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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities EVALUATION OF CHEMICAL EVENTS at Army Chemical Agent Disposal Facilities Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Board on Army Science and Technology Division on Engineering and Physical Sciences NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. DAAD 19-01-C-0051 between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number 0-309-08629-9 Cover: Decontaminated chemical munitions and containers at Johnston Atoll Chemical Agent Disposal System. Photographs for composite image courtesy of Colin Drury. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, D.C. 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu Copyright 2002 by the National Academy of Sciences. All rights reserved. Printed in the United States of America
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities COMMITTEE ON EVALUATION OF CHEMICAL EVENTS AT ARMY CHEMICAL AGENT DISPOSAL FACILITIES CHARLES E. KOLB, Chair, Aerodyne Research, Inc., Billerica, Massachusetts DENNIS C. BLEY, Buttonwood Consulting, Inc., Oakton, Virginia COLIN G. DRURY, University of Buffalo, New York JERRY FITZGERALD ENGLISH, Cooper, Rose and English LLP, Summit, New Jersey J. ROBERT GIBSON, Consultant, Wilmington, Delaware HANK C. JENKINS-SMITH, Texas A&M University, College Station WALTER G. MAY, NAE, University of Illinois at Urbana-Champaign GREGORY McRAE, Massachusetts Institute of Technology, Cambridge IRVING F. MILLER, Consultant, Chicago, Illinois DONALD W. MURPHY, NAE, Consultant, Davis, California ALVIN H. MUSHKATEL, Arizona State University, Tempe LEIGH SHORT, Consultant, Mount Pleasant, South Carolina LEO WEITZMAN, Consultant, West Lafayette, Indiana National Research Council Staff NANCY T. SCHULTE, Study Director (from June 2002) MARGARET N. NOVACK, Study Director (to June 2002) WILLIAM E. CAMPBELL, Administrative Officer JIM MYSKA, Research Associate PAMELA A. LEWIS, Senior Project Assistant SONNETT HOSSANAH, Senior Project Assistant CARTER W. FORD, Senior Project Assistant
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities BOARD ON ARMY SCIENCE AND TECHNOLOGY JOHN E. MILLER, Chair, Oracle Corporation, Reston, Virginia GEORGE T. SINGLEY III, Vice Chair, Hicks and Associates, Inc., McLean, Virginia ROBERT L. CATTOI, Rockwell International (retired), Dallas, Texas RICHARD A. CONWAY, Union Carbide Corporation (retired), Charleston, West Virginia GILBERT F. DECKER, Walt Disney Imagineering (retired), Glendale, California ROBERT R. EVERETT, MITRE Corporation (retired), New Seabury, Massachusetts PATRICK F. FLYNN, Cummins Engine Company, Inc. (retired), Columbus, Indiana HENRY J. HATCH, Army Chief of Engineers (retired), Oakton, Virginia EDWARD J. HAUG, University of Iowa, Iowa City GERALD J. IAFRATE, North Carolina State University, Raleigh MIRIAM E. JOHN, California Laboratory, Sandia National Laboratories, Livermore DONALD R. KEITH, Cypress International (retired), Alexandria, Virginia CLARENCE W. KITCHENS, IIT Research Institute, Alexandria, Virginia SHIRLEY A. LIEBMAN, CECON Group (retired), Holtwood, Pennsylvania KATHRYN V. LOGAN, Georgia Institute of Technology (professor emerita), Roswell STEPHEN C. LUBARD, S-L Technology, Woodland Hills, California JOHN W. LYONS, U.S. Army Research Laboratory (retired), Ellicott City, Maryland JOHN H. MOXLEY, Korn/Ferry International, Los Angeles, California STEWART D. PERSONICK, Drexel University, Philadelphia, Pennsylvania MILLARD F. ROSE, Radiance Technologies, Huntsville, Alabama JOSEPH J. VERVIER, ENSCO, Inc., Melbourne, Florida Staff BRUCE A. BRAUN, Director MICHAEL A. CLARKE, Associate Director WILLIAM E. CAMPBELL, Administrative Officer CHRIS JONES, Financial Associate DANIEL E.J. TALMAGE, JR., Research Associate DEANNA P. SPARGER, Senior Project Assistant
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Preface For over half a century the United States has maintained a stockpile of chemical weapons at Army depots distributed around the country. These weapons are now obsolete, and some have deteriorated to an alarming extent. Since 1990, in response to P.L. 99-145 and, later, P.L. 102-484, the Army’s Program Manager for Chemical Demilitarization (PMCD) has been engaged in active destruction of the chemical weapons stockpile. Operation of the two initial chemical agent demilitarization facilities utilizing incinerator technology—Johnston Atoll Chemical Agent Disposal System (JACADS) and Tooele Chemical Agent Disposal Facility (TOCDF) (see Appendix A)—has achieved destruction of more than 23 percent of the original chemical agent tonnage (U.S. Army, 2001a) but has not been without incident. A number of chemical events have resulted in various levels of chemical agent migrating at higher than anticipated levels into areas within the plants themselves, and in a few incidents small amounts of chemical agent have been released into the ambient atmosphere (see Appendix B). Although none of these incidents resulted in agent releases large enough to be measured at the chemical demilitarization plant perimeters (U.S. Army, 2001c) and thus posed no threat to nearby communities, they did raise concern among affected public officials and citizens about the fundamental safety of incineration-based chemical demilitarization facilities, particularly the three third-generation incineration facilities scheduled to begin operation at depots near Anniston, Alabama; Umatilla, Oregon; and Pine Bluff, Arkansas. STATEMENT OF TASK This report was motivated by congressional concern that incidents at JACADS and TOCDF might indicate systemic safety issues with either the technology or the management and operational systems employed at those two initial chemical demilitarization facilities. The Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities, convened in April 2001 by the National Research Council (NRC), was charged with the following statement of task negotiated between the Army and the NRC: The National Research Council will assemble a committee to evaluate chemical events that have occurred at the Johnston Atoll Chemical Agent Disposal System (JACADS) and the Tooele Chemical Agent Disposal Facility (TOCDF). The committee will: review process technology, operational activities (including training, operations and maintenance), and management by both the Army and its contractors to identify the causes of chemical events review applicable risk management and safety programs review emergency response activities that have occurred as a result of each chemical event, including information dissemination review actions and changes that have occurred in response to each chemical event and evaluate the impact and adequacy of these actions and changes visit JACADS and TOCDF to review facility configurations and to meet with personnel involved with operational activities, facility management, and emergency response make recommendations regarding improvements in operational activities, facility management, and emergency response review and recommend the needs to enable credible and more rapid investigation and corrective actions in response to future chemical events at chemical demilitarization sites, including consideration of needs of external stakeholders (e.g., regulators and concerned public). To ensure that new facilities for the destruction of chemical agent are operated as safely as possible, the NRC was further asked to recommend how lessons learned from the
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities events at JACADS and TOCDF should influence future operations, particularly at the new facilities in Alabama, Oregon, and Arkansas scheduled for completion and initial operations in the near future. COMMITTEE COMPOSITION AND PROCESS Committee members brought to their task extensive experience in chemical process engineering, chemical plant operations, human factors and ergonomics, industrial engineering, risk assessment and management, atmospheric sciences, environmental chemistry, toxicology, environmental regulations and law, emergency management, and public involvement and community relations (see Appendix H). In conducting this study, committee members drew on insights gained from their experiences in academia, chemical and related industries, federal and state agencies, private sector laboratories and consulting firms, and a law firm. The committee first met as a whole in Washington, D.C., in May 2001 to hear Army briefings on JACADS and TOCDF general operations and chemical events. (Appendix I lists the committee’s several meetings.) In early June many committee members attended an informational meeting on Capitol Hill hosted by Congressman Bob Riley (R-Ala.), who represents the region around the Anniston Chemical Demilitarization Facility, which is currently undergoing systemization and preoperational testing. Local government officials, emergency management professionals, and concerned citizens from the area near Anniston, Alabama, shared their perspectives with the committee. Committee members and staff also visited PMCD and its supporting contractors located at the Aberdeen Proving Ground, Maryland. The committee made site visits to JACADS in late June 2001 and to TOCDF in late July 2001 where it investigated the operational history, management procedures, and evaluations of and responses to chemical events at these facilities and discussed these issues with contractors and PMCD personnel at many levels. At a meeting at Woods Hole, Massachusetts, in October 2001 the committee completed the bulk of the data-gathering process as well as much of the initial draft of its report. The November 2001 meeting, in Washington, D.C., was dedicated to completing the initial report draft. A portion of the committee also visited Anniston, Alabama, in early December 2001 to inspect a completed third-generation incineration facility and a storage depot with an extensive nearby population base. As a part of the visit the committee visited the County Emergency Response Facility, met with County Commissioners, and participated in a public meeting. A draft report suitable for NRC prereview editing was produced subsequent to the Anniston visit. A final committee meeting in January 2002 focused on reviewing this draft, including refining the report’s findings and recommendations. The committee consulted with and received input from many stakeholders, both principals and agents, including personnel assigned to the office of the PMCD and its support contractors; contractor and subcontractor personnel responsible for operating chemical demilitarization facilities; former employees of chemical demilitarization facilities; congressional, state, and local officials; members of state citizen advisory committees; members of citizen activist groups; and local citizens. (See Appendixes C, D, and I.) The committee has also benefited from previous NRC reports on the chemical demilitarization program. Many of these reports were prepared by a standing NRC committee, the Committee on Review and Evaluation of the Army Chemical Stockpile Disposal Program (the Stockpile Committee), which evaluates aspects of the disposal program at the request of the Army. Several of the Stockpile Committee reports provided background for this committee’s study. In preparing, reviewing, printing, and distributing this report, the National Research Council (NRC) and this committee are acting as an expert agent for several principals, including the U.S. Congress; the Army, which contracted with the NRC to perform the study; and the U.S. public. The committee’s goals for this report were to respond, as thoroughly as feasible in the short time allotted, to the concerns stakeholders have expressed about past chemical events at JACADS and TOCDF, to determine the impact of these events on ongoing operations at TOCDF, and to assess the implications of these events for the safe and efficient operation of incineration-based chemical demilitarization facilities scheduled to begin operation at Anniston, Umatilla, and Pine Bluff. The committee greatly appreciates the support and assistance of National Research Council staff members Bruce A. Braun, Margaret Novack, Nancy Schulte, Bill Campbell, Jim Myska, Sonnett Hossanah, Pamela Lewis, and Carter Ford in the production of this report. NOTE: Following preparation of this report two chemical events, one at TOCDF on July 15, 2002, and one at JACADS on August 12, 2002, have taken place. Although these incidents occurred after the committee completed its analysis, they are similar in nature to events analyzed by the committee and reinforce the validity of the findings and the utility of the recommendations presented in this report. Charles E. Kolb, Chair Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Acknowledgment of Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Richard J. Ayen, Waste Management, Inc. (retired) Judith A. Bradbury, Battelle Patuxent River Dennis R. Downs, Utah Department of Environmental Quality Charles A. Eckert, Georgia Institute of Technology Richard S. Magee, Carmagan Engineering Lewis S. Nelson, New York City Poison Control Center George W. Parshall, E.I. DuPont de Nemours & Co. (retired) William R. Rhyne, Informatics Corporation, and Palmer W. Taylor, University of California, San Diego. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Royce W. Murray, University of North Carolina, Chapel Hill. Appointed by the National Research Council, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Contents EXECUTIVE SUMMARY 1 1 THE CHEMICAL DEMILITARIZATION CHALLENGE 7 Stockpile Content, Disposal Deadline, and Disposal Technology, 7 Chemical Events, 9 Chemical Events Associated with Disposal, 9 Chemical Events Occurring During Storage, 10 Tools for Assessing Hazards in the Operation of Chemical Stockpile Disposal Facilities, 11 Prospective Risk Analysis Tools, 11 Health Risk Assessment, 11 Systems Hazard Analysis, 11 Quantitative Risk Assessment, 11 Retrospective Analysis Tools, 12 Monitoring Systems, 12 Chemical Event Investigations, 12 Putting It All Together, 12 Monitoring Methods, 14 Event Analysis and Significance, 14 Chemical Demilitarization Institutional Issues, 14 Trust and Institutional Arrangements, 14 The Institutional Setting of Chemical Demilitarization, 15 Report Roadmap, 15 2 CAUSAL FACTORS IN EVENTS AT CHEMICAL DEMILITARIZATION FACILITIES 17 Definitions, 17 Sources of Input and Selection of Events for In-depth Analysis, 17 The PMCD Incident List, 18 The Calhoun County Commissioners’ List, 18 The Chemical Weapons Working Group Incident List, 18 Notice of Violation Reports, 21 Analysis of Selected Chemical Events, 22 Causal Factors, 22 Causal Tree Analysis of Two Events, 24 General Observations, 24 Specific Observations, 25
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities 3 RESPONSES TO CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES 26 Formal Event Reporting Protocols, 26 Actual On-Site Responses, 27 December 3-5, 2000, Event at JACADS, 27 May 8-9, 2000, Event at TOCDF, 28 Observations, 28 External and Regulatory Responses to Chemical Events, 29 Applicable Statutes, Regulations, and Guidelines, 29 Memorandum of Understanding Between Deseret Chemical Depot and Tooele County, 29 Levels of Investigation, 30 Modeling Potential Population Exposure, 30 Emergency Response: Preparedness, Plans, Notification, and Coordination at TOCDF, 32 Public Responses to Chemical Events, 35 4 IMPLICATIONS OF PAST CHEMICAL EVENTS FOR ONGOING AND FUTURE CHEMICAL DEMILITARIZATION ACTIVITIES 37 Risk and Management of Change Programs Already in Place, 37 Safety Programs, 39 Programmatic Lessons Learned Program, 40 PLL Program Database, 40 Resultant Changes, 42 5 PREPARING FOR POTENTIAL FUTURE CHEMICAL EVENTS AT BASELINE CHEMICAL DEMILITARIZATION FACILITIES 44 Summary of Chemical Events Analyses, 44 Chemical Event Response and Review by Management, 44 Building on the Results of Risk Assessment, 45 Building a Safety Culture, 46 Operational Changes, 46 Worker Education, Training, and Involvement, 47 Desired Principal-Agent Interactions, 47 Rapid and Safe Restart Requirements, 49 Restarts After Changeovers and Maintenance, 49 Restarts After a Chemical Event, 49 6 FINDINGS AND RECOMMENDATIONS 51 REFERENCES 57 APPENDIXES A Specific Design Features of fhe Tooele Chemical Agent Disposal Facility Baseline Incineration System 61 B Chronicle of Chemical Events and Other Occurrences at TOCDF and JACADS as Identified by PMCD 71 C List of Individual Incidents from the Chemical Weapons Working Group 79 D List of Individual Incidents from Calhoun County Commission, Anniston, Alabama 90 E Additional Information Concerning Risk 97 F Causal Tree Analysis of December 3-5, 2000, Event at JACADS 103 G Memorandum of Understanding Between Deseret Chemical Depot and Tooele County for Information Exchange 106 H Biographical Sketches of Committee Members 114 I Committee Meetings 117
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Figures, Tables, and Boxes FIGURES 1-1 Location and size (percentage of original stockpile) of eight continental U.S. storage sites, 8 3-1 Component parts of an integrated system for modeling the impact of release of chemical agents, 31 4-1 TOCDF recordable injury rate 12-month rolling average, August 1996 (the start of agent operations) through December 2001, 39 A-1 Layout of the TOCDF, 62 A-2 Rocket-handling system, 63 A-3 Bulk handling system, 64 A-4 Projectile-handling system, 65 A-5 Mine-handling system, 66 A-6 Deactivation furnace system, 67 A-7 Metal parts furnace, 67 A-8 Liquid incinerator, 68 A-9 Dunnage furnace, 68 A-10 Pollution abatement system, 69 E-1 Schematic illustration of risk elements at a chemical agent and munitions storage and destruction site, 98 E-2 Contributors to the average public fatality risk from continued storage at Deseret Chemical Depot 99 E-3 Comparison of risks to the public during processing at Deseret Chemical Depot and the Tooele Chemical Agent Disposal Facility, 100 E-4 Contributors to the average public fatality risk from disposal operations at DCD and TOCDF, 100 E-5 Contributors to the average risk of fatality for disposal-related workers at DCD and TOCDF, 101 F-1 Causal tree for December 3-5, 2000, JACADS event, 104-105 TABLES 2-1 Events on the PMCD List That Were Examined by the Committee, 19 2-2 Events on the PMCD List That Were Chosen by the Committee for Detailed Analysis, 19
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities 2-3 Committee’s Classification of 69 Items Cited in Notice of Violation Reports, 22 2-4 Frequency of Causal Factors in the Seven Incidents Analyzed by the Committee, 23 4-1 Issues and Factors in Assessing the Value of Change Options, 38 BOXES 1-1 Details on Airborne Chemical Agent Monitoring Methods and Standards at Chemical Demilitarization Facilities, 13 2-1 December 3-5, 2000, JACADS Event, 20 2-2 May 8-9, 2000, TOCDF Event, 21 2-3 An Example of Negative Effects of Mind-set, 25 3-1 Previous Concerns About and Recommendations for Achieving Efficient CSEPP Operations, 33 4-1 Additional PLL Program Components, 41 5-1 Examples of Observations That the Committee Concluded Were Uninformed, 48
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities Acronyms and Abbreviations ACAMS automatic continuous air monitoring system AEGL Acute Exposure Guideline Level AMC Army Materiel Command ASC allowable stack concentration CAC Citizens Advisory Commission CAMDS Chemical Agent Munitions Disposal System CDC Centers for Disease Control and Prevention Chem demil chemical demilitarization CSDP U.S. Chemical Stockpile Disposal Program CSEPP Chemical Stockpile Emergency Preparedness Program CWC Chemical Weapons Convention CWWG Chemical Weapons Working Group DAAMS depot area air monitoring system DCD Deseret Chemical Depot DEQ (Utah) Department of Environment Quality DFS deactivation furnace system DoD Department of Defense DSHW (Utah) Division of Solid and Hazardous Waste DWL drinking water level ECP engineering change proposal ECR explosive containment room EG&G Edgerton, Germerhausen and Grier (a contracting company) EMIS Emergency Management Information System EOC emergency operations center EPA Environmental Protection Agency FEMA Federal Emergency Management Agency FPD flame photometric detector GAO General Accounting Office GB sarin (a nerve agent) GC gas chromatograph, gas chromatography GPL general population limit
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Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities H sulfur mustard HAZMAT hazardous material HAZOP hazardous operation HD sulfur mustard (distilled) HDC heated discharge conveyor HRA health risk assessment HT vesicant mixture: 60 percent agent H and 40 percent bis[2(2-chloroethylthio)ethyl] ether HVAC heating, ventilation, and air conditioning JACADS Johnston Atoll Chemical Agent Disposal System LIC liquid incinerator MDB munitions demilitarization building MOU memorandum of understanding MPF metal parts furnace MSD mass spectrometric detector NARAC National Atmospheric Release Advisory Center NRC National Research Council OSHA Occupational Safety and Health Administration PARDOS partial dosage PAS pollution abatement system P.L. public law PLL programmatic lessons learned (program and database) PMACWA Program Manager for Assembled Chemical Weapons Assessment PMATA Product Manager for Alternative Technologies and Approaches PMCD Program Manager for Chemical Demilitarization PMCSD Project Manager for Chemical Stockpile Disposal QA quality assurance QC quality control QRA quantitative risk assessment RCRA Resource Conservation and Recovery Act RIR recordable injury rate SAIC Science Applications International Corporation SBCCOM U.S. Army Soldier and Biological Chemical Command SHA systems hazard analysis SOP standard operating procedure TOCDF Tooele Chemical Agent Disposal Facility TWA time-weighted average UPA unpack area USACAP U.S. Army Chemical Activity Pacific USACHPPM U.S. Army Center for Health Promotion and Preventive Medicine U.S.C. United States Code VX a nerve agent WCL waste control limit WPL worker population limit 5X level of decontamination (suitable for commercial release)