Appendix B
Chronicle of Chemical Events and Other Occurrences at TOCDF and JACADS As Identified by PMCD

TOCDF

Date

Event Control Number

Building

Comments

24-Aug-96

TOCDF 96-01 (Chemical Event) [PMCD]

Carbon Filter Vestibule

GB agent migration from MDB filter into vestibule. Probable cause of the agent readings in the containment vestibules was the method used for placing the filter units off-line when not in service. The method used closed both the inlet and outlet dampers, which allowed the pressure in the filter plenum to equilibrate with the filter containment vestibules. No indication of a leak.

09-Oct-96

TOCDF 96 – (Chemical Event)

Chemical Analysis Lab - Rm. 113

Operators used the room-breathing zone ACAMS to monitor for agent vapors inside the transportation over pack.

14-Oct-96

TOCDF 97-01 (Chemical Event)

Explosive Containment Room B

Rocket remained at the punch and drain station with the sequencer not reset due to PLS 3-sensor failure. Rocket hung up on conveyor. Rocket freed and processed.

26-Jan-97

TOCDF 97-02 (Chemical Event)

Observation Corridor - Buffer Storage Area

Operators had shut down the LIC # 2 and adjusted the atomizing air pressure to stabilize flame strength. Ventilation upset allowed vapor to migrate to the Observation Corridor. Agent maintained under engineering controls.

08-Apr-97

TOCDF 97-03 (Chemical Event)

Chemical Assessment Lab

Waste was being transferred from satellite hood # 5 to the 90-day area hood # 6. Following the transfer, ACAMS went into alarm.

NOTE: This appendix is reprinted from U.S. Army (2001c). Boldfaced bracketed notations in the column headed “Event Control Number” indicate that external investigations were conducted. Legend: CDC, Centers for Disease Control and Prevention; DAIG, Department of the Army Inspector General; DA Safety, Department of the Army Office of Safety; DOD, Department of Defense; PMCD, Program Manager for Chemical Demilitarization; UTAH DEQ, Department of Environmental Quality, State of Utah.



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Appendix B Chronicle of Chemical Events and Other Occurrences at TOCDF and JACADS As Identified by PMCD TOCDF Event Control Date Number Building Comments 24-Aug-96 TOCDF 96-01 Carbon Filter Vestibule GB agent migration from MDB filter into ves- (Chemical Event) tibule. Probable cause of the agent readings in the con- [PMCD] tainment vestibules was the method used for placing the filter units off-line when not in service. The method used closed both the inlet and outlet dampers, which allowed the pressure in the filter plenum to equilibrate with the filter containment vestibules. No indication of a leak. 09-Oct-96 TOCDF 96 – Chemical Analysis Lab - Operators used the room-breathing zone ACAMS to (Chemical Event) Rm. 113 monitor for agent vapors inside the transportation over pack. 14-Oct-96 TOCDF 97-01 Explosive Containment Rocket remained at the punch and drain station with the (Chemical Event) Room B sequencer not reset due to PLS 3-sensor failure. Rocket hung up on conveyor. Rocket freed and processed. 26-Jan-97 TOCDF 97-02 Observation Corridor - Operators had shut down the LIC # 2 and adjusted the (Chemical Event) Buffer Storage Area atomizing air pressure to stabilize flame strength. Venti- lation upset allowed vapor to migrate to the Observation Corridor. Agent maintained under engineering controls. 08-Apr-97 TOCDF 97-03 Chemical Assessment Lab Waste was being transferred from satellite hood # 5 to the (Chemical Event) 90-day area hood # 6. Following the transfer, ACAMS went into alarm. NOTE: This appendix is reprinted from U.S. Army (2001c). Boldfaced bracketed notations in the column headed “Event Control Number” indicate that external investigations were conducted. Legend: CDC, Centers for Disease Control and Prevention; DAIG, Department of the Army Inspector General; DA Safety, Department of the Army Office of Safety; DOD, Department of Defense; PMCD, Program Manager for Chemical Demilitarization; UTAH DEQ, Department of Environmental Quality, State of Utah. 71

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72 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES 30-May-97 TOCDF / DCD 97-22 CHB Three (3) MC-1 bomb casings were delivered to TOCDF (Chemical Event) from DCD. The bomb casings were certified 3X. A low- [DAIG & DOD] level vapor reading of GB was detected inside an empty MC-1 bomb casing. ACAMS located within 12 feet of the bomb casings did not detect agent. DAIG conducted investigation of allegations of civilian exposure to chemi- cal agent during a tour of TOCDF. Conclusion of inves- tigation, Army policy does not adequately address protec- tion of civilians in a chemical hazard area. Regulatory guidance and procedures changed. 06-Aug-97 TOCDF 97-04 MBD - Observation During scheduled power outage test, back-up power did (Chemical Event) Corridors not come on line in the prescribed time. Agent vapor mi- gration to Observation Corridors due to HVAC failure during global loss of power. 30-Mar-98 TOCDF 98-01 DEMIL FACILITY Incomplete drain of an MC-1 bomb allowed excess of (Chemical Event) agent to enter metal parts furnace. The resulting tempera- ture variations caused the system to shut down as de- signed. No agent was release to the environment as a re- sult of the event. 13-Dec-98 TOCDF 99-01 Toxic Cubicle The strainer system on ACS-tank-101 was incorrectly re- (Chemical Event) assembled following solids removal from the strainer bas- ket. This allowed approximately 142 gals of liquid agent to spill into the containment sump of the Toxic Cubicle. The TOX containment sump can hold 512 gals of liquid. The agent was collected into the sump in the toxic cubicle and subsequently pumped to the agent spill tank. The TOX is designed for this contingency. The cause of the leak was an improperly sealed lid following a change-out of the agent strainer. 04-Apr-99 Weekly Report DFS Cyclone Bin DAAMS tube detected agent for the DFS cyclone bin en- (GM 0674-99) closure at 16.36 TWA. A second DAAMS analysis re- (Chemical Event) sulted in 7.99 TWA. A portable ACAMS was then used to monitor the cyclone bin and enclosure. ACAMS read- ings were 0.0 TWA. Real-time Analysis Platform (RTAP) support was requested to monitor the area around the cyclone enclosure. The results of the RTAP monitoring were 0.00 TWA. 02-May-99 Weekly Report Unpack Area Unpack Area (UPA) ACAMS - 203 alarmed at maximum (GM 0756-99) (Chemical Event) reading of 508 TWA and the local ACAMS displayed 2080 TWA. UPA workers were evacuated and monitored out using ACAMS. Blood draws were performed on all potentially exposed workers. Blood draws on workers in dicated no depression of CHE. Once the ACAMS level dropped below the level of quantification, Monitoring Personnel went into the UPA to challenge ACAMS-203 and pull DAAMS tubes. ACAMS-203 alarmed at 0.29 TWA while personnel were in level C protective equip- ment. DAAMS tubes confirmed for GB Agent at 0.54 TWA. A safety investigation conducted. 21-May-99 TOCDF 99-02 Unpack Area Agent migrates from an Explosive Containment Room to (Chemical Event) Unpack Area (UPA). UPA ACAMS alarmed and seven [PMCD] workers donned their masks. Blood draws on workers indicated no depression of CHE. Probable source of agent vapors was migration from the ECR through the EVC to the UPA through the transfer airlocks, during the transfer of 2 ton containers.

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73 APPENDIX B 24-May-99 TOCDF 99-03 Unpack Area After removal of nose closures on 105mm projectiles, one (Chemical Event) had liquid agent in the burster well. Agent was not sus- [PMCD] pected to be present in the burster well. 26-May-99 TOCDF 99-04 Toxic Maintenance Area Workers in the Toxic Maintenance Area (TMA) were re- (Chemical Event) moving bags of waste from trays for segregation and fur- [PMCD] ther processing. ACAMS alarmed and workers exited the TMA. Blood draws on workers indicated no depression of CHE. 04-Jun-99 TOCDF 99-05 MDB TOCDF experienced a global loss of power due to a loss (Chemical Event) of a substation in Tooele, Utah. Emergency generator # [PMCD] 101 failed to take the electrical load initially and genera- tor # 102 had frequency and voltage fluctuations. These fluctuations caused breakers to trip open. MDB ventila- tion system began to degrade allowing agent vapor mi- gration. A technical engineering analysis of the emer- gency electrical system was conducted. 20-Feb-00 TOCDF 00-01 DFS Room Two workers were repairing the Heated Discharge Con- (Chemical Event) veyor (HDC) when an ACAMS alarmed. Workers ex- ited immediately and sent to TOCDF Medical Clinic for evaluation. Blood draws on workers indicated no depres- sion of CHE. 23-Feb-00 TOCDF 00-02 Liquid Incinerator 30-gal barrel of slag tipped over by mechanical lift and (non-surety) (LIC # 2) ignited a small fire, which damaged a slag conveyor mo- tor and electrical controls. Cause was failure of a sensor which stops conveyor when a barrel is present. Repairs to Slag conveyor motor and electrical controls. 27-Feb-00 TOCDF 00-03 CHB Agent detected inside an On-Site Container (ONC). The (non-surety) ONC is used to safety transport munitions from the stor- age area to demil facility. ONC moved to the UPA and processed. Leak contained in engineering controls. 19-Mar-00 TOCDF 00-04 TOCDF High winds interrupted commercial power. As a precau- (non-surety) tion TOCDF suspended munition processing. Demil pro- cess resumed after commercial power restored. 20-Apr-00 TOCDF 00-05 DFS Air lock Commercial power disrupted and TOCDF changed to (non-surety) emergency backup power. ACAMS alarmed in the DFS due to the interruption of the airflow. As a precaution TOCDF suspended munition processing and RTAPS de- ployed with negative readings. Demil process resumed after commercial power restored. 08-May-00 TOCDF 00-06 TOCDF During processing of GB rockets the Deactivation Fur- (Chemical Event) nace System (DFS) interlock shut off all burners due to [DA SAFETY, CDC & pollution abatement system (PAS) air flow meter failure. UTAH DEQ] ACAMS alarmed in the furnace stack during re-light of the furnace. No agent or munitions were being processed at time of the alarms. The perimeter monitor readings were all negative for agent. Investigation teams from CDC, Department of Army Safety and Utah (DSHW) con- ducted the investigation of stack release. Technical inves- tigation completed with recommended procedural and de- sign changes.

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74 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES 26-Jun-00 TOCDF 00-07 TOCDF Non-confirmed reading - False positive readings at com- (non-surety) mon stack caused by contaminated DAAMS tubes. Con- tamination caused by the calibration standards. Event closed. 14-Aug-00 TOCDF 00-08 TOCDF (Non-surety) Office employee suffering from acute allergies and (non-surety) Asthma had an adverse reaction to the cutting of weeds. The employee was transported to the hospital for treat- ment. Hospital doctors recommended she remain for ob- servation and released the next day. 13-Oct-00 TOCDF 01-01 DCD BLDG. 4544 Truck driver fell from his truck and bruised his shoulder. (Non-surety) The driver was taken to the hospital for treatment and released. No agent or munitions involved. 15-Oct-00 TOCDF 01-02 TOCDF Employee had cardiac symptoms and was transported to (Non-surety) hospital. Doctors concluded the man suffered from digi- talis (excess salt) due to poor diet. Non-work related and no agent or munitions involved. 26-Oct-00 TOCDF 01-03 TOCDF Employee suffered from shortness of breath due to a res- (Non-surety) piratory infection. Non-work related and no agent or mu- nitions involved. Sent to hospital. 03-Nov-00 TOCDF 01-04 TOCDF A propane leak at TOCDF caused a temporary shut down (Non-surety) of operations. DCD Fire Department was summoned. The fire department set up gas detectors and determined that there was no immediate danger. No agent or muni- tions involved. 17-Nov-00 TOCDF 01-05 TOCDF Operational shutdown - natural gas supplier Questar, (Non-surety) informed DCD due to unseasonably cold weather gas sup- ply was low. 20 Nov natural gas supply restored and pro- cessing resumed. 25-Nov-01 TOCDF 01-06 Personnel Maintenance A bag of TAP gear was being monitored when ACAMS (Non-surety) Building, alarmed. Bag sent to TMA to be processed. 26-Nov-01 TOCDF 01-07 Personnel Maintenance A bag of TAP gear was being monitored when ACAMS (Non-Surety) Building, alarmed. Bag sent to TMA to be processed. 05-Dec-00 TOCDF 01-08 Liquid Incinerator Slag barrel spilled causing a small fire. Repairs to Slag (Non-Surety) (LIC # 1) conveyor motor and electrical controls. 18-Dec-01 TOCDF 01-09 Filter Bank # 9 During filter change operation the plastic bag ripped. No (Non-Surety) agent detected. 28-Dec-00 TOCDF 01-10 TOCDF Employee had symptoms of an appendicitis or gall blad- (Non-Surety) der attack. He was transported hospital. Non-work re- lated and no agent or munitions involved. 01-Jan-01 TOCDF 01-11 ACAMS 107B TOCDF experienced a small electrical fire (heat trace) (Non-Surety) with ACAMS sample line. Fire extinguished with dry- chemical fire extinguisher. No agent or munitions in- volved. 02-Feb-01 TOCDF 01-12 Chemical Assessment Lab waste was not sufficiently deconned prior to move- (Non-Surety) Lab (CAL) - 90 Day ment to the 90-day hood. Lab area under engineering [PMCD] hood (Non-Surety) controls no agent release. Local investigation being con- ducted.

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75 APPENDIX B 16-Feb-01 TOCDF 01-13 CAL - Rm. 114 Two 50-ml plastic centrifuge tubes containing 10-ml so- (Non-Surety) lution were transported between rooms without second- [PMCD] ary containment. No Lab personnel were in room at time of the ACAMS alarm. 21-Feb-01 TOCDF 01-14 CAL - Rm. 115 Waste vial was not filled with bleach. Investigation into (Non-Surety) Lab practices initiated covering recent Non-surety events [PMCD] with the Lab. 27-Feb-01 TOCDF 01-15 Liquid Incinerator- Inadvertently shut down of ventilation system. All agent (Non-surety) Secondary Room vapor maintained under engineering controls. LIC sec- ondary room was maintained under engineering controls. No agent release. 13-Mar-01 TOCDF 01-16 Liquid Incinerator Slag barrel overfilled during slag tap causing a small fire. (Non-surety) (LIC # 2) Damaged electrical wiring and conveyor system in the slag pit. 02-Apr-01 TOCDF 01-17 Explosive Containment Bottom gated opened and failed to cycle completely - Gate (Non-surety) Room B remained in the open position. Sheared rocket pieces over- heated and flashed. Deluge system activated extinguish- ing the fire. 19-Apr-01 TOCDF 01-18 Personnel Maintenance Monitoring of TAP Gear in the cotton goods room (Non-surety) Building ACAMS alarmed. Bags moved to the Toxic Maintenance Area for further processing. 05-May-01 TOCDF 01-19 Liquid Incinerator Slag fire of less than 1 pound burned out a sensor. Not (Non-surety) (LIC # 2) reported as event because of size. JACADS Event Control Date Number Building Comments 30-Jun-90 JACADS – Munitions Demilitarization After processing the first 15 rockets, the DAAMS tubes (Unusual Occurrence) Building (MDB) were collected and analyzed. Several DAAMS tubes were [PMCD] confirmed positive, but there were no ACAMS alarms. Determined to be the analysis of a DAAMS tube from the ECR which was saturated with GB. 08-Dec-90 JACADS – Common Stack Agent feed to the LIC was shut off and the 20 PSIG air (Unusual Occurrence) purge for 10 seconds was insufficient to purge the agent line into the furnace. As the furnace cooled down, agent vapors were released into the chamber and pulled through the furnace system by the ID fan. Technical investigation conducted and procedures changed. 31-Oct-90 JACADS – Observation Corridor During feed rate capacity test the primary burner locked (Unusual Occurrence) (09-123) out on flamed failure. Possible agent migration through cracks in the wall which separates the LIC from the Ob- servation Corridor. HVAC engineers performed smoke test and found leaks at the upper joint. Separation wall repaired. 15-Nov-90 JACADS – Perimeter Stations No ACAMS agent alarms sounded in the “Red Hat” or (Unusual Occurrence) any other JACADS area. No DAAMS confirmation was

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76 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES received from any other operation. Investigation conclu- sion was no agent present. DAAMS tubes were con- taminated. 30-Sep-91 JACADS – Lower Observation Worker dropped a vial of dilute VX standard. Spill (Unusual Occurrence) Corridor deconned and area monitored. 22-Dec-91 JACADS – LSS Station # 77 Detection of VX in DAAMS samples taken from LSS (Chemical Event) station # 77. Contamination of the DAAMS valve, LSS- VALVE-868 silver fluoride pads assembly. Operator was wearing contaminated gloves and transferred contamina- tion. LSS reconnected to a different manifold with zero readings. Operating procedures changed. 21-Jan-92 JACADS – DFS Processing VX-filled M55 Rockets when a detonation (Unusual Occurrence) occurred within the DFS, causing the kiln to stop rotating. [PMCD] 30-May-92 JACADS – Liquid During slag removal and small sliver of glass punctured (Unusual Occurrence) the operators Tyvex protective clothing cutting the opera- tors calf. Blood draw was normal. 03-Jul-92 JACADS – Toxic Cubicle Maintenance personnel enter toxic cubicle to replace an (Unusual Occurrence) instrument and valve. When one of the agent transfer lines was cut, a dark oily substance leaked out. ACAMS read- ings began to rise. Personnel in level B left the toxic cu- bicle. Blood draw on entrants was negative. Operators re- entered in DPE suits and finished maintenance operation. 2-Jan-93 JACADS – Explosive Containment During M60 105mm projectile processing within the ECR (Unusual Occurrence) Room-A a fire occurred along the miscellaneous parts conveyor. [PMCD] Fire was contained within the ECR. Changes made to the equipment and increased frequency of ECR cleanup of residual explosives. 17-Mar-93 JACADS – MDB Raytheon Engineering and Constructors worker poten- (Chemical Event) tially exposure to Mustard Agent (HD). Worker devel- [PMCD] oped blister(s) on leg after handling HD contaminated waste materials. 19-Mar-93 JACADS – MPB 120V AC extension cord over heated due to a short caus- (Unusual Occurrence) ing a small fire. The fire was extinguished with an ABC fire extinguisher 8-Dec-93 JACADS – MDB CON operator noted the agent level in ACS-tank-102 was (Chemical Event) not increasing. Draining process stopped and a remote camera scan of MPB conducted. Scan revealed agent dis- charging onto the floor. Investigation revealed a manual block value was closed on the ACS Tank. Agent backed up the piping and spilled onto the floor of the MPB. All agent maintained under engineering controls. Corrective actions taken to prevent reoccurrence 13-Dec-93 JACADS – Lower Observation Entrants entrained agent into LOC via airlocks. Technical (Chemical Event) Corridor (LOC) Investigation completed and operation procedures changed. 18-Dec-93 JACADS – SDS-Pump Worker received a caustic burn (non-chemical agent) on (Unusual Occurrence) his left hand. Protective clothing inadequate for task.

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77 APPENDIX B 07-Jan-94 JACADS – MDB - Exhaust Filter Momentary power failure and subsequent loss of ventila- (Unusual Occurrence) System tion in the MDB. No confirmed agent detected in Cat- egory C areas. Corrective action JACADS on own sepa- rate power distribution system. 13-Jan-94 JACADS – Lower Observation Entrants entrained agent into LOC via airlocks. ACAMS (Unusual Occurrence) Corridor (LOC) monitoring the LOC had a positive reading slightly above LOQ but below the TWA. Technical Investigation com- pleted and operation procedures changed. 14-Mar-94 JACADS – Explosive Containment Top feed gate did not open allowing cut rocket sections 2, (Chemical Event) Room B 3, 4, and 5 to remain on top of the feed gate. Cut sections flashed causing a small fire. Deluge system water spray extinguished the fire. Rocket processing halted. All agent vapors maintained under engineering controls. Investiga- tion conducted and corrective actions taken - install top feed gate brushes and program change to Logic Controller. 15-Mar-94 JACADS – MPF During Capability test of Metal Parts Furnace (MPF) (Unusual Occurrence) three- (3) pressure spikes were observed. Note all projec- tiles had the burster wells pulled. 23-Mar-94 JACADS – Common Stack LIC was being ramped down (controlled cooling opera- (Chemical Event) tion) for slag removal. Minute amount of GB released via [PMCD] common stack. Technical Investigation completed and operation procedures changed. 20-Apr-94 JACADS – Lower Observation Entrants entrained agent into LOC via airlocks. ACAMS (Unusual Occurrence) Corridor (LOC) monitoring the LOC had a positive reading slightly above LOQ but below the TWA. Technical Investigation com- pleted and operation procedures changed. 21-Apr-94 JACADS – LIC/MPF airlock MDB filter unit taken off-line to perform maintenance. (Unusual Occurrence) Air dampers on spare filter did not operate properly caus- ing a fluctuation in the MDB. Agent maintained under engineering controls. Agent alarm in LIC/MPF airlock. Cause limit switch failure. Corrective actions taken. 19-Nov-94 JACADS – Explosive Detonation of rocket on fuzz shear causes agent migra- (Unusual Occurrence) Containment tion to observation corridor. All agent vapor contained [PMCD] Room under engineering controls and exhausted through the MDB charcoal filter units. 2-Mar-95 JACADS – JACADS Perimeter Unconfirmed perimeter DAAMS for GB. (Unusual Occurrence) 17-Mar-95 JACADS – Filter 404 Release of agent vapor from filter bank 404. Agent de- (Chemical Event) tected in temporary enclosure below the GPI level and registered within the range of 0.31 - 0.39 of the GPI level. Filter bank was off line and restarted and “air-washed”. 17-Jan-95 JACADS – JACADS - MDB Power failure with agent migration. No agent detected in (Unusual Occurrence) Category C areas. 16-Aug-96 JACADS – Upper Observation A low-level indication of GB vapor was detected in the (Unusual Occurrence) Corridor Observation Corridors. Cause temporary loss of power. 28-Aug-96 JACADS – JACADS Loss of power. (Unusual Occurrence)

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78 EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES 19-Dec-96 JACADS – Upper Observation During a heavy rainstorm a ground fault occurred causing (Unusual Occurrence) Corridor the power grid to become unstable. Loss of power with agent readings in an Observation Corridor. 22-Apr-97 JACADS – JACADS CONR-110 rack 16 faulted resulting in loss of power. (Unusual Occurrence) 17-Jul-97 JACADS – Filter 407 GB vapors in filter airlock for filter bank 407. (Unusual Occurrence) 7-Sep-97 JACADS – MDB Observation Indications of GB vapors in MDB Observation Corridors. (Unusual Occurrence) Corridor 2-Feb-98 JACADS – Common PAS ACAMS alarm at common PAS stack (due to promo w/ (Unusual Occurrence) burster case intact being sent to MPF), no agent detected. ACAMS alarmed due to products of incomplete combus- tion. 16-Jan-00 JACADS – JACADS Treaty Trailer Operational anomaly in JACADS Treaty Trailer. No (Unusual Occurrence) agent operations at the time of reading. False positive. 04-Apr-00 JACADS – MDB Removing contaminated clothes after deconned. Blood (Unusual Occurrence) draws on workers indicated no depression of CHE. 11-Apr-00 JACADS – JACADS Operational anomaly during training exercise. (Unusual Occurrence) 23-Apr-00 USACAP 00-01 – JACADS Sample of liquid contained in a 55-gal drum had a posi- (Chemical Event) tive reading for VX. Blood draws on 29 people indicated no depression of CHE. Technical investigation completed with recommended procedural changes. 19-Oct-00 USACAP 01-01 – DFS PAS Ash from DFS cyclone contained low levels of VX. 4 (Chemical Event) workers & 1 OPCW inspector sent for blood draw. All five individuals with no CHE depression. 05-Dec-00 USACAP 01-02 – JACADS HDC Waste Agent detected in ash removed from the DFS. Agent con- (Chemical Event) Bin tainment spill pillows are the possible source of agent [PMCD] readings in ash. No personnel exposures.