9.6 Appendix 6 – Aiken County Emergency Services After-Action Report
Aiken County Government After-Action Report
Graniteville Train Wreck
On January 6, 2005, at approximately 02:45, two Norfolk Southern freight trains collided in Graniteville, South Carolina. The collision resulted in a catastrophic release of chlorine gas to the atmosphere from a tank car damaged in the derailment. This release rapidly vaporized to form a dense and highly toxic airborne cloud affecting Graniteville residents and employees of nearby Avondale Mill. Other hazardous materials cars involved in the derailment included 2 additional chlorine cars, 1 sodium hydroxide car and 1 creosol car.
More than 500 people sought medical evaluation, approximately 70 people were admitted to hospitals and 9 people were killed due to chlorine exposure.
Initial responding agencies from Aiken County included the Graniteville-Vaucluse-Warrenville (GVW) Fire Department, Aiken County Emergency Medical Services (ACEMS), Aiken County Sheriff’s Office (ACSO), Aiken Department of Public Safety (ADPS), Aiken County Hazardous Materials Team (ACHMT) and Aiken County Emergency Management Division (ACEMD). Approximately 600 Federal, state and local personnel participated in the response to this disaster.
This report will focus primarily on the actions and observations of the Aiken County agencies involved in the initial response.
Strengths and Improvement Items will be identified to document the Aiken County Emergency Services Department’s ability to recognize, respond to, and control a hazardous materials emergency, as well as to coordinate an integrated response that will protect the health and safety of emergency response personnel, the general public and the environment.
Strengths are those areas in which responders demonstrated exceptional ability or knowledge, or other areas of programmatic solidity. Improvement Items are deviations or concerns regarding a particular issue. An Improvement Item, by itself, does not degrade the response, but the emergency response may be more effective if alternative measures were implemented. Strengths and Improvement Items will be identified utilizing objectives that are applicable to the agency’s response authority.
OBJECTIVE 1: SAFETY
Demonstrate the ability for agency personnel to perform response activities safely.
Criteria 1: Emergency response agency members perform response activities safely.
- ACEMS personnel experienced no injuries during the response.
- Habitability surveys were not conducted initially at Command Post or Forward Operations.
- First ACEMS unit responded directly to the scene and had to leave the area due to fumes. Entry should be coordinated with IC.
Criteria 2: Effective scene safety operations through appointment of Safety Officer position reporting to Incident Commander (IC).
- Safety Officer was not designated for EMS operations. Safety Officer responsibilities defaulted to ACEMS Shift Manager.
OBJECTIVE 2: PROTECTIVE ACTIONS
Demonstrate the ability to develop and implement appropriate protective actions.
Criteria 1: Determine/implement protective actions for the area.
- Reverse 911 was not activated in a timely manner due to access available only by Emergency Management personnel. This weakness has been corrected so that Reverse 911 can now be activated through direction from Dispatch supervisor or authorization of Incident Commander. Capability will also be established at North Augusta Public Safety and Aiken Public Safety dispatch centers.
- The database used to initiate calls was five years old. This was identified post incident and updated info is now available for input into the system.
- Public unaware that unlisted phone number results in not being on 911 call list.
Criteria 2: Demonstrate effective communications.
- Key representatives of fire, law enforcement and emergency services at Command Post actively discussed evacuation versus shelter in place.
- ACEMD had to contact SC Emergency Management Division (SCEMD) to initiate the Emergency Alerting System (EAS) which only works if radio station is in auto position. ACEMD did not have (EAS) monitoring capability to determine if EAS message had been transmitted to citizens.
- SCEMD resource issues can impact initiation of EAS.
- Procedure to confirm dissemination of public protective action notifications should be developed.
OBJECTIVE 3: MITIGATION
Demonstrate the ability to properly mitigate, stabilize conditions and gain control over the emergency situation.
Criteria 1: The emergency response agency mitigates the emergency effectively.
- US Environmental Protection Agency (EPA) stated that Geographical Information System (GIS) maps in place when they arrived were very beneficial to planning mitigation activities.
- Plume models and GIS mapping need to use same coordinates.
Criteria 2: The county EOC provides adequate support to assist in mitigating the incident.
- ACEMD initiated early request for assistance from SC Emergency Management Division (SCEMD). 75% of State Emergency Support Functions were activated.
- ACEMS equipment needs were quickly met, once requested through the EOC. EOC personnel maintain a current list of resources.
- Shift turnovers were preplanned and worked well.
- School District representatives notified at approximately 3:30 am and decision was made to close schools prior to EOC activation.
- Credibility of EOC hampered by lack of a dedicated, adequate facility.
- Lack of coordination between EOC and CP affected logistics, food deliveries housing, etc. CP was duplicating effort, and info wasn’t being shared effectively.
- Formal status briefings need to be conducted for EOC staff on a regular basis.
Criteria 4: Demonstrate Command and Control.
- The Incident Command System and key positions were implemented early in response.
- Better communications between response personnel would have resulted in pertinent information sharing. Unified CP was in place when EPA arrived. Clear lines of authority had not been established, but the right things were occurring, although maybe not as smoothly as they could have.
Criteria 5: Agencies effectively integrate additional support into UC/EOC operations.
- SC Department of Health and Environmental Control were well-informed of incident by time of arrival at CP.
- ACEMS supervisor was not present at initial Command Post (CP).
- Local/National Red Cross point of contact needed at the CP to coordinate food for personnel in outlying areas.
- National Red Cross position may be needed in the EOC.
- EPA personnel were initially unaware that the Aiken County EOC was operational.
- Aiken County GIS resources were not involved in UCP planning meetings.
- ACEMS observed additional EMS support arrive from outside Aiken County. Additional units were not coordinated with ACEMS.
- Large number of individuals at the CP did not have a reason to be there. Better identification of key command staff would have helped.
- State Fire Marshals were contacted through SC Firefighter Mobilization Plan without the knowledge of the Damage Assessment Chief in the EOC. A Mutual Aid Agreement is in place with the Building Officials Association of SC, but was not utilized initially.
- Shelter staffing issues arose when a shelter was opened without EOC coordination and/or knowledge of DSS/Red Cross. There is a potential for county liability and financial responsibility if the Red Cross has not been involved with shelter opening.
Criteria 6: Appropriate actions are taken to protect and account for emergency responders at the scene.
- EMS Supervisor relayed info to arriving units within 10 minutes to stay clear of the incident scene.
- ACEMS access was restricted after first entry due to lack of PPE availability and to fit incomplete testing on equipment received from Department of Homeland Security.
- Accountability system (hazmat wristbands) implemented by Fire Department was not communicated to all responding agencies.
- Pre-determined accountability system needed for Aiken County emergency response agencies.
- Agency accountability was being maintained, but not being shared with other agencies.
OBJECTIVE 4: CHEMICAL MONITORING
Demonstrate the ability to minimize exposure and control chemical conditions.
Criteria 1: Demonstrate command and control of Haz-Mat personnel and activities.
- ACHMT staged at parking lot near Pine Log / Silverbluff Road for safe-area accountability and to determine number of responders available. Staging hazmat at Kroger negated the need to provide specific entry routes to responders unfamiliar with the Graniteville area.
- LEL (lower explosive limit) and standard O2 levels monitored by ACHMT, indicating crash scene impact only. Chlorine could have been indicated with proper monitoring equipment.
- ACHMT was not effectively integrated into haz-mat operations.
- Decon areas were not monitored due to no haz-mat support at decon locations.
OBJECTIVE 5: STAFF & ACTIVATE
Activate emergency response facilities in an effective and timely manner based on the type and extent of emergency.
Criteria 1: Activated emergency response members report and perform their assigned duties.
- Aiken County GIS personnel responded to the EOC after seeing news report. A GIS position will be established for future EOC activations.
- ACSO Dispatch was requested to contact EOC personnel, but individual calls were also made by ACEMD staff to ensure response members were contacted.
- Responding EOC staff was not provided specific routes of travel. ACEMD should consider adding safe route determination to EOC procedures.
- Pre-event coordination of consistent GIS data needed.
- All ACEMS personnel do not have County issued pagers. No process in place for call-back other than landline which resulted in approximately 25% response.
OBJECTIVE 6: PUBLIC INFORMATION
Develop and disseminate accurate and timely information to the news media and the public.
Criteria 1: Inform state and county elected officials, local and national news agencies of the event, and disseminate accurate information and instructions to the public.
- EOC did not have press releases prior to distribution at CP. Hard copies of press releases were not initially distributed at press conferences.
- Unmanned radio stations limited ability for local alerts to be made.
- Initial notification did not go out through NOAA Weather Radio, although it was utilized later in the day.
- EOC PIO could not get response from PIOs at CP to coordinate message for media at EOC.
- Citizens in shelters had no official information source.
Criteria 2: Demonstrate effective communications.
- Salvation Army provided interpreters for Hispanic population.
- 211 (Aiken County Help Line) received calls immediately but had no info to provide initially. 211 received updated information via television news report. As a result, 211 personnel did not learn key information such as the shelter in place message that had been transmitted to residents.
- 211 is not accessible via cell phone. Additional number needs to be provided.
- EOC was receiving updated information via television news reports.
- Media staging area was located too close to CP.
OBJECTIVE 7: MEDICAL
Demonstrate the ability to provide appropriate medical care for injured personnel.
Criteria 1: First responders provide proper first aid care for injured personnel.
- ACEMS utilized PPE from Aiken County COBRA team which allowed EMS personnel to re-enter scene for rapid rescue.
Criteria 2: Demonstrate command and control of the medical emergency.
- ACEMS attempted to medical monitor other responders, but they were entering incident area without EMS coordination.
- Triage tags were not utilized, although they were available.
- The on-duty EMS supervisor must relinquish control of outside incidents and focus on major incident being responded to.
Criteria 3: EMS personnel provide proper emergency medical care for injured and/or contaminated personnel.
- ACEMS supported three separate decon sites with medical monitoring.
- Due to overwhelming number of calls for assistance being received from Graniteville area, decision was made to enter with Level-B suits by haz-mat technician-level EMS personnel.
- Decision to not transport patients prior to decon was made by ACEMS Shift Supervisor.
- EMS entry into the hot zone was coordinated thru ACSO Dispatch who contacted the EMS supervisor at USCA. No coordination with GVWFD.
Criteria 4: Demonstrate effective communications.
- Local Hospitals were contacted early on by EMS supervisor informing them of patient potential.
- Mass casualty plan not implemented initially due to communications difficulties.
- Communication of patient status at decon was not well-coordinated with Red Cross shelter representatives. Persons at shelters were registered, but if they were sent to the hospital or left with friends/family, their status was unknown.
OBJECTIVE 8: RECOVERY
Perform recovery activities.
Criteria 1: Develop a recovery plan outline that identifies appropriate recovery strategies.
- EPA led recovery effort to re-open schools and area businesses. Coordination occurred through UCP. A school rep was onsite for all entries.
- County finance office implemented hour code to assist in tracking costs.
- Not all agencies attended Critical Incident Stress Debriefings (CISD). This needs to be added to recovery plan checklist.
- EOC had some difficulty obtaining some resources due to weekend hours. Commercial disaster recovery resource books may be useful in the EOC, as well as emergency contacts for local suppliers.
- County Damage Assessment official initially left out of planning loop for reentry.
- All support agencies (Salvation Army, Red Cross, DSS, etc.) were not kept informed of recovery status. Although daily status meetings were held at the UCP, the information was not communicated with the EOC.
OBJECTIVE 9: FACILITIES AND EQUIPMENT
Demonstrate the adequacy and functionality of facilities and equipment to support emergency operations.
Criteria 1: Facilities and equipment are adequate, functional and safe to operate.
- SC Department of Social Services called in individuals to staff shelter at USCA campus which had not been previously designated in planning.
- Generator noise made it difficult to communicate at or with the CP. Electric capabilities earlier on would have helped.
- Ladders were available for phone setup in EOC but due to the chaos, people were standing on chairs to connect the lines.
- There was difficulty in obtaining contacts for telephone installation, however once SCEMD became involved it went smoothly. Procedure is now in place to obtain phones in emergency situations.
Criteria 2: EOC/ICP/UC maintains appropriate technological equipment to maintain effective communication with Federal/state and local agencies.
- Field charging capabilities are needed for portable radios and cell phones. Mobile Command Center is obtaining additional radios/batteries.
- Web EOC communication and tracking system was not utilized due to time consuming effort to set up basic needs in EOC.
- Lack of copiers at CP significantly hindered information distribution.
- GIS map plotters being used were 1 mile away at County planning office. Portable plotter capabilities need to be addressed.
- EOC printing capabilities were limited.
- Joint training between EOC personnel and CP responders is needed. Agencies need to understand each other’s roles and capabilities.
- Hurricane responders are excellent at communicating during crises, and may be a good benchmark.
- SCEMD is developing the concept of a County EOC team (comprised of multiple county EP personnel) as well as an “Incident Response Support Team” to assist CP personnel with various activities (facility needs, communication needs, etc.).
- Reverse 911 may be useful for personnel recall (pre-designated call groups) and training on the Reverse 911 process is needed.
- 211 being added to phone priority list should be considered. Lessons Learned from other 211s is that some local governments release non-essential personnel to support 211 calls during times of crisis.
- EOC PIO suggests meetings with local agency PIOs to discuss lessons learned and preparedness for future incidents.
The following agencies and departments participated in the Aiken County Government after action review and contributed to the information contained in this report.
Aiken County Emergency Services Department
Aiken County Emergency Management Division
Aiken County Emergency Medical Services
Aiken County Hazardous Materials Team
Aiken County Administrator’s Office
Aiken County Planning and Development
Aiken County Information Technology Department
Aiken County Public Works and Engineering
Aiken County Finance Department
Aiken County Department of Social Services
Aiken County Help Line / 2-1-1
Aiken County Public Schools
American Red Cross
The Salvation Army
South Carolina Emergency Management Division
South Carolina Department of Health and Environmental Control
US Environmental Protection Agency
February 6, 2006