Office of Operations
21st Century Operations Using 21st Century Technologies

5.13 Lessons Learned

There are several lessons that were learned from the South Salt Lake City incident.

Employ Additional Staff Early in the Incident

The police department felt that additional command (supervisory) staff could have been used earlier in the process. There was the belief that sufficient resources were initially available, but as the incident unfolded, it became apparent that additional staff was needed. In retrospect, additional command staff with specific assignments would have been useful.

Ensure Notification of the Evacuation to Dispatch Center

Dispatch (Valley Emergency Communications Center) should have been notified of evacuation details such as implementation, lifting of the evacuation orders, and location of evacuation centers. The dispatch center was not necessarily in the communication loop, nor was the Salt Lake Valley Health Department.

Ensure Nursing Staff at Public Shelters

There should be trained nurses at the public shelters to look for symptoms of the evacuees and provide support and answer questions. The Salt Lake Valley Health Department did not have personnel at the evacuation site for support or evaluation and, as a result, is changing its processes to achieve this.

Establish the Command Post Further Away So It Does Not Need to Be Moved

The incident command post was initially established. However, due to concerns with the winds and the plume, it was decided to move the post 1 mile further away from the incident area.

Examine a Handheld Communication Device for Communication Purposes

A compact handheld communication device was expressed as being potentially useful in the field. It could eliminate the radio and be small enough to allow for both voice and text messaging.

Improve Assess Control/Site Security and Provide Visual Identification for Command Staff

People were seen wandering around the rail yard with no identification and no determination if they were authorized staff.

Know the Resources of Private Industry in the Area

There was limited knowledge of what resources and equipment the private industry could provide. Additional resources may be located next to the incident scene if private resources are known.

Make Sure the Calldown List Has Correct Contacts

Create redundancies in the call-down list to make sure relevant entities are notified.

Make Sure Entity Representatives Can Be Found

Law enforcement had difficulty at times in finding a fire incident commander that could answer questions.

Open a Joint Information Center Earlier in an Incident

An incident gradually builds up to a point where it can become too big for one person or entity to handle. Media response can be overwhelming during an incident, so an early coordinated response would be beneficial.

Provide Additional Public Information Officers

When the evacuation process started, the public information officers were located at the scene. When the decision was made to establish a joint information center, the center was located away from the incident scene at the Highway Patrol Dispatch Center. At this facility, they had a conference room, telephones lines, computer connections, and access to the Utah Department of Transportation highway monitors.

The media was located at the scene, and public information officers fielded calls at the center. As a result, they ran out of public information officers. For this incident, at least two public information officers per entity would have been sufficient, one at the joint information center and one on the scene. The media wants to talk to firefighters on fire topics and police officers on police topics.

Provide Enough Protective Gear

Law enforcement officers did not have proper protective gear and only a few police department officers had masks.

Carry Extra Cell Phone Batteries and/or Chargers

The police department public information officer went through several cell phone batteries and had to retrieve a battery charger during the incident. Chargers are now located in some patrol cars.

Radio communication was an issue at times due to the lack of batteries for the radios.

Request Samples of Product During the Initial Reconnaissance for Quicker Laboratory Analysis and Ensure Chain of Custody of the Samples

The Salt Lake Valley Health Department, by protocol, is responsible for the packaging of the samples and delivery to the State Laboratory; but in this instance, they did not provide the sample to the State Laboratory. There was inadequate volume for multiple analyses, the sample was not properly packaged or labeled, and the sample container was inappropriate (the sample received burned through the bottle material).

Review and Incorporate the Incident into the Fire Department Training Process

Each incident can be viewed as a training opportunity and for lessons to be learned.

Utilize Traffic Engineers Earlier in the Incident

The Utah Department of Transportation felt that traffic engineers could have been utilized earlier in the incident. During the closure of the interstates, traffic operators managed the traffic flows. As the incident proceeded and there was the possibility of the interstates not opening before the Monday morning commuter, traffic engineers were brought in to develop a plan for the morning commute. Next time, bring in the traffic engineers earlier to develop the traffic plan.

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