U.S. ENVIRONMENTAL PROTECTION AGENCY
         OFFICE OF INSPECTOR GENERAL
                            Catalyst for Improving the Environment
Special Report
       Congressionally Requested Inquiry
       into EPA's Response to a Report of a
       Leaking Well in North Carolina and the
       National Response Center Hotline

       Project No. 10-P-0027
       November 10, 2009

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Report Contributors:                         Christine El-Zoghbi
                                            Tim Roach
                                            Larry Dare
                                            Eric Lewis
Abbreviations

COOP       Continuity of Operations
EPA         U.S. Environmental Protection Agency
NRC         National Response Center
OIG         Office of Inspector General
OSC         On-Scene Coordinator
TCE         Trichloroethylene
TISCOM     Telephone and Information Systems Command

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I
5
                   U.S. Environmental Protection Agency
                   Office of Inspector General

                  At   a  Glance
                                                         10-P-0027
                                                  November 10, 2009
Why We Did This Review

Representative Heath Shuler
requested that we investigate the
events surrounding a response to
an April 25, 2009, telephone
report of a leaking well in
Skyland, North Carolina.
We conducted this review to
determine whether the U.S.
Environmental Protection
Agency's (EPA's) receipt and
disposition of that telephone call
followed applicable policies and
procedures.

Background

The National Response Center
(NRC), operated by the U.S.
Coast Guard, Department of
Homeland Security, is the sole
national point of contact for
reporting all oil, chemical,
radiological, and biological
discharges into the environment.
During non-business hours, the
EPA emergency hotline is
programmed to forward all
incoming calls to the NRC phone
system, which is staffed at all
times.

For further information,
contact our Office of
Congressional, Public Affairs and
Management at (202) 566-2391.

To view the full report,
click on the following link:
www.epa.qov/oiq/reports/2010/
20091110-10-P-0027.pdf
                                                               Catalyst for Improving the Environment
Congressionally Requested Inquiry into EPA's
Response to a Report of a Leaking Well in North
Carolina and the National Response Center Hotline
 What We Found
We found that EPA staff did not receive any calls or voicemail messages on
April 25, 2009, from the Skyland, North Carolina, constituent about a leaking
well. However, when the Agency was informed of the leak by a local news
reporter, EPA's On-Scene Coordinator contacted the constituent and the
constituent's neighbors. The On-Scene Coordinator then arranged for
permanent repairs to the well, which were completed April 28, 2009.

We found that NRC did receive voicemails about the leaking well.  On
April 25, 2009, two other callers reported separate environmental emergencies
by voicemail. The NRC Operations Officer informed us NRC did not listen to
the voicemails until September 2009. We confirmed that NRC did not provide
any response to these voicemails. Once the voicemails were discovered, NRC
staff took no actions to inform EPA that callers had been channeled into a
voicemail system.

Prior to April 25, 2009, we determined that  12 voicemails were left with NRC.
The earliest of these voicemails was dated October 12, 2006. We have found
inconsistencies in the statements of NRC and NRC telephone contractors
regarding who within NRC may have been aware of the voicemail problem and
when.

We will present our findings to the Department of Homeland Security Office of
Inspector General so it may determine the degree to which the telephone
contractors have repaired the NRC phone system and to fully investigate the
inconsistencies in information provided by NRC staff and telephone
contractors.

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 I
 5
MEMORANDUM
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
              WASHINGTON, D.C. 20460
                                                                            OFFICE OF
                                                                        INSPECTOR GENERAL
                                  November 10, 2009
SUBJECT:
FROM:
TO:
Congress! onally Requested Inquiry into EPA's Response to a Report of a
Leaking Well in North Carolina and the National Response Center Hotline
Report No. 10-P-0027
Wade T. Najjum
Assistant Inspector General for Program Evaluation

Mathy Stanislaus
Assistant Administrator for Solid Waste and Emergency Response
This is our report on the subject evaluation conducted by the Office of Inspector General (OIG)
of the U.S. Environmental Protection Agency (EPA). This report contains findings that describe
the problems the OIG has identified and corrective actions the OIG recommends. This report
represents the opinion of the OIG and does not necessarily represent the final EPA position.
Final determinations on matters in this report will be made by EPA managers in accordance with
established resolution procedures.

The estimated cost of this report - calculated by multiplying the project's staff days by the
applicable daily full cost billing rates in effect at the time - is $120,684.

Action Required

In accordance with EPA Manual 2750, you are required to provide a written response to this
report within 90 calendar days.  You should include a report of your follow-up actions with the
U.S. Coast Guard/National Response Center as per the Office of Emergency Management,
Program Operations & Coordination Division Director's e-mail of October 20, 2009. We have
no objections to the further release of this report to the public. This report will be available at
http ://www. epa. gov/oig.

If you or your staff have any questions, please contact Eric Lewis at (202) 566-2664 or
lewis.eric@epa.gov.

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Congressionally Requested Inquiry into EPA's Response                        10-P-0027
to a Report of a Leaking Well in North Carolina and the
National Response Center Hotline
                     Table of Contents
   Purpose of Review	    1

   Background	    1

   Scope and Methodology	    1

   Results of Review	    2

      EPA Responds Promptly	    2
      Another Skyland Area Resident Made Calls to the Region and NRC	    2
      Status  of the Region 4 Emergency Line on April 25, 2009	    2
      Status  of NRC on April 25, 2009	    3
      Voicemails Left with NRC on April 25, 2009	    3
      Voicemails Left with NRC prior to April 25, 2009	    4

   Conclusions	    4

   Status of Recommendations and Potential Monetary Benefits	    6



Appendices

   A   Voicemails Left with  NRC on April 25, 2009	    7

   B   Voicemails Left with  NRC Prior to April 25, 2009	    9

   C   Distribution	   10

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                                                                             10-P-0027
Purpose of Review

Representative Heath Shuler of North Carolina requested that we investigate the events
surrounding the response to an April 25, 2009, telephone report of a leaking well in Skyland,
North Carolina.  We conducted this review to determine whether the U.S. Environmental
Protection Agency's (EPA's) receipt and disposition of that telephone call followed applicable
policies and procedures.

Background

On Saturday, April 25, 2009, a constituent (Constituent 1) of Representative Shuler living in
Skyland became aware that a well in her yard was leaking.  The day prior to the leak, an EPA
contractor had collected samples from this well. While the well is not used as a drinking water
source, the leaking water is contaminated with trichloroethylene (TCE), which is a degreaser that
is reasonably anticipated to be a human carcinogen.  According to Representative Shuler's letter
to the EPA Office of Inspector General (OIG) dated April 28, 2009, as well as subsequent
information provided by Representative Shuler's office, a constituent reported making several
attempts on that Saturday to call the EPA emergency hotline but received no response.

There are two 24-hour emergency numbers listed on the EPA's Region 4 Website:

   •   An EPA regional spill reporting number.
   •   The telephone number for the National Response Center (NRC), operated by the
       U.S. Coast Guard, Department of Homeland  Security.

EPA staff members monitor the regional number during normal business hours and phones are
programmed to forward calls to NRC after hours and on weekends. Therefore, any call made to
Region 4 on Saturday, April 25, should have been transferred to NRC.  The Coast Guard staffs
NRC at all times.  NRC is the sole national point of contact for reporting all oil, chemical,
radiological, and biological discharges into the environment anywhere  in the United States and
its territories.  NRC disseminates telephone and electronic (fax, e-mail) reports of oil discharges
and chemical releases to appropriate federal On-Scene Coordinators (OSCs).

Scope and Methodology

We conducted field work from June 2009 to November 2009 in accordance with generally
accepted government auditing standards.  Those standards require that  based on our objectives,
we plan and perform the audit to obtain sufficient and appropriate evidence to provide  a
reasonable basis for our findings and conclusions.  We reviewed documentation surrounding the
reviewed event, including telephone records and transcripts of telephone calls.  We interviewed
Skyland-area residents, as well as staff and managers from EPA and NRC.  We believe that the
evidence obtained provides a reasonable basis for our findings and conclusions based on our
audit objectives.

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                                                                            10-P-0027
Results of Review

EPA Responds Promptly

Region 4's OSC reported becoming aware of the leaking well that Saturday, April 25, 2009, in
either the afternoon or early evening, when a local newspaper reporter left him a voicemail
message seeking comment on the leaking well. After the OSC learned of the leaking well, he
attempted to contact Constituent 1 as well as her neighbors, but was unable to do so. He stated
he left a voice message for Constituent 1, which she confirmed receiving. The OSC reported he
then contacted the EPA regional phone duty officer to determine whether there was an NRC
report of the leaking well. The phone duty officer informed the OSC there was no such report.
We reviewed NRC phone records and emergency reports.  These records did not show any phone
calls from Skyland.

The OSC reported to us that he immediately contacted the EPA contractor who would be
responsible for repairing the leaking well.  The leaking well was temporarily repaired by the
local fire  department on April 25. EPA's contractor arrived at the residence of Constituent 1 on
the evening of April 26. The OSC made the necessary arrangements and the contractor finished
the repair, which an EPA hydrogeologist inspected and approved on April 28. We believe
EPA's actions were appropriate and responsive.

Another Skyland Area Resident Made Calls to the Region and NRC

Representative Shuler's staff informed us that both Constituent 1 and a second constituent
(Constituent 2) had made calls to the hotlines. Stories in the local press made the same reports.
Initially, Constituent 1 told us she had made the calls. During our interview, we requested that
Constituent 1 provide us with the numbers she called so that we could confirm that the calls had
been made. Constituent 1 then said she did not report the leak to either the Region 4 or NRC
hotlines.  She believed that Constituent 2  and perhaps another person placed the calls, and she
provided us with the names.

When we contacted Constituent 2, he stated that he did not make any calls, but identified another
Skyland resident who he claimed had made the calls (Constituent 3). We contacted
Constituent 3, who said he called both the Region 4 and the NRC hotline from a friend's phone.
His friend agreed to provide her phone records but could not do so because her phone company
would not provide them without a subpoena. We confirmed this requirement with the phone
company and issued a subpoena for the phone records. On August 20, 2009, the phone company
provided us the records. Those records confirmed that calls to Region 4  and the NRC hotline
were made on April 25, 2009, between 2:00 and 2:30 p.m.  Constituent 3 said he reached a
voicemail system at each number. He also said that he had left voicemail messages as requested
but had not been contacted.

Status of the Region 4 Emergency Line on April 25,  2009

EPA Region 4 personnel  said the region's emergency line was programmed on April 25, 2009, to
forward all incoming calls to the NRC hotline. This is standard procedure for the Region 4

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                                                                             10-P-0027
hotline during evenings and weekends. NRC handles EPA regional hotline after-hours calls
according to an interagency agreement.

We obtained records from the EPA phone system, which confirmed at least one call had been
placed to the Region 4 hotline on April 25. Records show this call was forwarded to the NRC
hotline.

Status of NRC on April 25, 2009

On July 24, 2009, we interviewed the NRC Chief and the Senior Watchstander. Watchstander is
a term used by the Coast Guard to refer to personnel on duty in NRC responding to incoming
phone calls.  The NRC Senior Watchstander was on duty on April 25, 2009, and he said the
hotline was staffed and operating. The Senior Watchstander also said that NRC was conducting
a continuity of operations (COOP) exercise on April 25, 2009, which involved using an alternate
telephone operations center and phone system for a portion of the day. The Senior Watchstander
said that the exercise ran from 6:00 a.m. until 7:00 p.m. The NRC Chief and Senior
Watchstander stated it was not possible for callers to leave a voicemail on the NRC emergency
line during the April 25 COOP exercise because the system had no voicemail option.

The NRC Chief and Senior Watchstander provided the OIG with phone records that listed all
incoming and outgoing calls to and from NRC on April 25, 2009.  These records do not show
any incoming call from Skyland,  North Carolina. The NRC Chief and Senior Watchstander said
these records would not include the numbers of callers who hung up before speaking to hotline
personnel.

On September 17, 2009, we met with NRC staff and the telephone contractors who perform
technical work on the phone system.  We sought to determine how the NRC telephone system
did not record the call forwarded  from the EPA hotline and Constituent 3's call directly to the
NRC hotline. The telephone contractors told us the NRC telephone system sent some callers
directly into voicemail for a portion of April 25, 2009. They stated that before April 25 they did
not know of this voicemail system on the NRC emergency hotline.

Contrary to what we were told by the Coast Guard personnel we interviewed, the contractor
personnel said the Senior Watchstander informed them that calls were being forwarded to
voicemail at approximately 2:00 p.m. on April 25. We checked NRC phone records and
observed numerous phone calls showing NRC staff calling the hotline that day, apparently
testing the system.  The telephone contractors said they worked to fix the problem while NRC
personnel continued to respond to phone calls from their COOP site.

Voicemails Left with NRC on April  25, 2009

In September 2009, NRC telephone contractors provided us with information (including
transcripts) from the voicemails left with NRC on April 25, 2009. The telephone contractors
reported that the NRC Chief would not permit them to release audio copies of the voicemails
directly to the OIG. Later, the NRC Chief provided a CD containing the voicemail messages
from April 25, including calls from Constituent 3. These voicemails state Constituent  3's name,

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                                                                              10-P-0027
contact information, nature of the issue, and a request for a return phone call. The telephone
records associated with these calls indicate Constituent 3 first called the NRC hotline directly.
The second call was made to EPA Region 4 (after duty hours) and it was forwarded to the NRC
hotline.  A transcription of the calls is in Appendix A.

Two other incidents, reported in three voicemails, may have also warranted NRC action to
contact EPA or other federal, State, or local agencies.  The first call reported an oil sheen in a
Houston, Texas, ship channel. Another call reported "several thousand tons" of chromium VI at
a dumpsite in Missouri. Chromium VI (hexavalent chromium) is ranked eighteenth on the
priority list of substances on the 2007 Comprehensive  Environmental Response, Compensation,
and Liability Act List of Hazardous Substances.  NRC staff stated they had not contacted any of
the callers.

The Coast Guard Telephone and Information Systems  Command (TISCOM) also left four
voicemails on the system that day. TISCOM provides telecommunications, electronics, and
information systems support to the Coast Guard. None of these voicemails included substantive
information. We believe these calls represent TISCOM staff checking on system functions
during the COOP exercise.

Voicemails Left with NRC prior to April 25, 2009

During our field work, NRC telephone contractors provided us with additional voicemail
records. These records show that 12 voicemails were left with NRC between October 2006 and
April 24, 2009. Information on the date, time, and duration of these voicemails is in Appendix B.
NRC staff reported they had not listened to these voicemails. The NRC Operations Officer
informed us the  NRC did not listen to the voicemails until September 2009. We have made this
information available to an EPA official and that official said there would be follow-up with
NRC.

Conclusions

Our review indicated that EPA staff provided a timely  and effective response to the leaking well
in Skyland, North Carolina. However, we believe there are weaknesses with the NRC
emergency hotline system used as an EPA Region 4 hotline backup. During non-business hours,
EPA depends on  the U.S. Coast Guard to properly operate the NRC hotline. The NRC telephone
problems that occurred on April 25, 2009, resulted in missed calls for EPA's help or assistance
with possible environmental dangers. When NRC staff discovered that emergency calls were
going into a voicemail system, they took no action to retrieve any of those calls.  Although NRC
staff reportedly informed contractors that calls were going to voicemail on April 25, 2009, NRC
staff informed  the EPA OIG that it was not possible to leave a message on the emergency hotline
when the system  is operational. Once the voicemails were discovered, NRC staff took no actions
to contact the callers or inform EPA that calls had been missed.

Addressing the issues in Representative Shuler's letter took more time than necessary because
some of his constituents and the NRC Chief and Senior Watchstander did not initially provide
complete or accurate accounts of the incidents.  Constituent 1 did not call either the EPA

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                                                                               10-P-0027
Region 4 or the NRC hotlines after initially reporting she had done so.  As previously noted,
NRC personnel initially said there is no ability to leave a voicemail when the system is
operational. We had to subpoena records, verify calls, and interview NRC contract support
personnel to determine what had actually happened.

We believe that NRC did not effectively fulfill its mission when emergency calls were
mishandled and unanswered.  We also believe the unanswered calls were knowingly left
uncorrected. In our opinion, these conditions represent a material internal control weakness in
the process and an unsatisfactory control  environment. We will present our findings to the
Department of Homeland Security OIG so it may determine the degree to which the contractors
have repaired the NRC phone system and to fully investigate the inconsistencies in information
provided by NRC staff.

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                                                                            10-P-0027
                Status of Recommendations and
                    Potential Monetary Benefits
                                                                     POTENTIAL MONETARY
                          RECOMMENDATIONS                                BENEFITS (in $OOOs)
                                                           Planned
Rec.   Page                                                  Completion    Claimed   Agreed To
No.   No.             Subject            Status1     Action Official      Date      Amount    Amount
               No recommendations to EPA
 0 = recommendation is open with agreed-to corrective actions pending
 C = recommendation is closed with all agreed-to actions completed
 U = recommendation is undecided with resolution efforts in progress

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                                                                                10-P-0027
                                                                            Appendix A
          Voicemails Left with  NRC on April 25,  2009
 Time
     From
 Duration
                   Transcription
2:04 pm
U.S.G/9703313
     xxx1
 1 second
None
2:11 pm
     U.S.
 G/9703313xxx
148 seconds
[This voicemail sounds as if the caller does not know he is
being recorded. The main caller speaks to a voice in the
background which he identifies as one of the NRC
employees. They discuss other telephone numbers
associated with NRC, such as the Federal Railroad
Administration Hotline. The main speaker notes twice
that, "Somebody did something wrong up  there."]
2:17 pm
     U.S.
G/9703313xxxx
 6 seconds
None
2:18 pm
[Constituent 3's
 friend's phone
owner]/[number]
35 seconds
Yeah this is [Constituent 3 gives his name] calling at
Saturday afternoon at about 2:18.  Wanted to report a spill
that's happening.  TCE running out all over the ground in
Asheville, North Carolina.  Please feel free to give me a
ring. I thought, it says, 24-hour spill reporting hotline,  but
nobody answers on your end. Pretty amazing. Anyway,
my number is: [Constituent 3 gives his phone number]
and the name is [Constituent 3 gives his name]. Thank
you. Bye bye.
2:19 pm
     Line
 49/914045682
    868412
   Note: 9 1
 (404) 568-2868
  is the EPA
 Region 4 Spill
   Reporting
    Number
48 seconds
Yeah, this is [Constituent 3 gives his name] calling,
[Constituent 3 spells his last name], it's twenty minutes
after two Saturday afternoon.  I wanted to tell you about a
spill. Three months ago this well had 1,100 parts per
billion of TCE. It's an artesian well, it's improperly sealed,
it's coming up all over the ground and every three months
this well has been doubling in the amount of TCE so there
we go and there are small kids playing next door.  Please
feel free to give me a ring. My  number: [Constituent 3
gives his number].  Have a nice afternoon. Bye bye.
2:23 pm
Cell Phone TX7
   [number]
55 seconds
This is [Texas Caller gives his name] with [Texas Caller
gives his company's name].  I was calling the National
Response Center at 1-800-424-8802. I need to report a
sheen in the water of the Houston ship channel and we
are not the response - [Texas Caller gives his company
name] is not the responsible party and we don't know who
is. But we wanted to make a notification so that there
would be an awareness.  My cell phone number is [Texas
Caller gives part of his phone number] excuse me.
[Texas Caller gives part of his phone number] oh I forgot
it.  I will call back this number and leave a message with
the correct number.
2:23 pm
     U.S.
 G/9703313xxx
 2 seconds
None
 Note: (703) 313-xxxx is the number for U.S. Coast Guard's TISCOM

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                                                                                     10-P-0027
Time
2:24 pm
2:41 pm
2:42 pm
From
Cell Phone TX/
[number]
[name 2]/
[number]
Anonymous/
17230
Duration
33 seconds
[information
not provided]
4 seconds
Transcription
This is [Texas Caller gives his name] with [Texas Caller
gives his company's name], [Texas Caller gives his
number], calling to report a sheen of water, oil, in the
Houston ship channel to the national response center.
I called 1-800-424-8802 and I've gotten this recording.
Normally I would expect to reach the National Response
Center. Thank you.
This is [Missouri Caller gives his name, spells last name],
and I'm the EMD for Harrison County. I need to speak to
someone about getting some soil testing done as soon as
possible. I found a dumpsite here in Harrison County that
has several thousand tons [emphasis heard in original] of
Chromium VI in a concentrated area and I'd like to start
some kind of process of getting this tested. My cell
number is [Missouri Caller gives his phone number] and
I'd like some help as soon as possible. Thank you.
None
Source: NRC phone records.

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                                                 10-P-0027
                                              Appendix B



Voicemails Left with NRC Prior to April 25, 2009
Date
10/12/2006
10/12/2006
1/19/2007
1/20/2007
1/20/2007
1/22/2007
1/23/2007
1/24/2007
1/24/2007
1/25/2007
1/25/2007
6/27/2008
Time
3:48am
3:58am
9:06am
1:28pm
10:23pm
7:15pm
12:37pm
5:37am
11:57pm
12:14pm
4:27pm
6:57pm
Duration
11 seconds
11 seconds
56 seconds
47 seconds
77 seconds
3 seconds
14 seconds
18 seconds
175 seconds
2 seconds
4 seconds
295 seconds
     Source: NRC phone records.

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                                                                           10-P-0027
                                                                       Appendix C

                                 Distribution
Office of the Administrator
Assistant Administrator, Office of Solid Waste and Emergency Response
Acting Regional Administrator, Region 4
Agency Follow-up Official (the CFO)
Agency Follow-up Coordinator
General Counsel
Associate Administrator for Congressional and Intergovernmental Relations
Associate Administrator for Public Affairs
Audit Follow-up Coordinator, Office of Solid Waste and Emergency Response
Acting Inspector General
                                         10

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