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1.3 Summary of the Findings

The four incidents selected are incidents that can happen almost any day, anywhere in the United States. These incidents are on a smaller scale than those such as 9/11 or the East Coast blackouts in 2003, but they have a higher probability of occurring at any time, in any place. In fact, while Booz Allen conducted the interviews for this project on the Old Fire incident, three major forest fires were burning in southern California and one was burning in the San Bernardino National Forest area.

1.3.1 Common Successes

Common themes throughout the case studies are the use of the incident command system and training for possible incidents.

Incident Command

In all of the case studies, an incident command was quickly established after the incident, with entities understanding their roles and responsibilities. Not all establishments of an incident command went smoothly. However, once established and functioning, the use of an incident command allowed for a unified response to the incident.


The case studies highlighted the impact of inter-entity training on the management of incidents. Due to the training, entities responded to the incidents effectively and coordinated their responses. Entities that train together are able to establish a unified command quickly and have a more effective response.

Training ranges from tabletop exercises to full-scale incidents such as a weapons-of-mass-destruction scenario. Inter-entity training provides pre-incident planning with the ability to revise procedures before having to actually exercise them. It allows entities to establish relationships as well as build on existing ones.

Training allows an entity to test its resources in a safe environment and learn from its mistakes safely. Training contributed to the success of the responses to the incidents that are the subjects of the case studies presented in this report.

1.3.2 Transportation Impacts

Impacts to the transportation system depend on the incident. Two of the incidents resulted in little to no impact on the local transportation systems, while two others did have an impact.

El Dorado, Arkansas

There appeared to be no impact to the transportation system due to the El Dorado incident. The police department cordoned off the evacuation zone, and traffic was rerouted through town. The main north-south roadway, US 167, was closed, but traffic was rerouted around the downtown. This incident happened on a Sunday morning, but if it had occurred during the week, there still would have been little impact on the traffic system.

However, since the residents of the nursing homes and prisoners at the county jail facility are without personal vehicles, ambulances and school buses were used to evacuate the nursing home residents and school buses were used to evacuate the prisoners.

Graniteville, South Carolina

There appeared to be little impact to the transportation system due to the Graniteville incident. The Aiken County Sheriff’s Office cordoned off the evacuation zone, and traffic was rerouted through the community. The main thoroughfare (Aiken/Augusta highway), a four-lane roadway connecting Aiken, South Carolina, to Augusta, Georgia, was closed for over a week, but traffic was rerouted through the area onto parallel roads or Interstate 20.

South Salt Lake City, Utah

The rail yard is located near the intersection of Interstate 15 (I-15) and Interstate 80 (I-80), which had to be closed. In addition, some local streets were also closed.

The South Salt Lake City Police Department, Utah Department of Public Safety, and Utah Highway Patrol were involved in the closing of the roadways. Roadways were quickly blocked with barricades and barrels.

As the neighborhoods were evacuating, the local streets were barricaded with roadblocks to prevent the reentry of residents and the entry of unauthorized personnel.

At approximately 12:45 pm on Sunday, March 6, 2005, I-15 and I-80 were shut down, which took a little more than 1 ½ hours. Initially, Utah Department of Transportation resources were used to close the interstates. Once it was determined that the closure would take longer than anticipated, a decision was made to use an authorized traffic management contractor to close down the interstates with barriers and electronic signs.

State troopers were sent to patrol and monitor the closed freeways to ensure motorists did not drive onto the roadways.

The main means of communication to the traveling public was with fixed and portable dynamic message signs, 511 travel services, highway advisory radio, and the commuter link Web site. It was felt that the notification worked well.

There was an initial backup of approximately 1 to 2 miles when the interstate was initially closed, but this was quickly dissipated. While not associated with this incident, the Utah Department of Transportation conducted a public opinion poll and found that 70 percent of people will change their travel pattern if information is provided. After the initial closure, traffic was manageable.

Big Bear Valley, California

There are three main evacuation routes out of Big Bear Valley; one to the west, which was closed, and two that are north and south of the valley. There was concern with the loss of the remaining roads as evacuation routes and with possible accidents that would slow the progress of evacuees. The emergency community looked into the possibility of staging resources along the evacuation route to push vehicles off the roadway if necessary.   

The roadways in the valley did not allow for a quick evacuation. However, there were no incidents on the road; people were patient and there were no recorded instances of flared tempers. People made the best of the situation.

Based on experience, the local emergency management community now has an estimated time to evacuate the valley, in case this is necessary in the future.

1.3.3 Transit Agency Participation

Public transit agencies played a factor in the evacuation of Big Bear Valley. Through their coordination of efforts, the evacuation of residents without transportation was successful.

The Mountain Area Regional Transit Authority (MARTA) was one of two public transit agencies that participated in the evacuation of residents from the valley down the mountain and into public shelters.

MARTA provided the initial transportation in the valley and off the mountain. The agency learned of the need for an evacuation through its seat at the unified command center and received information at the same time as the other participants. MARTA was represented 24/7 and used its radio system to contact its base and operators.

MARTA vehicles and manpower were staged at the command post to allow for the evacuation of residents. Initially, six vehicles were utilized, but through creation of 12-hour shifts, three vehicles were used to evacuate approximately 1,200 residents.

Omnitrans was the second transit agency involved in the evacuation of Big Bear Valley. The agency provided assistance by meeting MARTA buses at the bottom of the mountain at evacuation centers and transporting the people to public shelters established in San Bernardino County. Eventually, the public shelters were merged into one super-shelter at the San Bernardino International Airport. Omnitrans provided transportation to that location.

1.3.4 Difficulties in the Evacuation

All of the incidents reviewed involved some difficulty in either the incident and/or evacuation, and they varied per incident.

El Dorado, Arkansas

Difficulties included:

  • Determination of the chemical involved
  • Legal actions
  • Receipt of information from other entities.

Graniteville, South Carolina

Difficulties included:

  • Internal bickering over the establishment of the initial incident command center
  • Loss of the main fire station.

South Salt Lake City, Utah

Difficulties included:

  • Identification of the chemicals on the leaking rail car
  • Incorrect train manifest.

Tools cited as necessary due to the South Salt Lake City incident difficulties are continued use of placards on the sides of the railcars indicating the product in the tank car and regulations on how to properly load rail cars.

Big Bear Valley, California

Difficulties included:

  • Incompatible communication systems
  • No communication when the valley incident commander was unable to access the incident command center.

1.3.5 Special Needs Evacuations

Three of the four incidents reviewed involved special needs evacuations. Two nursing homes, a county jail, pets, a community hospital, and schools were all successfully evacuated.

El Dorado, Arkansas – El Dorado County Jail Facility

When the sheriff decided to evacuate the jail facility, a choice regarding which roadways to use was made. It was determined that the convoy would proceed down state roadways rather than county roadways due to several factors: (a) the state roadways were felt to be more secure; (b) there were wide shoulders and, in case of an accident, buses could be moved onto the shoulder or, in the case of an automobile accident, the automobile could be moved onto the shoulder not impeding the movement of the buses; and (c) there are more lanes allowing for faster speeds and movement past an accident.

Why Was the Evacuation a Success?

The sheriff felt that there has always been the threat of an evacuation, and he had “years to think about it.” He communicated the plan with two others on his staff, the chief deputy and the jail administrator, so they knew what to do in case the sheriff was incapacitated. To ensure the availability of someone who knows the plan, the sheriff makes certain that all three persons are not off duty at the same time. There is at least one of them on site at all times. The sheriff realizes that the evacuation plan should be written down and taught to others of his staff, but this may not happen in the near future due to a lack of resources.

El Dorado, Arkansas – Hillsboro Manor Nursing Home

The director of nursing received a page from the 911 system while attending church and was told to: (a) be prepared to evacuate and (b) prepare for a return call to evacuate. After this initial contact, Hillsboro started to evacuate the residents before the order to evacuate was received. Shortly thereafter, a call was received to evacuate the nursing home.

The police department and volunteers from the community acquired buses for the transportation of residents to their designated public shelter. There were approximately 96 patients and over 50 staff that needed to be evacuated. Most of the residents could be moved by either school or church bus (regular and wheelchair accessible), but residents who could not walk were transported by ambulances to the hospital or other nursing homes.

One man from a church brought a truck that was used to move wheelchairs, bedding, linen, the medicine carts, and food prepared for lunch.

The police department provided an escort to the public shelter.

Why Was the Evacuation a Success?

Numerous reasons contributed to the success of the evacuation:

  • Community volunteers assisted in the evacuation, such as by providing a truck to transport items or church buses to transport residents and staff.
  • There was easy access to transportation.
    Hillsboro had written procedures on evacuations. At least annually, the nursing home had practiced an emergency drill for evacuation of the nursing home.
  • The delegation and assignment of activities to staff kept them focused on the evacuation and not on what-if scenarios.
  • There was the experience of previous partial evacuations.

El Dorado, Arkansas – Oakridge Nursing Home

At 9:30 on Sunday morning, the assistant administrator was contacted at home and informed by the 911 system that the Teris plant was exploding. Within 10 minutes of the phone call, the assistant administrator arrived at the nursing home. At this point, it was decided to start shelter-in-place procedures.

After this initial activity, the assistant administrator was waiting for the word to evacuate Oakridge. Approximately 1 hour after the initial call, someone from a church arrived to help Oakridge evacuate. This individual informed the assistant administrator that “everyone was evacuating,” and the evacuation started at this point.

There was no official call from the local emergency management officials for an evacuation, nor were there American Red Cross officials assisting in the evacuation of the Oakridge Nursing Home. The assistant administrator would have liked to have emergency officials helping during the evacuation. “If not for the churches and family members, we would have had a problem.”

A total of six church and school buses were used to evacuate the residents. One of the school buses was wheelchair-lift equipped, and Oakridge could have used more of those types of buses.

Why Was the Evacuation a Success?

Oakridge staff has received training on evacuation and has reviewed the shelter-in-place video. That information combined with the knowledge of how to handle other types of emergencies led to a successful self-evacuation.

Graniteville, South Carolina

Some residents who evacuated left behind pets and later became concerned about their pets when they realized the extent of the incident. The Aiken County Animal Control Department called on other animal control departments to assist in the retrieval of pets from the evacuation zone. Evacuees contacted animal control with pet information and keys to their homes. Once the pets were retrieved, evacuees had to contact animal control and set up an appointment to pick up their pet. As a result, more than 287 pets were reunited with their owners.

Big Bear Valley, California – Bear Valley Community Hospital

Bear Valley Community Hospital long-term residents were evacuated during the Old Fire incident. Once the decision was made to evacuate the community, the hospital instituted an internal disaster plan. When the hospital was informed of a voluntary evacuation, the director of nursing provided guidance to the staff and delegated responsibilities to perform certain tasks. Some staff were directed to prepare the residents for an evacuation, pack up resident’s medical records, pack up 3 days of food, pick up the medications, call in additional clinical staff, and contact families. By delegating tasks, the staff focused on the evacuation of patients and not necessarily on the fire situation.

Why Was the Evacuation a Success?

The evacuation of the hospital was coordinated with the Bear City Fire Department and the City of Big Bear Lake Emergency Management Services through the Emergency Operations Center. A week before the evacuation occurred, the fire chief contacted the hospital and conducted pre-disaster planning such as, if the need for an evacuation was clear, what type of transportation was needed and from where would the transportation come.

Big Bear Valley, California – Bear Valley Schools

Schools in Big Bear Valley were evacuated. The day before the evacuation of the valley, the superintendent of the schools was informed of the potential for an evacuation and passed this information along to staff of the school district. Students of the schools were sent home. District staff were told that the local emergency management officials would not try to evacuate when school was in session. However, the next day, after students were at school, the winds picked up and a mandatory evacuation of the valley occurred.

Why Was the Evacuation a Success?

The evacuation of schools in Big Bear Valley was a success due to several factors:

  • An orderly process was developed to allow parents to pick up their children in a calm setting.
  • There was school training for emergency drills.
The Big Bear Valley incident commander decided to hold off announcement of an evacuation until the school children arrived at school, rather than while they were in transit, thus allowing for an orderly evacuation of students.

1.3.6 Lessons Learned

Numerous lessons were learned during all of the incidents. Lessons learned were categorized into advance planning, advance technology, coordination, communication and transportation.

Sample lessons learned include:

Advance Planning

  • Adopt a reentry plan – Big Bear Valley, California.
  • Provide standardized identification badges – Graniteville, South Carolina.
  • Review incidents (including others) for lessons to be learned – El Dorado, Arkansas.
  • Utilize traffic engineers earlier in the incident – South Salt Lake City, Utah.

Advance Technology

  • Use technology and tools during the incident – Graniteville, South Carolina.


  • Activate local emergency planning committee members early in the incident – El Dorado, Arkansas.
  • Verify mutual aid sources – Graniteville, South Carolina.


  • Ensure notification of the evacuation to dispatch center – South Salt Lake City, Utah.
  • Ensure the Reverse 911® system has current information – Graniteville, South Carolina.
  • Have secure lines of communication – Big Bear Valley, California.
  • Keep a current list of media contacts and include alternate numbers – El Dorado, Arkansas.


  • Know the location of specialized equipment to transport nursing home residents – El Dorado, Arkansas.

1.3.7 Best Practices

All of the incidents reviewed utilized some best practices regarding evacuation management to a degree. The following best practices were identified based on the interviews:

  • Ability to change procedures on the fly
  • Communication workarounds
  • Controlling a potentially chaotic scene with evacuation procedures
  • Daily meetings
  • Fact sheets and press briefings
  • Joint information center 
  • Pet unification plan
  • Placement of an incident command quickly
  • Town hall meetings
  • Training, including tabletop exercises
  • Unified incident command
  • Use of the 2-1-1 system for human and volunteer services
  • Use of an incident command
  • Use of the national incident management system.

February 6, 2006
Publication #FHWA-HOP-08-014