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CHAPTER 4. CONTINGENCY PLANNING AND MANAGEMENT Anticipating emergencies and planning to meet them are vital steps in the development of procedures that will lead to quick, orderly, effective and efficient post-disaster response. Therefore, this chapter will address such topics as disaster planning, system safety analysis, emergency medical services, and emergency response mechanisms of the Federal government. Whereas special precautions, preparations, and procedures may be necessary to reduce the threat to life and increase the chances of evacuation, escape, and survival in the event of a disaster, it is necessary to understand that there is no sharp line between disasters and accidents, particularly in planning for control. Much of the material in this chapter is therefore applicable not only to post- disaster survival and rescue operations, but also to general hazard control activities as well. In addition, most of the methodology dis- cussed is already available but needs to be adapted to the mining industry. 4.1 DISASTER PLANS As long as hazard sources such as methane, coal dust, water pools, electrical equipment, etc., exist in mines, there is always a possi- bility that accidents will occur. Good mine planning and operating practices, greater choice in equipment, increasing mandatory and advisory regulatory standards, and vigilance by management and labor have greatly reduced, but not eliminated, the likelihood of hazards and of loss of control during an accident. Loss of control—and the time frame within which this loss takes place—depends on the type of acci- dent. Explosions, inundations, fires, and massive roof falls vary greatly in their potential for damage and the opportunities for re-establishing control. Successful response to a hazard or accident depends upon many factors. Among the more critical ones are: (1) the existence of emergency plans with which the mine personnel are thoroughly familiar as a result of regular training, (2) the time available to make judg- ments and (3) the mental ability and preparedness of the individuals on the scene. The appropriate actions to take during the first few moments after an accident depend on the type of accident. Quick and -73-

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correct response is vital. It is necessary to explore the source, identify corrective actions, and then take the best action to bring the incident under control. Sometimes it is necessary to abandon efforts at control and to redirect resources to safeguarding personnel. Review of past disasters indicates that at times even a well thought-out disaster plan is not well implemented. This happens most frequently when the disaster occurs at odd hours, on weekends, or over holidays when the usual or more experienced management personnel are not available. Such instances may result in an assistant delaying evacuation of the mine in order to "see for himself" or to personally attempt to "fight the fire" or "save the lives." When the hazard is not immediately brought under control, the delay in evacuation or other appropriate action may result in loss of life, lengthy rescue efforts, and loss of mine operation for a prolonged period because of disaster damage. While the first few moments after discovery of a hazard are crucial, the total plan for response to a hazard must be broader in scope, encompassing a number of steps from hazard recognition to final restoration of normal operations. These steps must be described in writing without ambiguity, and instilled in the mine personnel through rigorous education, training, disaster simulations, and drills. The instructions and training must clearly explain when to abandon the control effort and to initiate the evacuation procedure. Among the steps that may be required are: (1) development of a competent inte- grated organizational structure that will function even if key members are absent; (2) development of an emergency communication procedure that clearly identifies the essential information that must be noted and communicated upon discovery of a hazard; (3) hazard recognition and control procedures; (4) evacuation, escape, and survival procedures and equipment; (5) rescue procedures and equipment; and (6) surface organ- ization, facilities, outside sources of technical assistance, etc., to support the emergency operations. The lack of suitable emergency procedures and equipment can be tragic, as can a lack of familiarity with these. Review of past disasters suggest that in some cases escaping miners may not have been familiar with the escape equipment's operating characteristics, and this may have materially impeded their escape efforts. When a Disaster has occurred and rescue and recovery work is necessary, federal and state officials must be informed. An advisory body consisting of the mine management, federal and state mine officials, and union representatives should be formed as early as possible. The purpose of the advisory body should be to assist in planning rescue and recovery work, and to provide support and advice to the person in charge of the rescue. A review of past disasters does not reveal that the multi-jurisdictional and legal issues involved have affected the conduct of the rescue and recovery work. However, the committee has received the impression that, at least in the initial stages, there is some confusion. There is apparently no clearcut procedure defining the division of responsibility and accountability between federal, state, and local agencies, mine operators, labor unions, and others, in the event of a mine disaster. There is no question that there is a great need to exercise extreme care in making decisions and taking actions that can cost -74-

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lives, and all inputs to the decision-making process are useful and must be welcomed. However, there must be a single person in overall control of the rescue and recovery operation, with full responsibility for execution of the actions decided upon. This individual should be identified at the earliest possible time, and should be knowledgeable in rescue and recovery work and in the management of emergency opera- tions. In the event of a dispute as to what decision should be made, it is essential that someone have clear-cut responsibility; otherwise, not only will confusion result but valuable time will be lost. Because of the heavy responsibility that the person in charge of the rescue operation bears, and the need for quick and decisive action, means should be sought to protect that individual from being hampered in execution of the job by undue concerns about legal liability or about the less crucial "housekeeping" aspects of the emergency operation. It is important to ensure that in time of disaster the usual operating methodology is changed as little as possible. For example, communications will be more reliable if mine personnel can use the regular communication system (if it is operational) than if they must deploy a new system and hope that everyone will be able to properly use the equipment. Plans must take into account the need for crowd control. Families and on-lookers can be expected to be on site in a short time. Disaster plans must not only address prevention of unauthorized personnel from obstructing or even entering the mine, but must also identify areas where they can wait, and must make provisions for local clergy, food, and perhaps even housing during prolonged operations in inclement weather. Ties to local community services such as law enforcement and medical support should be provided. Equally important is the need to issue clear and detailed reports to the news media and briefings to families of the affected. Important though these aspects are, they should not be permitted to distract the individual in charge of directing the actual rescue operation. No one can totally plan for a major disaster with all of its unexpected emergencies. However, a good disaster plan, understood by all and practiced on a regular basis, will help to insure an orderly and efficient transition from routine operations to effective disaster response. 4.2 THE SYSTEM SAFETY APPROACH Current approaches to hazard identification in mining rely heavily upon the study of past accident experience. Whereas this has provided valuable information to aid safety performance, an inherent limitation is that the hazard must occur to reveal a failure in the system or the program. What is needed is an approach by which existing systems, and systems under design, can be analyzed for potential hazards. There is no reason to believe that a reliable measure of safety exists unless necessary controls have been applied to ensure that preventable hazards do not occur, and unless an emergency procedure has been established to provide for unpreventable hazards. During the early 1960s, a new conceptual approach to safety known as "system safety" evolved. This approach, developed specifically for -75-

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the space program, made it possible to generate safety statistics before the deployment of new products and systems—-i.e., to ensure safety on the basis of analysis of the system rather than on the basis of past history. In the space program this involved (1) making products of unexcelled quality and reliability, (2) identifying the failure characteristics of each unit and the impact of the unit's failure on the total system, (3) increasing system reliability by providing alternatives to permit safe functioning of the system in the face of failures of individual units, and (4) developing emergency procedures for contingencies. While the objectives of the space program permitted incurring larger costs in the interest of safety than may be practical in other programs, much of the system safety approach is applicable in other areas, mining among them. The system safety approach is a composite of elements from a number of diverse disciplines such as systems engineering, statistics, reliability theory, information theory, control theory, management, and behavioral psychology. The "system approach" to the safety problem focuses on the system taken as a whole, and not on its parts separately. It involves the interaction of people, machines, and environment within procedural constraints. It does not imply that the system must be risk-free, but rather that risk can be identified, managed and controlled. This systematic approach as applied to mine safety should include all phases from conceptual formulation of the system through design, testing, evaluation, construction, training, approval, operation, and maintenance. It requires (1) a logical examination of all the elements of the system and their interactions, (2) identification of all sources of hazards, (3) calculation of the probability of hazard occurrence, (4) a search for the available options for hazard elimination or mini- mization, and in the extreme case, provisions for evacuation, escape, survival, and rescue, and (5) an analysis of costs and of problems associated with implementation and other procedural aspects of the various alternatives. Appropriate management and organizational structure are essential because overlapping tasks with unclear limits of responsibilities can lead to confusion and system failure. Development of data to support managerial decision-making is of great importance. The data and information should come from both external and internal sources. The external sources include the general public, government at different levels, other organizations involved in similar activities, and pro- fessional bodies which share an interest in the system in question. Internal sources include field reports, design reviews, periodic audits, hazard analyses, and accident and disaster investigations. There are several aspects of mining in which the system safety approach can be applied. It can be used by regulatory agencies to evaluate mine plans and procedures before approval, and to conduct "post-audits" of disasters and accidents. It can be used by research organizations to unearth new sources of hazards in existing systems, to conduct "pre-design" audits for developing specifications and standards, and, through "post-design" audits, to evaluate the developed product or system for effectiveness. It can be used by mine operators -76-

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to evaluate existing systems, suggest modifications to operations or equipment or both, and develop training programs. Hazard analyses, both "pre" and "post," can be qualitative or quantitative. A qualitative analysis is a non-mathematical but logical analysis of all the factors that affect the safety of the system and its elements. It is a prerequisite for quantitative analysis. Quan- titative analyses are necessary to establish such things as frequencies of occurrence and magnitude of risks. Without distracting from the value of qualitative analysis, quantification of hazard potential must have a high priority. Unless hazards can be quantified and funds for safety research and development justified in terms of potential hazard reduction, there can be considerable outlay of time and money with no way of knowing its effectiveness and with no guidelines for future investment. 4.3 EMERGENCY MEDICAL SERVICES The federal mine regulations* require that selected persons be trained in first aid, and that such training be made available to all miners. First-aid training programs are also mandated for rescue teams, and the regulations require refresher first-aid training for all of the aove. Arrangements must be made by each mine for a licensed physician, clinic, or hospital to provide 24-hour emergency medical assistance for any injured person at the mine. Likewise, arrangements must be made for an ambulance or other means for transporting the injured to a medical facility, and for the establishment of communica- tion services between the mine and the nearest point of medical assistance. Other requirements for emergency medical training are in the proposal and evaluation stages. Emergency medical services in mines have two major functions: (1) day-to-day response to non-disaster illnesses and injuries; and (2) disaster response where there may be a number of injured personnel and their removal from the mine is hindered by fire, roof fall, explosion, or other hazardous situation. The injuries sustained in non-disaster situations appear to be of the same general type and severity as seen in non-mine medical services. Most of the larger mines have "emergency room" facilities staffed by trained Emergency Medical Technicians (EMTs). Routine injuries and illnesses are seen here, treated, and the miners are either returned to work or transferred to the local hospital. The time between injury and treatment is not prolonged. Very small mines, on the other hand, are not capable of maintaining such facilities, and must rely on the first aid training of their supervisory personnel. They may also utilize community ambulance services and emergency rooms. Treatment is still generally prompt. In a disaster, on the other hand, there may be delays of hours or even days before the injured reach the hands of a medical professional, and survival may well depend on the emergency medical care capabilities *30 CFR Chapter 1, Parts 57.18 and 75.1713 -77-

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of those who happen to be nearby. Therefore making adequate provisions for emergency medical care in the absence of a health professional is an essential part of disaster planning. Unavailability of properly trained emergency medical personnel does not appear to have been a problem in past mine disasters. Never- theless it is worthwhile to take a close look at what is involved in providing emergency medical care in mine disasters. Efforts by the federal government to upgrade the level of pre- hospital emergency care has led to the evolution throughout much of the country of an integrated emergency response system with excellent coordination, not only among emergency medical programs, but also with fire, police, public works and disaster response systems. Coordinated communication systems are evolving across the country that require only one radio in an emergency vehicle but allow it to communicate directly with all other agencies by interfacing frequencies at the radio com- munication center. Likewise, intercommunication with the telephone system is becoming commonplace via the communication center link. A mine disaster response system that does not take this modern program into account and use its component parts will inevitably be a system with an inferior capability for coordination and response. There are four major phases of pre-hospital care. First Aid; Ideally, each miner should know American Red Cross First Aid and Advanced First Aid and cardiopulmonary resuscitation (CPR). Such a capability on the part of each miner would mean that everyone in the mine would have an elementary knowledge of how to prevent further injury while awaiting the arrival of trained personnel. First Responder; This is the minimum level of emergency care training for people who are not involved in day-to-day care of emer- gency patients but who, because of their proximity to potential injury, may have occasion to stabilize patients until more definitive care is available. The nationally standardized course consists of about 40 hours of instruction. First responder training is appropriate for employees such as mine foremen who are in positions of authority and who may be immediately available to the ill and injured. Ambulance Attendant: The ambulance attendant should be an Emergency Medical Technician (EMT) and should have completed the nationally recognized 81-hour course and should have had at least 10 hours of in-hospital experience. The EMT is knowledgeable in the primary care and transport of the patient. This level of training requires the knowledge of specific skills, and these skills must be used or practiced frequently to be sure that they are maintained. Some smaller mines may find the use of miners trained as ambulance atten- dants so infrequent that consideration may be given to the use of EMT personnel from the surrounding community. Modern day communications make such a system feasible. Advanced EMT and Paramedic; The final step in pre-hospital care is provided by the advanced EMT and the EMT-paramedic. The paramedic has a broader base of training. The advanced EMT is trained in one or a few of such specialized areas as intravenous (IV) techniques and cardiac care. These people are normally allowed by state law to perform, under the supervision of a physician, such invasive procedures as starting IV1s, placing chest tubes, cardiac defibrillation, etc. -78-

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The availability of such personnel will be limited to very large mines or communities. In most instances, their services would be obtained from the EMS community of a nearby metropolitan area. There is currently an effort to identify other categories of EMT personnel with more limited training for specific functions in a specific setting. One such proposal is for the EMT-M for mining. The 81-hour EMT-A course curriculum would be reduced to around 40 hours by elimination of sections such as obstetrics, and by reductions in other areas with little impact on mine emergencies. There is currently no nationally or medically accepted standard for such a course, but several groups such as West Virginia University and NIOSH have proposed suggestions for an EMT-M curriculum. Should such a level of training be accepted nationally, these people might well become an important part of the third level of pre-hospital care in the mining industry and, in at least some mines, serve in place of the EMT-A, or between the First Responder and the EMT-A. Several problems arise in defining the specific levels of training needed for pre-hospital emergency medical care in mines. 1. Statistics for type of injury do not appear to be available. Most of the statistics collected relate to prevention of injury, not to cause of death or disability. Thus, a report will indicate that a miner was injured or killed by a roof fall. Whether the cause of death was a crushed chest, a hemorrhage, or a head injury is usually not recorded. 2. A very well trained person who does not use the skills that have been learned may end up being unable to properly provide the needed services—or even worse, may provide the wrong services in a given set of circumstances. Large mines employing many people may be able to provide (1) at least EMT level of training for some of their personnel; and (2) an opportunity for frequent use of their skills in a nearby community. Smaller mines may need to be satisfied with first aid training, and may have to rely on the surrounding community for the EMT type of care and transport. 3. Pre-hospital service must be economically feasible on the basis of proven need. Having paramedics trained and on hand in every mine would be an inefficient use of resources. Moreover, most of them would be of little or no use in time of need, due to lack of utiliza- tion of their skills on a day-to-day basis. Most mines will not be able to train and maintain paramedics. However, first aid training and training of first responders and ambulance attendants is reasonable and possible. Coordination of the emergency medical facilities in the community with facilities at the mine will insure the availability of well-trained people, will prevent duplication, and will avoid reliance on people who were trained to a given level but, because of lack of practice, are no longer able to provide the excellence of care that is expected. 4.4 EMERGENCY COMMUNICATIONS An adequate communication system, like the nervous system of the body, makes possible the coordination of all other systems. It can be the key to rapid detection of the emergency, early notification of essential personnel, and coordinated response. Wherever possible the -79-

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communication system should be used on a day-to-day basis, not only to insure its reliability in operation, but also to insure familiarity with the equipment in times of disaster. Many communities have evolved consolidated emergency communication centers for both day-to-day operations and disaster response. Such communication coordination allows each system (law enforcement, fire- fighting, emergency medical services, National Guard, etc.) to operate on its own communication channels for day-to-day operations, but pro- vides the capability for interconnects between the various systems, including telephone lines, in times of disaster. This obviates the need for multiple radio systems to insure cross-channel communications —for example, between police and EMS, police and firefighters, etc. By tying the mine safety system into such a center (whether by tele- phone line or radio), rapid response by off-mine disaster organizations in the event of a mine emergency can be greatly enhanced. 4.5 THE FEDERAL GOVERNMENT'S MECHANISMS FOR RESPONDING TO MINE EMERGENCIES While there are a number of Federal government mechanisms for responding to emergencies generally (e.g., the Federal Emergency Management Agency, the Civil Defense Program, the Emergency Broadcast System, etc.), the Mine Safety and Health Administration has specific responsibility for responding to mine emergencies. One element of MSHA's response is its Mine Emergency Operations group, discussed earlier, which provides facilities and equipment for communications, logistics, probe and rescue drilling, gas sampling, etc. Other elements of MSHA's response are assembled, ad hoc, from the ranks of MSHA's inspectors and district managers, and from MSHA's Technical Support division. The four topics discussed earlier in this chapter—disaster planning, system safety analysis, emergency medical services, and emergency communications—all have a bearing on MSHA's response mechanisms. Ideally, if disaster response were treated as a complete system, all four would interact: emergency medical services, along with emergency communications and other aspects of disaster planning, would be developed by mine operators under federal guidelines; plans would be approved by a federal agency; and the techniques of system safety analysis would be applied both to the operators' plans and to the federal agency's response mechanisms. The groundwork for such a systems approach to mine disasters does not yet exist, and will not exist until a foundation is laid through research in disaster simulation, disaster plan assessment, training techniques, and the like. However, the techniques of systems analysis could be applied, today, to MSHA's disaster response mechanisms. Two aspects of MSHA's emergency response system are of concern to the committee. First is the adequacy of the present arrangement, and particularly the ability of MEO and other elements of MSHA to provide the services needed in the event of a disaster. Second is the need for investigating alternative emergency response mechanisms that might be more effective or more economical than the current MEO. The two are obviously interrelated. The infrequency of disasters makes it -80-

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necessary to approach them both from a systems, rather than a historical or statistical, point of view. It is clearly essential to have a capability for mobilizing and deploying the equipment and facilities necessary to aid in the rescue of miners who may be trapped underground. In this respect, all the components of MEO—the location devices, communication equipment, TV probes, gas sampling systems, etc.—are important and can contribute to the conduct of rescue and recovery operations. However, a systems approach should be taken in examining such factors as (1) the condition of the equipment, (2) the experience of the crew with the equipment, (3) the time required to mobilize the equipment and the crew, (4) the travel time to the deployment site, and (5) the set-up time for the equipment. This will aid in developing optimum procedures, optimum locations for storage of equipment and supplies, and optimum means for transporting equipment and personnel to the disaster site. In addition, to ensure that MEO does not run into unanticipated problems during an actual emergency, deployment of the system under simulated disaster conditions must be carried out. Further, the equipment must be constantly updated with improved versions as they become available, if they are more reliable or more quickly deployable. Financial and manpower requirements for all this, in terms of both capital investment and operating costs, can be substantial. It would be tragic, in the event of a disaster, not to have available a facility like MEO—particularly when it is technologically feasible to have one. Because of the rarity and potential severity of disasters, justification of the cost of such a facility should not be based solely on statistical considerations such as the number of lives likely to be saved, or on purely financial considerations. On the other hand, development of disaster response facilities optimally suited to meet the needs of mine emergencies around the country must be subject to rigorous assessment of need and cost. The committee notes that MSHA's present facilities and organiza- tion may not be the most ideal, particularly when viewed in the context of the geographical distribution of mines and the geological diversity of mining conditions. Timely mobilization of the massive rescue dril- ling equipment may not always be possible if such equipment is stored at only a few locations. Some other kinds of equipment—such as com- munications and sampling systems—are more mobile than the rescue drills, and are more easily transported (by air, for example) and quickly deployed. Duplicating all emergency response facilities in mining districts around the country may not be feasible under realistic budgetary and manpower constraints. Even if such facilities could be duplicated, the requirements for upgrading the equipment and maintaining skills through simulated disaster drills could probably not be carried out as expedi- tiously as is necessary to keep the facilities and personnel in satis- factory operating condition. And operating such a facility without adequate maintenance and frequent drills may not serve the intended purpose, which is to respond to a "deploy" order with the most reliable equipment and personnel in the shortest possible time. -81-

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Another alternative would be to have available, at suitable loca- tions in all mining districts; the sampling, communications, and other kinds of emergency equipment that can be readily and quickly deployed. These could be provided and maintained by MSHA itself, or by state and local governments with technical and financial assistance from MSHA. (With regard to drilling capability, MSHA maintains a list of available drilling capabilities in each mining district, and can mobilize these facilities if the need arises. This makes it generally unnecessary to deploy MEO's small drill.) Several such decentralized regional facilities, established in cooperation with state, local and regional emergency response agencies, may be a more effective response system than a limited number of centralized MEOs. 4.6 RECOMMENDATIONS The committee's recommendations fall into four main areas: disaster planning, the system safety approach, emergency medical services, and mine emergency operations. Disaster Planning Adequate disaster plans, appropriate training of personnel, and continual assessment of plans and training through drills and disaster simulations are essential elements of disaster preparedness. Guidelines should be established for use by mine operators in developing disaster plans and training programs and by MSHA in evaluating those plans and programs. Among the critical elements of disaster planning are provisions for identifying, immediately after a disaster occurs, the individual who will "take charge" and be responsible for the disaster response operation, and provisions for the division of responsibility and accountability among the federal, state, and local agencies, the mine operator, the union, and other groups participating in the disaster operation. While this is clearly an MSHA responsibility, the Bureau of Mines should provide the necessary foundation by conducting research aimed at developing methodologies for testing and evaluating mine emergency plans using simulation and other appropriate techniques. These methodologies should be made available to MSHA and to the mining industry. Similarly, methodologies should be developed both for using simulation and other techniques to train miners, mine managers, and government personnel in disaster operations, and for testing the effectiveness of such training. The System Safety Approach There should be widespread application of the techniques of system safety analysis to mine disasters. This will require considerable research and development to develop specific techniques appropriate for use in mines. The system safety approach should be applied by the Bureau of Mines throughout its R&D program and in its determination of research priorities. It should be applied by MSHA to its post-disaster audits, its rule-making, its emergency plan approval procedures, and its mine -82-

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emergency operations. It should be applied by mining companies to the determination of appropriate organizational structure for disaster response. And it should be applied, more generally, to all aspects of mine safety. System safety analysis should also be applied to the development of systematic methods for identifying and investigating potential disaster situations. It is as important to know why some of these do not develop into full-scale disasters as it is to know why others do. Procedures for identifying and acquiring data on such situations, analogous to the aviation safety procedures for reporting "near misses" of aircraft, would be helpful. Emergency Medical Services A mine's emergency medical care system should be integrated with that of the local community in whatever manner promotes greatest effectiveness. No one approach will be appropriate to all mines or all communities, but guidelines and standards should be provided, and the plan developed should be evaluated as part of the mine's emergency plan. Similarly, the mine's emergency communication system should be integrated with the local emergency medical communication system, and with other appropriate local communication systems (e.g., the local civil defense system). Emergency medical care training for miners should be developed and evaluated in light of realistic assessments of need and utilization. Ongoing refresher training must be a part of this system. In order to accomplish this, and to identify other means of protecting miners from the consequences of serious injury during disasters, it is essential to collect and analyze data on the medical causes of death or disability in mine disasters, as well as on the incidents that lead to death and disability. This will make it possible to determine the adequacy of the medical training, equipment, and procedures in the mine emergency response system, and to identify research needed to enhance the likelihood of survival for those injured in disasters. Mine Emergency Operations The federal government's mine emergency response capability, and specifically MSHA's Mine Emergency Operations (MEO) group, should be evaluated in the context of the complete emergency response system, and with particular regard to requirements for the maintenance and drills needed to ensure that response is rapid and effective. The feasibility and effectiveness of mechanisms other than the present MEO structure should be examined to see whether other strate- gies for storing and deploying the most potentially useful equipment (e.g., seismic locators and borehole probes) would be more responsive to the need or more cost-effective. -83-

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