agent detection outlined above, as well as for events falling into the defined chemical event classifications (Utah DEQ, 2000b). Had the above terms of notification and procedures now specified in the MOU been in place at the time of the May 8-9, 2000, incident at TOCDF, the impermissible delays between the time of detection and the time of reporting could have been avoided. The MOU between DCD and Tooele County and the new reporting procedures address a number of the recurring reporting deficiencies that have been experienced at the site. Missing from the MOU, however, are specific training requirements that should be implemented to ensure that the proposed reporting system can be implemented effectively. Levels of Investigation The multiple investigations of the May 8-9, 2000, Tooele chemical event probably prolonged operational shutdown unnecessarily. Arguably, multiple levels of review by independent agencies increase the ability to thoroughly characterize an incident. There is a point, however, where the scale tips and accuracy and completeness give way to redundancy and inefficiency with no added benefits. The loss of operating time is expensive. During the committee’s visit to TOCDF, operating staff estimated that the cost to operate the Tooele chemical demilitarization facility is approximately $10,000 per hour or $240,000 per day (U.S. Army, 2001g). Long facility shutdowns also lead to a deterioration of operating skills. Facility down-time following chemical events can be minimized by implementing policies that permit a coordinated review effort between multiple oversight entities, in addition to the development and submittal of a single comprehensive incident report. Preagreement among responsible oversight agencies to establish a single review team with a predetermined distribution of representatives from various agencies and their areas of expertise would allow the rapid deployment of a single, comprehensive event investigation. Consolidating the investigation process can still ensure that the facilities are operating with the highest margin of safety, while at the same time ensuring that procedures are in place that will minimize plant shutdown time following chemical events or other safety infractions. MODELING POTENTIAL POPULATION EXPOSURE When chemical agents are released into the atmosphere, a key challenge is to predict the affected population’s exposure. This information is needed for developing effective evacuation plans and implementing any needed mitigation measures. Figure 3-1 illustrates the four elements that must be integrated, the linkage between these components, and some of the information needed to perform the calculations. As used by the Community Stockpile Emergency Preparedness Program (CSEPP), the current implementation of the system shown in Figure 3-1 is called D2PC, which is used to calculate dosages and concentrations from accidental releases of chemical warfare agents. The model is based on a Gaussian plume/puff formulation for transport and dispersion in the atmosphere (Seinfeld and Pandis, 1998). D2PC is a revision of an older dispersion model, D2, which was documented in 1982. The D2PC model runs on a personal computer and is based on the technical paper “Methodology for Chemical Hazard Prediction” (DoD, 1980). The June 1992 revision of D2PC was the version originally approved by the Army for use by the CSEPP. Subsequently, D2PC has under- 4 The Chemical Notification Hotline is a dedicated phone line between DCD and Tooele County. The Chemical Notification Form (see Attachment A of Utah DEQ, 2000b) provides the format for any information communicated via the Hotline.
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities 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 Nuclear and Chemical Agency approved an October 1993 version of D2PC for all CSEPP and chemical stockpile emergency planning and response actions. In March 1997, it approved the Emergency Management Information System (EMIS), version 3.0 (with the exception of the automated calculation of atmospheric stability), for CSEPP as well. D2PC was most recently upgraded in March 1998, and it is this version that is embedded in EMIS 3.1. The D2PC model is currently supplemented with the Partial Dosage (PARDOS) model, which uses the D2PC methodology to predict cloud arrival and departure times and dosage accumulation times. The D2PC/PARDOS models assume flat terrain and steady-state meteorological conditions. Many demilitarization sites, however, are in regions of complex terrain, and the steady-state assumption is realistic only for small, short-term releases. Gaussian puff/plume dispersion modeling techniques embedded in D2PC are representative of the state of the art in the late 1970s. Since then, there have been many technical advances in understanding atmospheric turbulence, boundary layer structure, and the effects of complex terrain that could benefit the CSEPP program. In 1996, in response to some of the limitations of D2PC, the Army tasked Innovative Emergency Management, Inc., to develop a new model called D2-Puff. D2-Puff predicts dosages and concentrations in changing meteorological conditions, including wind shifts. D2-Puff uses the same methodology for release of agents and the same atmospheric dispersion coefficients as D2PC. The technical basis for the model and its verification are described in three comprehensive documents (IEM, 2001a,b; U.S. Army, 1999b). At present, the modeling system is used in two modes. In the first, a planning mode, the model is used to determine potential population exposure to agent at a particular level in accident scenarios that might occur during routine operations. In the second mode, when emergencies occur the system is used to predict the dispersion of the agents and the likely population exposure. D2-Puff includes the following new features and capabilities: A Lagrangian puff model that allows concentrations and dosages to be calculated when meteorological conditions change in time or vary over a region The calculation of concentrations and dosages within enclosed structures, such as buildings used as shelters The ability to handle multiple release locations The ability to simulate dosages received by individuals who are exposed to only a portion of a plume The ability to include meteorological observations from multiple locations The ability to include data from weather forecasting models (assuming that a suitable meteorological data assimilation capability is attached to D2-Puff) The ability to model the effects of complex terrain on plume motion The ability to compute dispersion based on measurements of the variance of wind direction The ability to compute for acute exposure guideline levels (AEGLs) (NRC, 2001b)5 A graphical user interface. 5 Acute Exposure Guideline Levels (AEGLs) are a hazard communication measure developed by the National Advisory Committee on Acute Exposure Guideline Levels for Hazardous Substances. The committee developed detailed guidelines for devising uniform, meaningful emergency response standards for the general public. The guidelines define three tiers of AEGLs as follows:
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Another important change in approach concerns the way that the hazard is represented in D2-Puff. D2PC produces cigar-shaped footprints for 1 percent lethality, no-deaths, and no-effects dosages. With D2-Puff the analyst can no longer think of dosages solely in terms of distances or relatively simple cigar-shaped footprints. With varying meteorological conditions, D2-Puff produces irregularly shaped footprints for 1 percent lethality, no-deaths, and no-effects dosages. The no-effects footprint for D2-Puff will generally not be as long as the no-effects footprint (no-effects distance) for D2PC, although the D2-Puff footprint will generally be wider. This difference will have an impact on protective action decisions. As with D2PC, D2-Puff indicates that persons living in the downwind direction near a release will be the first exposed to the hazard. However, the wind direction may shift before populations farther away are exposed to the hazard. This wind shift may result in exposure of a broader area in the immediate vicinity of the release location—an area larger than the initial downwind path of the plume. In this situation, emergency managers may find that they have to change their priorities for protective actions. The D2-Puff model, and other plume dispersion models, can be calibrated for the effects of complex terrain at specific sites by experimental releases and downwind measurements of an inert gaseous tracer under a variety of representative meteorological conditions. These calibrations can significantly enhance the accuracy of dispersion calculations from specific fixed sites like chemical agent storage yards and demilitarization facilities. While D2-Puff represents an advance in capabilities over D2PC, it is still based on Gaussian dispersion modeling with its attendant limitations. Perhaps the most serious limitation of the D2-Puff/D2PC methodology for chemical hazard prediction arises from the neglect of the variation in wind speed with height. Because both the D2-Puff and D2PC models assume that the wind speed measured at 10 m above ground level is representative of the transport wind speed at all downwind distances, they tend to overestimate transport speeds for low-level releases at short range and underestimate transport wind speeds for all release heights at longer downwind distances. Thus, the toxic cloud produced by a large accident will arrive in areas more than 1 to 2 km from the release sooner than predicted by the models. This is especially relevant to sites close to population centers. A further limitation of the Gaussian dispersion formulation is its low predictive accuracy for long-range transport (>50 km). If a substantial release were to occur, the current D2PC/ D2-Puff models are not suited for predicting the impacts on populations that might be 100 km or more downwind from the release site. As with any model, the results produced are limited by the accuracy of the inputs. These limitations include uncertainties about the amounts of chemical agents released and about meteorological conditions. D2-Puff, like other models, can produce hazard estimates that are helpful for emergency planning and response. In light of the limitations of Gaussian dispersion models, a key part of the CSEPP should be an ongoing evaluation of alternative approaches to modeling the release and impact of chemical agents. A considerable wealth of relevant modeling experience has been developed for coping with such events as fires and explosions at chemical plants, transportation spills, nuclear accidents, tunnel fires, uncontrolled forest burns, volcanic eruptions, and oil well fires. Many different models and methodologies are available. For example, one option would be to supplement each stockpile site with the capabilities of the National Atmospheric Release Advisory Center (NARAC)6 that is located at the University of California’s Lawrence Livermore National Laboratory. A more accurate modeling capability is valuable only if it is coupled with timely communication of results and appropriate responses by the stockpile site and surrounding communities. In the case of sites located close to large communities it is particularly important to have fast communication and alert procedures. The committee found, based on several site visits and interviews, that these procedures should be reviewed to identify bottlenecks that could be removed through better communications technologies. EMERGENCY RESPONSE: PREPAREDNESS, PLANS, NOTIFICATION, AND COORDINATION AT TOCDF This section focuses on the May 8-9, 2000, TOCDF incident but also draws on the December 3-5, 2000, JACADS event in discussing the importance of reporting requirements. The TOCDF incident is the primary focus because of that AEGL-1: The airborne concentration of a substance above which it is predicted that the general population, including susceptible individuals, could experience notable discomfort, irritation, or certain asymptomatic nonsensory effects. However, the effects are not disabling and are transient 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 effects or an impaired ability to escape. AEGL-3: The airborne concentration of a substance above which it is predicted that the general population, including susceptible individuals, could experience life-threatening health effects or death. Guidelines for each of the three levels of AEGL—AEGL-1, AEGL-2, and AEGL-3—have been developed for each of five exposure periods: 10 minutes, 30 minutes, 1 hour, 4 hours, and 8 hours. See NRC (2001b). 6 NARAC is a national emergency response service for real-time assessment of incidents involving nuclear, chemical, biological, or natural hazardous material. NARAC’s primary function is to support the Department of Energy and the Department of Defense for radiological releases. Under the auspices of the Federal Radiological Emergency Response Plan and the Federal Response Plan, the state-of-the-art NARAC modeling system has the capability to perform assessments of impacts from local to global scales. More information is available online at <http://narac.llnl.gov>.
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities event’s potential implications for the safety not only of the workers at the plant, but also for residents in the nearby community. This National Research Council (NRC) committee is not the first to express concern about the emergency response and management capabilities at TOCDF. Previous findings and concerns regarding the response system noted by other NRC committees and the General Accounting Office (GAO) (see Box 3-1) provide some necessary context for the committee’s examination. This committee’s evaluation of the emergency response to the two JACADS and TOCDF incidents that it examined in detail focuses on how effectively the division of responsibilities between the Army and the Federal Emergency Management Agency (FEMA) (see Box 3-1) actually functioned, and analyzes how it is likely to continue to function in the future. Although it is critical to have well-exercised plans, a communication system that enables adequate warning, effective communication among responders, and personnel who are appropriately attired for the nature of the hazard, it is equally critical that the organizational structure functions as designed, enabling an effective response. Indeed, how effectively the emergency response system is organized and how capable it is of functioning in a coordinated fashion have important implications for the three additional incinerator-based chemical demilitarization sites that are close to beginning operations. One of the important components of this committee’s examination of the emergency response to the two JACADS and TOCDF incidents has been a review of the preparedness of the emergency management system when required to function during stressing events. Relevant to the examination of emergency preparedness are a recent GAO report that examined FEMA’s and the Army’s efforts to prepare states for chemical weapons emergencies (GAO, 2001) and a CSEPP report describing CSEPP and Army benchmarking of the system (CSEPP, 2000). As pointed out in the GAO report, FEMA has adopted a series of national quantitative performance indicators that use benchmarks to evaluate the preparedness of different states in the program (GAO, 2001). These benchmarks are supposed to focus on outcomes rather than outputs as measures of performance in ensuring the essentials of public safety, including warning system effectiveness, readiness of coordination systems, reliability of critical communication systems, and public awareness of protective actions. FEMA is responsible for benchmarking emergency management compliance off-post; the Army uses a similar system at its instal-lations (GAO, 2001). The 2001 GAO report also mentions that Utah is one of three states considered to be fully prepared for a chemical emergency and that an active cooperative effort by the community is essential to the state’s current 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- BOX 3-1 Previous Concerns About and Recommendations for Achieving Efficient CSEPP Operations In its first systemization report produced when the plant was about to begin operations in 1996 (NRC, 1996), and as summarized in the National Research Council (NRC) report Tooele Chemical Agent Disposal Facility—Update on National Research Council Recommendations (NRC, 1999a), the NRC’s Stockpile Committee called on the Army and the Federal Emergency Management Agency (FEMA) where appropriate to: ensure that local and state Chemical Stockpile Emergency Preparedness Program (CSEPP) plans for responding to chemical events were complete and well exercised increase its efforts to work with the Utah Division of Comprehensive Emergency Management to ensure that first responders were adequately trained to use personnel protective equipment make certain that the Army/FEMA provided the necessary resources for completing the planned Tooele County emergency communications system. In 1999, the NRC added another recommendation: that the Army ensure that CSEPP and FEMA officials understand how the quantitative risk assessment (QRA) and other activities might affect risk and reflect this understanding in emergency planning and preparedness activities (NRC, 1999a). The 1999 NRC report reviewed and updated recommendations on operations at the Tooele Chemical Agent Disposal Facility (TOCDF). It noted that in accordance with the formal reorganization of responsibilities that had just been carried out between the Army and FEMA, all on-site responsibilities for emergency management were retained by the Army and all off-site responsibilities for emergency management and planning were given to FEMA. The 1999 Stockpile Committee report, noting previous General Accounting Office (GAO) reports that had cited existing problems with the CSEPP, stated, “The Committee is also concerned about CSEPP and about the horizontal fragmentation of responsibility at the federal level.” The report further commented (NRC, 1999a): Previous briefings by directors (both Army and FEMA) of the CSEPP, as well as discussions with directors of state emergency management agencies, have all stressed the importance of a well-coordinated response-management capability…. The recent reorganization will require excellent coordination and communication to overcome the barriers of separate organizational responsibilities. Finally, the 1999 NRC report expressed skepticism about the reorganization’s impact on improving the capacity for responding to an emergency.
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities munity, or guidance on when it is appropriate to notify citizens to leave shelters following an event. The committee judges that the benchmarks demonstrate a significant effort by FEMA and the Army to coordinate their efforts to measure a program’s status and to guide funding. For example, these measures have been developed over time and include the initial guidance document issued in 1993 (FEMA, 1993), and revised in 1996 (FEMA, 1996) to include nine benchmarks. These benchmarks were later revised again in 1997, and then again in a joint policy paper (FEMA, 1997) that added three additional benchmarks. The GAO used these 12 agreed-upon benchmarks in 19 “critical items” for its review of the program. The development of jointly used benchmarks does not reveal the full extent of the efforts by the Army and FEMA to jointly coordinate the emergency response/management system for chemical incidents. On October 8, 1997, coinciding with the formal division of the program, an MOU between the Army and FEMA formally identified their respective roles and responsibilities and joint efforts for “ . . . emergency response, preparedness involving the storage and ultimate disposal of the U.S. stockpile of chemical warfare material” (FEMA, 1997). Despite these efforts, the GAO has continued to find uneven performance measures being used and a lack of effectiveness in providing technical assistance and guidance to the states and communities (GAO, 2001). The performance of the emergency management system during the TOCDF May 8-9, 2000, event is not reassuring. It raises questions about how to interpret the system’s performance and what is meant by the term “fully prepared.” The lack of timely notification that an event had occurred has several important implications. First, benchmarking performance evaluations aside, the real test of an emergency management and response system is how it functions during an incident rather than performance during training exercises. What is particularly troubling is that something as simple as notification of an alarm (even after it was confirmed) was not reported to the Tooele County Emergency Operating Center (EOC). No one disputes the fact that the Tooele County EOC and Utah officials should have been notified of the events. This notification is part of the standard operating procedures (SOPs) and is probably the most exercised component of the system during operations testing and exercises. The fact that SOPs were clearly disregarded, and the off-site community potentially put at risk because of the lack of notification and knowledge of the event, demonstrates a clear breakdown of the system at the most elementary level. While some action aimed at preventing the repeating of this sequence of events has been taken through a new MOU for Information Exchange (Utah DEQ, 2000b), as discussed previously, the events surrounding this incident raise questions in critics of the program concerning the trustworthiness of those in charge of the emergency response and notification system. This trust is crucial to surrounding communities’ participation and cooperation in these programs, and questions concerning the credibility and functioning of the emergency notification and response systems have serious implications not only for communities where operating systems are currently located, but also for communities where they are planned, like Anniston. As pointed out above, this cooperation was cited in the GAO 2001 report as being a fundamental condition for the three programs gaining fully prepared status from FEMA and the Army. During their tours of TOCDF and DCD, members of the committee raised questions concerning the responsibilities of personnel as they related to the Tooele County EOC and Utah DEQ. In several instances personnel reported that their responsibilities “ended at the fence” and that they were not responsible for emergency management operations in the community. Similar attitudes were expressed at the JACADS facility, although the lack of a community near the facility mitigates the impact of such views. Technically, this view is correct concerning the division of responsibilities. However, for an effective response the program requires a strong degree of coordination between the DCD EOC and the Tooele County Office of Emergency Management. It should be remembered that at both JACADS and TOCDF the emergency response system functioned with only a few problems (such as those at JACADS when important personnel could not be notified because of communication problems). That is, the failures of notification occurred in alerting the civilian authorities that are a part of CSEPP. Within the Army structure at JACADS, for example, the personnel were assembled at checkpoint “Charlie” for possible evacuation once the alarm was sounded. The plant control room at Tooele informed the DCD’s EOC in a timely fashion of the alarms and provided it with updates on the situation. However, the DCD EOC then failed to pass on the notice to the Tooele County EOC and relevant State of Utah agencies. It is impossible to determine how the CSEPP portion of the emergency management system functioned as it was not provided timely notification of the events. Other communities soon to host chemical demilitarization facilities can learn a good deal from these two events and the nature of the “fix” that has been made by the Army and Tooele officials. Given this failure of communication and adequate notification, it is reasonable to assume that efforts to correct the problems associated with the response would focus on information exchange, such as through the MOU entered into by Tooele County and the DCD (Appendix G). The lack of notification and warning between the DCD and Tooele County and appropriate local and state agencies was caused in part by a lack of coordination between components of the two programs (CSEPP/FEMA and the Army), and in part because of DCD’s emergency management responsibilities that “end at the fence” (although timely communication cannot). The recent GAO report (GAO, 2001) on FEMA and Army efforts to prepare communities for a chemical emergency is vague on how to improve what is
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities being done other than suggesting that the two entities become proactive in doing so. Even if the various components of the emergency response system are designed to be fully coordinated, the system will not function well unless there is a high level of trust among the personnel involved. In particular, there needs to be trust between those “inside the fence” (professional personnel) and those “outside the fence” (local officials and the public). PUBLIC RESPONSES TO CHEMICAL EVENTS A significant aspect of the responses to chemical events concerns when and how the event is communicated to local officials and the local public.7 While much of the focus of post-event response is necessarily on the requirements of the formal regulatory process, interactions with the affected local officials and public have important implications as well. From the perspectives of the public and their officials, “chemical events” are largely involuntary risks that are potentially catastrophic and of technological origin. These characteristics render chemical events and incidents subject to substantial “social amplification” in which the characteristics of the events interact with individuals’ perceptions of the risk associated with them and the pattern of communication with the public and their response to both the event and the communication (Kasperson, 1992; Kasperson et al., 1988). According to this formulation, news reporters, interest groups, and concerned citizens monitor events and select and retransmit risk signals pertinent to those events via the news media and informal networks, which in turn results in a ripple effect of secondary impacts. These secondary impacts could include changes in perceived levels of risk, altered trust for the organizations and officials involved, pressure for legal and institutional change, changes in property values, and a myriad of other effects. Thus, the pattern of communication with and responsiveness to the public and their officials can have substantial “real” effects beyond the immediate health and environmental impacts posed by the chemical event. From a programmatic perspective, most importantly, these secondary effects can delay and further debilitate a program by undercutting the credibility of the agency(ies) entrusted with implementing the program, reinforcing negative messages about the technology being utilized and leading the public to question reports and official statements about progress in meeting program objectives. Understanding how chemical events might initiate the “social amplification” process is facilitated by elucidating critical aspects of the trust relationship engendered by activities such as the chemical weapons demilitarization program. Officials and citizens of the affected local communities, along with national officials, share the objective of destroying the chemical stockpile but must rely on others to carry out that destruction in a safe and timely manner. To undertake the program, these “principals” must establish a relationship with agencies (PMCD) and contractors—or “agents”8—to carry out the mission.9 The technological requirements of the process, and the magnitude of the potential 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 of principals and agents is discussed further in Chapter 1. Effective management of the principal-agent relationship in the chemical demilitarization program in order to achieve the required level of trust appears to require (1) monitoring processes that assure principals of their role in effective oversight, (2) complete and timely disclosure of events by the agents, and (3) demonstrable and timely assessments of the problems leading to chemical events and their correction. The JACADS December 3-5, 2000, incident raises several important issues concerning interactions with external principals. First, failure to believe the first sample analysis and act immediately to isolate the contaminated material is troubling. Absent very careful monitoring (in the form of investigations) by regulators, the event would have been misunderstood, potentially inhibiting appropriate responses. Second, tardy compliance with reporting requirements (as discussed above in this chapter), even when very permissive assumptions are made about the timing of the event onset, may well raise significant concerns among public officials, media, and affected citizens. Though JACADS is itself a geographically isolated facility, if the lapses associated with the December 2000 incident are repeated at other sites, residents living near similar facilities might lose confidence in the monitoring process. Moreover, these incidents could be seen as indicators of larger, unobserved problems in plant operations, such as insufficient willingness to forthrightly identify and correct conditions that could lead to chemical events. The committee’s investigation did not indicate that JACADS personnel intended to distort the December 3-5, 2000, event or delay reporting. However, the context (the “mere waste” mind-set versus the “agent” mind-set) and outcome could erode the confidence of external principals at a continental U.S. site in the monitoring and control processes. 7 Almost by definition, the communication process includes the local news media and interested citizens’ groups. 8 It is unfortunate that use of the term “agents” to indicate those who carry out tasks for “principals” might in this report be a source of confusion in the context of the chemical demilitarization program (where “agent” usually refers to chemical agent). Where agent is used in the institutional sense, it is italicized to reduce the potential for confusion. 9 There is a large and growing literature on what is referred to as the principal-agent relationship. For some of the more important work, see Wood (1992) and Scholz and Wei (1986).
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities The substantial costs in terms of resources and time required for multiple investigations of chemical events involving environmental releases, such as those that occurred in the TOCDF May 8-9, 2000, event, might contribute to a defensive mentality on the part of the operating personnel. At the same time, it is essential that local officials and local citizens have trusted representatives involved in these investigations both to ensure that they are competently undertaken and to facilitate effective communication of the results. The need for such local representation is underlined by the findings of delayed reporting or failure to report, indicating the significant flaws in the reporting process that stimulated the new notification and communication MOU between the DCD and Tooele County.
Representative terms from entire chapter: