Challenges Faced During
the Environmental Protection Agency's
Response to Anthrax and Recommendations
for Enhancing Response Capabilities
A Lessons Learned Report
U.S. Environmental
Protection Agency
September 2002
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Table of Contents
Pa«o
I executive Summary ii
Acronym I .ist , .. ix
Chapter 1: Introduction 1 1
Chapter 2: Lessons Learned and Recommendations ,, . 2-1
Chapter 3: Conclusions and Cross-Cutting Recommendations 3-1
Appendix A: Report N'1elliod«>lo.u> A-1
Appendix B: Sample Inien iew Quorums ................ , B-I
September 2002
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Executive Summary
Background This report describes lessons learned and priority recommendations for
improvement regarding emergency response to anthrax-related incidents.
based on the associated activities conducted by the Environmental Protection
Agency (EPA) from October 2001 through February 2002. It reflects the
retrospective observations and recommendations of EPA personnel involved
in this effort, including front line responders, technical and support personnel,
and both headquarters and regional management. In no way should this report
be represented as critical of the outstanding performance of many individuals,
or the demonstrated effectiveness and capacity of EPA as an organization.
The report is intended as constructive feedback to the Agency, from the
Agency, on its multifaceted anthrax response, to maximize learning from this
unfamiliar challenge in the event of a future, similar attack.
During September and October 2001, at least four letters containing a
powdered form of anthrax were mailed through the United States Postal
Service (USPS), resulting in the presence of anthrax spores at various
Congressional office buildings on Capitol Hill in Washington, DC; USPS
facilities; and other government and private facilities in several locations
nationwide. Beginning in October 2001. EPA responded to the environmental
threats created by confirmed and suspected cases of anthrax contamination.
EPA personnel demonstrated the ability to develop site management and
cleanup plans for an entirely new response scenario involving a biological
contaminant. EPA's capabilities and efforts were central to the ultimate
success of this unprecedented cleanup.
The Agency's resources were mobiti/cd and coordinated using national and
regional support, EPA's responses included the three-month anthrax response
on Capitol Hill, as well as responses at other federal facilities. Approximately
128 EPA personnel and 54 On-Scene Coordinators fOSCs) came from all 10
EPA regional offices to respond to the anthrax cleanup.
In addition to the application of professional emergency response knowledge
and skill to unfamiliar challenges, EPA personnel devoted extraordinarily
long hours to difficult and stressful work. From October 2001 through
February 2002, EPA responders worked with other agencies and organizations
to ensure the protection of public health and the environment, as well as the
continued operations of the U.S. Government.
This report captures lessons learned and cross-cutting recommendations in the
following area categories: Authorities; Operations; Communications and
Coordination; Health and Safety; and Resources,
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Executive Summary (continued)
Study initiation EPA Administrator Christine Todd Whitman charged Assistant Administrator
Marianne Lament Horinko. Office of Solid Waste and Emergency Response
(OSWER). to chair an effort to draw out lessons learned from the wide-
ranging activities m which EPA was engaged following the terrorist attacks oi
September 1 I, 2001. Due in part to the relevance of an initial report. Lessons
Learned in the Aftermath of September J1. 2001. developed by EP.-Vs Office
of Emergency and Remedial Response (OERR), this lessons learned report.
Challenges Faced During the Environmental Protection Agency 's Response
to A nth rax and Recommendations for Enhancing Response Capabilities, was
commissioned on March 6, 2002.
Goals for the
studv
In any response of this magnitude, lessons learned will assist EPA in
responding to future incidents. EPA views this report as an opportunity to
learn from the experiences of its personnel. The goals of this report are as
follows:
1. Document the major actions taken by EPA;
2. Identify the key accomplishments as related to significant advancement
of the science and technology of detecting and remediating anthrax, as
well as define areas where enhanced capabilities are most desirable; and
3. Develop lessons learned and present recommendations for meeting the
challenges ahead in the areas of emergency preparedness and counter-
terrorism response.
A focused study based on extensive interviews of (i7 individuals was
conducted between March 6, 2002. and April 30, 2002. Interviewees were
representative of headquarters arid regional management, OSC's, other
respondcrs. and personnel at ail levels who were involved with all aspects of
EPA s anthrax-related activities between October 2001 and Fcbruarv 2002,
Interviewees were asked to describe and assess their organization's anthrax
response activities and capabilities, arid to answer questions with respect to
HPA's authorities; operations; internal and external communications; health
and safely; and resources during the response.
Lessons learned jjlc information and assessments provided through interviews were examined
to document actions, establish patterns and themes across different
perspectives, identify lessons learned, develop specific recommendations, and
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Executive Summary (continued)
finally formulate overarching "cross-cutting" recommendations Lessons
learned are grouped in the following five area categories: Authorities;
Operations; Communications and Coordination; Health and Safety; and
Resources,
f ross-cuttin« Alter evaluating the lessons learned, she most .significant and broad-reading
recommend a- issues were identified as overarching challenges that span the previously
,ons identified area categories, and used to develop cross-cutting recommendations
that encompass the lessons described in Chapter 2, Key steps in
implementing the cross-cutting recommendations are further specified m
Chapter 3,
Although the Comprehensive Environmental Response, Compensation, and
Liability Act (CERCLA) and the National Oil and Hazardous Substances
Pollution Contingency Plan (NCP) provide authority to respond to biological
incidents, the NCP does not include a response plan for such incidents, and
the Federal Response Plan (FRP) was not activated to coordinate the agencies
involved in the response to anthrax on Capitol Hill. A number of
jurisdictional issues were raised during EPA's responses to the anthrax
incidents regarding constitutional; statutory and regulator}-; contractual, and
non-CEKCLA authorities.
Lessons learned in this area include:
Questions about lines of authority could potentially complicate or delay a
response to an incident on property under the control of the legislative or
judicial branches of the federal government. In the absence of FRP activation,
there is no clear structure defining the interaction of the various federal
agencies that may be involved in a large-scale response
The non-traditional response structure under which EPA was operating at
Capitol Hill did not make the best use of EPA's experience and established
procedures, resulting in defining roles and responsibilities "on the fly."
Cross-cutting recommendation:
Revisit and revise, as needed, EPA's existing internal emergent*) response
coordination authority, plans, and structures.
Operation*. The anthrax incidents occurred while EPA's response at the World Trade
Center and the Pentagon were ongoing. There were thousands of anthrax
incidents, scares, and hoaxes nationwide. EPA regions responded to many
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Executive Summary (continued)
incidents, most of which were false alarms. The operating environment wa>,
in the opinion of responders. "unlike any previous operating environment"
that EPA had faced. Although response personnel effectively solved the
problems they faced, EPA was not fuilv prepared to scale up its efforts to the
magnitude required for the anthrax cleanup, and did not have sufficient
technical information or procedural guidelines at hand.
Lessons learned in this area include:
Use of a clearly defined and fully implemented command structure would
have enabled more efficient management of a complex, national-scale
response involving multiple agencies.
Obtaining adequate expertise in the operational technicalities associated with
responding to anthrax contamination or other biological agents would enhance
planning efficiencies and the timeliness of response.
Finding and testing the most efficient response methods, and their costs, for
dealing with anthrax contamination would enable expeditious selection of
disinfection approaches.
Cross-cutting recommendations:
Enhance capability to scale up emergency response efficiently, and develop
specialized response skills for unfamiliar threats.
Develop, with the Office of Homeland Security, a response coordination
structure to be followed in a multi-federal agency response for which the FRP
is not activated.
Communications Coordination between organizations and creating a structure for sharing
and coordination information is critical, as is ensuring interagency familiarity with each others'
roles, responsibilities and capabilities.
Many of the communication processes worked well, such as the use of cellular
phones between OSCs and other key responders; daily conference calls;
wntten daily updates of site activities; community outreach; and frequent
press conferences and updates to Congress. However, a more ^>stematic
approach to on-site communications was needed. Although a central planning
and support section was in operation for interagency coordination, greater
familiarity with its existence and functions would improve coordination
among responders.
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September 2002
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Executive Summary (continued)
Lessons learned in this area include:
A more centralized process for tracking sue personnel, activities, and progress
toward completion at the Capitol Hill response would enhance coordination
among EPA staff, and thereby improve the efficiency of the response.
Implementing a traditional Incident Command System-Unified Command
(lCS-'L'C) structure would include a Joint Information Center for future
responses of this magnitude.
Using EPA's established systems for inter-office coordination, such as the
National Incident Coordination Team and the Regional Incident Coordination
Team (RICT), would help plan for emergency response situations.
Deployment of hPA's Emergency Communications and Outreach Team
(ECC)T) can provide additional support to the regional community
involvement staff.
Cross-cutting recommendation
Elevate the priority of emergency communications structures and capacity,
and implement existing communications programs developed for emergency
responses.
Health and At the time of the response. EPA had no standard mode or protocols for
safety addressing the special health and safety concerns associated with the release
of a biological agent such as anthrax. As a result. EPA relied on expertise and
information from other organizations, and the approaches to health and safety
changed and evolved during this response. While a Health and Safety Plan
was available and accessible to all responders on site, some responders
observed that more information should have been available in the plan to
specifically address reconnaissance safety.
The availability of useful, accurate scientific information for a response to
anthrax in a civilian environment was limited and anthrax-related information
front other health agencies was not initially as useful as EPA had anticipated.
In the initial days of the response, the lack of scientific data about anthrax
limited EPA's decision-making abilities regarding operational issues such as
personal protective equipment (PPE).
On-site medical support is another health and safety issue reviewed in this
report. EPA should examine medical policies, regulations, and laws that to
ensure that EPA will have adequate and continuous medical support at the
beginning of a future large-scale response.
September 2002
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Executive Summary (continued)
Lessons learned in this area include:
There is a need lor faster and greater access to better interagency (both
civilian and military) information on potential biological weapons of mass
destruction (WMD), and for providing a clear understanding of exposure
risks and correct prophylactic treatments available to protect responders from
exposure.
CPA's traditional approach to health and safety must be revisited when
responding to biological agents such as anthrax. Clear guidance on PPE
levels for biohazard responses must be established.
Special care must be taken to address sudden changes in field procedures
while operations are underway, including re-training, to avoid the potential for
human error affecting safety and health.
Cross-cutting recommendation:
Enhance safeguards to ensure that responder health and safety is given
precedence among competing priorities, especially in a multi-agency led
response.
The anthrax response was unprecedented in terms of the amount of resources
needed by EPA to accomplish its mission safely and effectively, EPA was
well prepared and trained for an emergency response, but not well trained or
prepared to handle the unfamiliar and unique aspects of a biohazard, or
specifically, anthrax response. As observed by the front-line responders.
resource availability proved to be multidimensional, affecting the conduct of
operations, communications, and health and safety issues. In addition, the
mechanisms typically used by EPA to obtain resources had to be exercised
and interpreted in ways not previously used by EPA in an emergency
response
Lessons learned in this area include:
There is a need for having a mechanism, procedure, or source of funding in
place to provide financial support for the magnitude of an emergency response
when the FRP had not been activated.
A more traditional command structure, such as the ICS. can manage resources
more effectively.
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September 2002
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Executive Summary (continued)
EPA's standard response contracts did not provide for the staffing needs for
biological emergencies. There were times when there were no! enough
qualified contractors available to conduct specialized work.
EPA does not have an inventory of equipment needed to sample microbial
agents or to perform disinfection. It also does not have a database of possible
sources of equipment as it does for chemical responses.
Adequate supplies of PPE must be provided for the OSCs.
Cross-cutting recommendations
Acquire equipment. lab capacity, funding and trained personnel sufficient to
support EPA's role in responding to biological agents and other WMD.
Improve response capability and develop in-house expertise in biological
agents and other WMD.
EPA considers the anthrax cleanup a success. Using the Agency's well-tested
problem so I vim: approach to emergencies. EPA met and resolved the
following challenges,
Cleaned up the anthrax on Capitol Hill efficiently and safely, while
having to adapt and operate within a command structure that used new
approaches to organizing an emergency response.
EPA worked within the established command structure facilitating the
management of its response activities and personnel while also
communicating and coordinating effectively with the other agencies and
organizations.
EPA responders had only limited technical information and experience
for cleaning up biological contaminants. Despite these challenges. EPA
was able to implement a plan of action based on sound science.
* EPA, along with others, worked to access the technical and medical
expertise necessary to identify appropriate health and safety procedures,
and implement safeguards for the biological response.
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Scptember 2002
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Acronym List
AA
Assistant Administrator
AMI
.American Media, inc.
BCR
Biological, Chemical, or Radiological
CDC
Centers for Disease Control and Prevention
CERCLA
Comprehensive Environmental Response, Compensation, and Liability Act
CID
Criminal Investigation Division
ClOC
Community Involvement and Outreach Center
DA
Deputy Administrator
DoD
U.S. Department of Defense
ECOT
Emergency Communications and Outreach Team
hoc
Emergency Operations Center
EPA
U.S. Environmental Protection Agency
ERT
Environmental Response Team
FBI
Federal Bureau of Investigation
1" FMA
Federal Linereeney Management Agency
PR?
Federal Response Plan
GSA
General Services Administration
HASP
Health and Safety Plan
HHS
U.S. Department of Health and Human Services
IC
Incident Commander Incident Command
ICS
Incident Command System
JiC
Joint Information Center
NCP
National Oil and Hazardous Substances Pollution Comtngene\ flan
NICT
National Incident Coordination Team
NIIMS
National Interagency Incident Management System
NIOSH
National Institute of Occupational Safety and Health
N'RS
National Response System
NRT
National Response Team
OERR
Office of Emergency anil Remedial Response
September 2002
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Acronym List (continued)
OGC
Office of General Counsel
OPA
Office of Public Affairs
OPC
Oil Program Center
OPPTS
Office of Pollution Prevention unci Toxic Substances
OSC
On-Scene Coordinator
OSWER
Office of Solid Waste and Emergency Response
FDD
Presidential Decision Directive
PPE
Personal Protective Equipment
RA
Regional Administrator
RICT
Regional Incident Coordination Team
RPM
Remedial Project Manager
UC
Unified Command
USAMRUD
United States Army Medical Research Institute of Infectious Diseases
USCG
United States Coast Guard
USFHS
United Slates Public Health Service
USPS
United States Postal Service
WML)
Weapons of Mass Destruction
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September 2002
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Chapter 1
Introduction
Overview
The Challenge, For more than 30 years, the Environmental Protection Agency's (EPA)
The Response, emergency response actions have reduced risks to public health and the
A Program of environment. EPA stands ready 24 hours a day to respond quiekiy whenever
hazardous substances are released.
Action
Every day across the country, a dedicated staff of On-Scene Coordinators
(OSCs) conduct and direct emergency responses. During the anthrax cleanup
on Capitol Hill, dozens of OSCs came together to apply their expertise to an
unknown situation involving a biological contaminant. As a result, human
health was protected. This historical response demonstrated the ability of
OSCs to adapt to uncertain situations and apply their knowledge of science in
meeting the challenges of anthrax.
Within days of the response to Capitol Hill. OSCs worked m partnership with
other agencies and organizations to manage site activities. They also worked
on designing a plan for sampling and cleaning up the anthrax. The
unprecedented level of coordination, communication and teamwork was the
key to the success of the response. Additionally, OSCs provided daily
briefings to Congress while ensuring that the surrounding community was
kept informed of the cleanup activities, and for the next three months, OSCs
worked to ensure a safe and expeditious cleanup.
In orchestrating a response of this magnitude. EPA effectively used its
problem-solving skills and applied sound science to the cleanup. This report
records a program in action and reflects EPA's commitment to conducting
effective responses and meeting our mission of protecting human health and
the environment,
Need for this Although EPA's response to anthrax is considered an overall success, it is
rePorl important 10 draw lessons learned from the Agency's technical and oversight
activities following the detection of anthrax contamination at several locations
across the United Slates. Although efforts to strengthen counter-terrorism and
disaster preparedness have been ongoing for several years within the
parameters of available resources, all responding programs and regions were
challenged by the extensive demands of responding lo the first large-scale
incident of anthrax contamination in the United States. Res ponders faced an
intense and mounting workload and new technical demands, in addition to ihe
1-1 September 2002
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Overview (continued)
emotional and physical stress related to the extreme hazards and the
realization that several civilian fatalities were associated with the anthrax
exposure. The challenge was compounded by ongoing criminal hoaxes and
false alarms involving anthrax contamination.
This report follows an initial lessons learned report, completed on Februan I.
2002, Lessons Learned in the Aftermath of September 1 /. 200!. The Cross-
Cutting Issues identified in Chapter 3 of this report may share similarities with
those identified tn the initial report. The first anthrax incidents took place in
the weeks following the attacks on the World Trade Center and the PemagoTi,
where EPA was still involved m response activities. There was no time lapse
between trie two phenomenally large responses in which lessons could be
drawn from one response and effectively applied to the next. Similarities in
findings should, therefore, not be seen as representative of an inabiiitv to
implement recommendations, but rather reinforce their relevance as
overarching issues to be addressed by EPA in preparation for future large-
scale response activities.
l-r«cncy for this The nation remains m a heightened state of alert, with an immediate need to
rePort apply these lessons learned. FPA is committed to responding to emergency
situations with increased quality, speed, and comprehensive action. The more
quickly lessons can be gathered and learned after such events, the more
quickly HPA can apply them both to an ongoing response and to the Agency's
long-term counter-terrorism strategy. The unprecedented nature of the
anthrax incidents has raised the nation's awareness of the potential for
terrorism using chemical or biological weapons. This awareness highlights
the need for EPA to be well prepared for new and unusual chemical or
biological threats, and to be able to respond during national-scale
emergencies. While this report focuses on actions taken in response to the
threat of anthrax, it also notes EPA's more general need to strengthen
capabilities to address the consequences of biological, chemical, or
radiological (BCR) threats, and to enhance preparedness for potential terrorist
attacks using weapons of mass destruction (WMDs).
This report focuses on the actions taken by EPA in response to confirmed or
suspected cases of anthrax contamination at various Congressional office
buildings on Capitol Hill, U.S. Postal Sendee (USPS) facilities, and other
government and private facilities since October 2001. However, lessons
learned from these responses that are applicable to other types of BCR
incidents are mentioned.
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September 2002
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Overview (continued)
what does this This chapter includes die following information:
chapter
u'ntjin- Report Purpose
Report Methodology
Events Pnor to EPA Involvement
EPA's Role in Responding to Anthrax Contamination
Activities and Conditions at Major Response Sices
Content Overview
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September 2002
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Report Purpose
Intent in any response of this magnitude, lessons learned will assist EPA in
responding to future incidents. However, the purpose of this report is not to
undermine or question the effectiveness of the Agency's response lo the
anthrax incidents. I:PA is proud of the efforts of its personnel, and views thi^
report as an opportunity to learn from their experience.
Goals for the The goals of the study efforts culminating in this report are as follows:
study
» Document the major actions taken by I:PA;
» Identify the kev accomplishments as related to significant advancement oi
the science and technology of detecting and remediating anthrax, as well
as define areas where enhanced capabilities are most desirable; and
Develop lessons learned and presem recommendations for meeting the
challenges ahead in the areas of emergency preparedness and counter-
terrorism response.
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September 2002
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Report Methodology
Gathering the A focused study based on extensive interviews ol"67 indn iduaK wa>
information conducted between March 6, 2002, and April 30, 2002, Interviewees involved
in various facets of EPA's anthrax response were selected from across I.PA.
from both headquarters and regional organizations. Respondents were asked
to describe and assess their organization's anthrax response activities and
capabilities, and to answer questions with respect to EPA\s authorities;
operations: internal and external communications; health and safety: and
resources during the response.
Stuch initiation I-PA Administrator Christine Todd Whitman charged Assistant Administrator
Marianne Lament Horinko, Office of Solid Waste and Emergency Response
lOSWER}, to chair an effort to draw lessons learned from EPA activities
following the events of September 11, 2001. Due in part to the relevance of
an initial report, 1.assorts Learned in the Aftermath of September 11, 2001,
developed by Office of Emergency and Remedial Response (OERR). this
lessons learned report. Challenges Faced During the Environmental
protection Agencv's Response to Anthrax and Recommendation- for
Enhancing Response Capabilities, was commissioned on March 6, 2(102
Information EPA offices were asked to identify a cross-section of individuals involved
collection and with all aspects of EPA "s anthrax-related activ ities between October 2001 and
analysis February 2002. Individuals were representative of headquarters and regional
management, OSC's. other responders, and personnel at all levels. The
process for this effort, based on information collected from these respondents,
is shown in the diagram below.
Development of Recommendations
Recommendations
Conclusions ana 7
Ctsss-Cur-ig
Re5e-t7wr>;lsr,o»*j
6? Inter/tews wtn
Tia^agenen! ar.i
!(&>!-'ne wsoine:
Iran 10 Regions
and HQ
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September 2002
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Report Methodology (continued)
The information and assessments provided through interviews were examined
to document actions, establish patterns and themes across different
perspectives, identify lessons learned, and develop overarching "cross-
cutting" recommendations. A more detailed description of the methodology is
presented in Appendix A.
Data collected During the course of the interviews, managers and personnel from EPA
offices and regions described the following:
Actions taken
Authorities activated
Organizational decision-making
Operational environments
Preparedness levels
Communication successes and challenges
Coordination with outside entities
Methods of information exchange
Health and safety measures
Available resources
Tools used for maintaining essential operations
Overall successes and challenges of the response
Based on their firsthand know ledge, interviewees rated their satisfaction with
bPA's ability to respond to the anthrax incidents in terms of five major areas:
Authority
Operations
Communications and coordination
Health and safety
Resources
Finally, respondents listed up to five of the greatest challenges they felt the
Agency faced in responding to anthrax contamination. See Appendix B for
example questionnaires.
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September 2002
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Events Prior to EPA Involvement
Background Bacillus anthrcicis, commonly known as anthrax, is a naturally occurring
spore-forming bacterium that causes acute infectious disease that is
potentially fatal m humans. Occasionally, anthrax is found in some hooted
mammals and. in rare cases, infects people working closely with such animals
or animal products. Prior to September 200], anthrax had not been released in
this country as a terrorist weapon, and much is still unknown about the
properties of lab-produced anthrax spores. No anthrax cleanup of this scale
had ever been attempted, and no registered antimicrobial agents were
approved for civilian use against anthrax prior to October 2001. The logistics
and engineering of decontaminating large areas within buildings had to be
developed quickly, with limited knowledge about anthrax risk levels or the
effectiveness of anthrax detection, cleanup, and disposal methods.
Anthrax-laced Dunne September and October 2001, at least tour letters containing a
letters caused powdered form of anthrax were mailed through the USPS. The first such
contamination letter wa> received bv American Media, inc. < AMI) in Boca Raton, Florida on
or around September 25, 2001. The contamination was discovered after one
employee died of inhalation anthrax on October 5, 2001. and another was
sickened..
ami outbreak
Other anthrax-contaminated letters were received in October at NBC News in
New York, and at U.S. Senator Torn Daschle's office in the Hart Senate
Office Building in Washington, DC. Contamination of the Brentwood Post
Office in Washington, DC was discovered after two workers died of
inhalation anthrax, and several others were .sickened. New cases of inhalation
and cutaneous anthrax emerged in October and November 2001, in New
York. New Jersey, and Connecticut. Another contaminated letter, addressed
to Senator Patrick Leahy, was later found m an off-site government mail
facility.
The presence of anthrax spores was discovered at various other locations,
including a maiiroom at ABC News in New York; in New York .Mayor
Giuliani's office; in New York Governor Pataki's offices; in New York City
Hall, the New York Post; and in various postal facilities in New York.
Washington DC. New Jersey. Connecticut. Florida. North Carolina, Indiana,
and Missouri. In the greater Washington, DC area, anthrax spores were
identified at a number of federal government facilities, predominantly m mail
areas, including at the Department of State, the Department of Justice, the
Supreme Court, the Department of Health and Human Services (I IMS), the
Department of Defense iDoDl. the Department of Treasury, and other
departments. Additional anthrax contamination was detected at the ford and
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Sc-ptembei 2002
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Events Prior to EPA Involvement (continued)
Longworth House Office Buildings and in a warehouse on P Street NW, on
Capitol Hill,
The scientific and medical information available to rcsponders at the time
I ncrramttieij when the contaminated letters were initially heim: identified indicated that
and unknown worker* in the poslxil facilities where the letters were proceed were not a:
risk of infection. When postal workers at several facilities became ill, and two
from the Brentwood Post Office subsequently died of inhalation anthrax, the
limitations of existing knowledge to calculate the risks associated with this
anthrax tragically became evident.
risks
A number of postal workers and other mail handlers at various locations
became infected, and it is still unconfirmed how two individuals, who died of
inhalation anthrax (a hospital worker in New York and an elderly woman in
Connecticut), were exposed.
National impact Five individuals died of inhalation anthrax in Florida, New York. Washington,
of anthrax DC. and Connecticut m the first known cases in the United States in over 20
contamination years. In total, 22 actual eases of the inhalation or cutaneous forms ol anthrax
were diagnosed, in addition to numerous confirmed exposures.
Approximately 10,000 potentially exposed people were tested and treated
with prophylactic regimens of antibiotics.
Widespread alarm over the fatalities and concent about the safety of the mail
resulted in many thousands of reports nationwide of suspicious substances
requiring investigation. False alarms and hoaxes nationwide placed a
significant dram on resources needed to conduct emergency response.
Cross-contamination of mail now appears to have caused the spread of
anthrax spores to some postal facilities that did not process the actuu; spore-
con taming envelopes, increasing the geographic scope of the incidents and
heightening uncertainties about the magnitude of the responses that would be
required.
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September 2002
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EPA's Role in Responding to Anthrax Contamination
Protection of
health and
environment
EPA is one of the chief guardians of public health and the environment in the
United Slates. In any large-scale environmental emergency, EPA coordinates
with local and state first responders. In the ease of anthrax contamination,
EPA provided technical expertise and oversight in detection and ensured that
the cleanup was fully protective of public health and the environment at both
government and privately owned facilities, EPA's Technology Innovation
Office led efforts to collect and disseminate information to appropriate entities
on technologies that detect and kill anthrax. Currently, EPA is pursuing the
development of additional procedures to handle bioterrorism, including
procedures for decontamination and disposal, and improved coordinating
mechanisms.
EPA responded to the recent anthrax incidents as part of a larger National
Response System (NRS) that has been in place for nearly 30 years to
effectively deal with a wide range of environmental emergencies. EPA is the
lead agency for Hazardous Materials Response under Emergency Support
function ¦? 10 of the Federal Response Plan (FRP), and is also assigned to
assist the Federal Emergency Management Agency tFEMA) during
consequence management, with environmental monitoring, decontamination,
and long-term site cleanup. Under the National Oil and Hazardous
Substances Pollution Contingency Plan (NCP). National Response Team
(NRTi member agencies engage in response efforts to environmental threats,
as set forth in the FRP. The NRT was activated on October 2lJ, 2001.
Generally, in planning efforts for responses to terrorism, the FRP provides the
coordinating mechanism for a NRT response. However, there was never a
Presidential declaration of a national disaster; therefore, the FRP was not
activated. Nevertheless, most NRT agencies were involved in some wa\ m
the response to anthrax as a pollutant or contaminant under the
Comprehensive Environmental Response, Compensation, and Liability Act
(CERCLAl. The following NRT member agencies were involved in anthrax
response activities*
Environmental Protection
Agency
« Federal Emergency
Management Agency
United States Coast Guard
Department of State
Department of Health and Human
Services
» Department of Justice
General Services Administration
Department of Defense
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September 2002
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EPA's Role in Responding to Anthrax Contamination
(continued)
Because certain anthrax-contaminated sites were determined to be crime
scenes, it was important for EPA to coordinate with the Federal Bureau of
Investigation (PBI). DoD was involved in providing expertise ;n hio-\\capons
analysis, for human health advice. EPA sought support from HHS, in
addition to National institute of Occupational Safetv and Health (NlOSiit.
Centers lor Disease Control and Prevention (CDC ], U.S. Public Health
Service s (LSPHS) Division ofl-edcral Occupational Health, and Agcncv for
Toxic Substances and Disease Registry. Because the maii was used as the
method ol anthrax delivery, USPS was another prtmarv response agenc\ w:ih
which EPA coordinated.
Technical ]-p,\ provided technical consultation and advice if requested bv a federal
expertise and agency conducting an anthrax remo\ul action,
oversight
EPA response activities ai anthrax sites included the following.
Sampling to confirm and determine the extent of contamination;
Evaluating sampling results;
Isolating areas to prevent the spread of contamination;
Removing critical objects for special decontamination procedures;
Working with the USPS and other agencies to evaluate the effectiveness
of potential disinfectants and cleanup technologies; and
Cleaning up areas of contamination.
In a short time, EPA significantly advanced the science and technology of
detecting and remediating anthrax. Prior to October 2001, no antimicrobial
pesticides had been approved for use against anthrax. Several different
chemicals and devices were initially tested and used under carefully
controlled conditions.
Chlorine dioxide
Ethylene oxide
Bleach
Paraformaldehyde
Development of
new methods
and
technologies
1-10
September 2002
-------
EPA's Role in Responding to Anthrax Contamination
(continued)
Additional chemicals tested later included hydrogen peroxide, pcroxyacetie
acid, and methyl bromide.
Anthrax decontamination is a rapidly evolving field, and new technologies are
now being tested and advanced continually. The EPA Office of Pollution
Prevention and Toxic Substances (OPPTS) is responsible for ensuring that
antimicrobial pesticides used in anthrax decontamination plans meet all
federal requirements for safety and effectiveness. In developing
decontamination strategies. EPA consulted a variety of experts, including the
following:
I-PA's Environmental Response Team (ERT)
¦ EPA research laboratories
NIOSH
CDC
U.S. Armv Medical Research Institute of Infectious Diseases
(USAMRHD)
« Defense Advance Research Projects Agency
State and local environmental and health officials
» National experts in universities and private industry
Counter- Several Presidential Decision Directives (PDIX) under the NRS specif) a role
terrorism role for EPA m counter-terrorism activities. PDD 39 assigned EPA the task of
assisting the FBI during crisis management in threat assessments and
determining the type of hazards associated with releases or potential releases
of materials in a terrorist incident. In addition to the activity generated by
testing and cleaning, the anthrax-contaminated sites were also treated as crime
scenes EPA's Criminal Investigation Division ICID) worked closely with the
FBI and local and state law enforcement agencies. CID assisted the FBI in
gathering evidence for use in identifying the criminals responsible for the
terrorist attacks.
PDD 62 reinforces EPA's mission to enhance the nation's capabilities to
respond to terrorist events, and gives EPA responsibility for cleaning up
buildings and other sites contaminated by chemical or biological agents as a
result of a terrorist act.
The primary response agencies for incidents resulting from a terrorist event
under PDDs 39 and 62 are the following:
September 2002
-------
EPA's Role in Responding to Anthrax Contamination
(continued)
Environmental Protection Agency *
Federal Bureau of Investigation/
Department of Justice
Federal Emergency Management
Agency
Department of I.i tie ray
Department of Defense
Department of Health and
Human Services
1-12
September 2002
-------
Activities and Conditions at Major Response Sites
Overall EPA j j»a responded io both ;ictual and potential releases of anthrax !ndi\ hIuli;
response to departments, agencies, and private companies performed sampling and
anthrax ^ cleanup to the extent of their capabilities, with EPA providing assistance as
emergencies appropriate. If initial sampling results by local authorities, CDC, or others
indicated the presence of anthrax, more comprehensive sampling was
undertaken with assistance from EPA to assess the extent and severity of
contamination. EPA provided expert technical advice to facility managers
throughout the country on sampling plans, worker safety, and actual site
cleanup methods. In general, most situations were relatively simple to
stabilize. If it was an emergency response, the situation was quickly
stabilized to a non-emergency response. Steps were taken to isolate the
contaminated area, and potentially exposed people were placed on
prophylactic antibiotics.
(W ashington.
DC)
Capitol Hill I: PA provided massive technical support and assistance as part of a nmlti-
facilities agency effort in response to anthrax contamination discovered in
Congressional buildings in the Capitol Complex. Using CERCLA authority,
EPA was able to write action memos to authorize EPA funds for the cleanup..
EPA responders reported to an Incident Commander (IO under the Capitol
Police Board, working in conjunction with the Congressional Offices of the
Architect of the Capitol, and of the Senate and House Sergeants at Arms. The
U.S. Coast Guard fUSCCi) Atlantic Strike Team Commander supported the IC
as Deput\ Incident Commander Strike Team personnel established and
staffed an Incident Command structure and provided logistical assistance to
EPA..
After anthrax spores were detected in the letter opened m Senator Daschle's
office in the Hart Senate Office Building, several areas of the building were
immediately evacuated and closed. Two days later, the entire Hart Building
and the House of Representatives were closed because of health and safety
concerns. The immediate threat to the United States government's Legislative
Branch resulted in extensive sampling of Capitol Hill buildings and testing of
staff for exposure,
EPA emergency responders took thousands of samples to determine the
presence of anthrax, and to design and carry out site-specific cleanup
strategics where contamination was found, Positive results indicating the
presence of anthrax spores were found at the Ford and Long worth House
Office Buildings, the Hart and Dirksen Senate Office Buildings, and the P
Street Mail Warehouse cm Capitol Hill. Once a decision was made to
decontaminate a building, EPA advised the IC about the extern to which a
building must be cleaned to make it safe.
1-13
September 2002
-------
Activities and Conditions at Major Response Sites (continued)
By far, ihe cieanup of the Hart Building posed the largesi and most extensive
anthrax cleanup challenge ever undertaken in a building The Hart Binidmg is
a 10,000,000 cubic foot building that houses the offices and staffs of 50
senators. Pol lowing the initial discover,', further contamination was detected
on the J1", 5:\ 6:\ and floors of the building, as well as m fillers w ithin a
regional heating, ventilation, air conditioning, and cooling system.
Fumigation with chlorine dioxide gas was conducted on December I and on
December 30. 2001. Approximately 100,000 cubic feet of the Hart Building
were sealed prior to i'umigation. Further fumigation was performed in the air
handling system that serves that area. Several other suites and common areas
in the Hart Building and in other buildings in the Capitol Complex were
cleaned using chlorine dioxide liquid, Sandia foam, and high efficiency
particulate air filter vacuuming. Post-cleanup sampling showed no remaining
viable anthrax, and on January 22, 2002. the Hart Building was cleared for
reoccupancy.
liPA has pro\ided USPS with technical expertise and advice in the cleanup of
contaminated USPS facilities. EPA was requested by USPS to provide full-
time OSC presence at the USPS command center, which was established at
USPS headquarters at L'Enfant Plaza in Washington, DC, for consolidation of
information and coordination. Postal facilities in HPA Regions 1. 2. 3. 4, 5,
and 7 were altected, including the following facilities:
l.S. Postal
Service facilities
Boca Raton main postal
facility, Boca Raton, PL
Green Acres postal facility.
Lake Worth, PL
Lucerne Station postal facility.
Lake Worth. FI
Lake Worth main postal
facility. Lake Worth, FL
West Palm Beach postal *
facility. West Palm Beach, FL
Blue Lakes postal facility,
Boca Raton, PL
Morgan postal facility. New
York, NY
Brentwood mail processing
facility, Washington, DC
Hamilton postal facility,
Hamilton, NJ
West Trenton postal facility,
Trenton. NJ
USPS Westgate Processing and
Distribution Center. Raleigh, NC
USPS Postal Distribution
Center. Wallingford. CT
DDD Building (USPS
Contractor), Indianapolis, IN
USPS Stamp Fulfillment Center.
Kansas City, MO
1-14
September 2002
-------
Activities and Conditions at Major Response Sites (continued)
The deaths of two workers at the Brentwood Post Office, and the serious
illnesses of two others, alerted authorities to the presence of anthrax spores at
the Washington, DC facility where two anthrax contaminated letters were
processed. The facility was closed on October 2L 2001, and remains closed
at this time. Decontamination of the facility using chlorine dioxide
fumigation will require sealing 17.5 million cubic feet. The successful
decontamination of the Hart Building is being used as a blueprint, although
the much larger scale of the Brentwood facility will require logistical
adjustments.
An EPA OSC has remained on site at the Brentwood postal facility since
October 2001. providing technical assistance, and serving as a technical
liaison with the USPS Command Center,
EPA GSCs have provided consultation during the various USPS sampling
operations, and cleanups conducted during the past months, and EPA
continues to assist IJ8PS in ongoing anthrax cleanup efforts. I'PA has
facilitated the creation of a National Coordination Council, a working group
composed of NRT member agencies and USPS, to involve USPS with NRT
and its creation of the Technical Assistance Document on Anthrax Response.
EPA is preparing a Memorandum of Understanding with USPS that will
formalize the relationship between USPS and EPA for anthrax response*, and
will provide a model for future interagency cooperation.
P.PA provided technical support and assistance to a number of other federal
agencies with anthrax-contaminated facilities. For federal agencies f other
than the Department of Energy and Dot)). EPA collaborated with the
Government Services Administration (GSA) to develop a list of
environmental contractors who were awarded GSA indefinite quantity
contracts tu sample for anthrax and perform remediation, A Region 3 OSC
was assigned to monitor the progress of the removal and remediation
operations being conducted by federal agencies other than USPS in the greater
Washington, DC area.
EPA collected data from each response, including: health and safety standards
and procedures; sampling and analysis methods; remediation and treatment
methods and technologies: and waste disposal procedures. In an emergency
situation. EPA ma\ conduct removal operations if the affected agency i>
incapable of performing the necessary actions.
The following federal agencies continued positive anthrax hits at one tit more
of their facilities:
I-utilities of
oilier ft*fk-r;s!
aycncit".
September 2002
-------
Activities and Conditions at Major Response Sites (continued)
Department of Justice *
« Department oi''Slate
Bureau of Alcohol, Tobacco
and Firearms
I) l* pa rtme n t o f A gri cult u re «
Veterans Administration *
Central Intelligence Agency
Corporation of National Service*
Federal Bureau of Prisons
National Aeronautics and Space
Administration
Defense Intelligence Agency
Federal Aviation Administration
(Dulles Airport)
General Services Administration
AMI and On or around September 25, 2001, a letter containing a powdery substance
private facilities was received and handled by several employees at the Sun offices of the AMI
building tn Boca Raton. Florida. The serious health and safety implications to
the employees in the building were not realized until October 5, 2001, when
one employee died of inhalation anthrax. Initially considered a health issue
by CDC, the site was quickly declared an FBI crime scene.
The FBI released control of AMI to EPA on October 20, 2001. FBI provided
data analyzed by CDC, and the information was used by EPA ERT and
operations team personnel to develop a site specific sampling plan. EPA and
the Florida Health Department secured laboratory resources of the
L SAMRIID. Of 278 samples collected from the AMI building, 32 samples
indicated positive results.
EPA also oversees private-sector sampling and clean-up efforts when
requested by local, state, or other federal agencies, such as the FBI. EPA
provided assistance in varying capacities to several privately-owned facilities
in Florida and New York, and to privately owned facilities of USP'S
contractors in Missouri and Indiana.
Hoaxes and Responding to false alarms and hoaxes with all necessary precautions diverted
false alarms valuable resources from other responses, Of the many thousands of reports of
suspected anthrax contamination received nationwide during the months of
the ongoing responses, the vast majority were false alarms, including a
number of pranks and criminal hoaxes. Most false alarms, however, were due
to public fear (of white powders) rather than intentional hoaxes. The number
of calls declined as response activities progressed, in part because dispatch
centers became more adept at screening calls, and in pan due to a better
educated public as additional guidance was released.
1-16
September 2002
-------
Activities and Conditions at Major Response Sites (continued)
False alarms occurred in all EPA regions, and the regions worked with state
arid local authorities to ensure the protection of public health and the
environment Because of the extreme hazards associated with anthrax
contamination, reports were treated seriously and investigated by state and
local authorities, with EPA consultation and assistance where appropriate.
1-17
September 2002
-------
Content Overview
Time period This report is inclusive of EPA anthrax response activities conducted from
October 2001 through February 2002. No major new anthrax contamination
lias occurred since November 2001. However, several sites remain
contaminated and sealed to date, and scattered hoaxes and false alarms
continue nationwide.
Report The report is organized as follows:
structure
« Executive Summary
Acronym List
Chapter L Introduction
Chapter 2: Lessons Learned and Recommendations
Chapter 3: Conclusions and Cross-Cutting Recommendations
» Appendix A: Report Methodology
Appendix B; Sample Interview Questions
Lessons learned Lessons learned are grouped in the following five categories:
Authorities
Operations
Communications and coordination
Health and safety-
Resources
To enhance clarity, lessons are framed in the following format:
Lessons learned
Recommendations
Cross-cutting After evaluating the above lessons, the most significant and broad-reaching
rccommcnda- issues were identified as overarching challenges that span the previously
described area categories. These issues are intended to encompass the more
specific icsM_>n> addressed in Chapter 2.
tioris
Conclusions
and action
items
The report concludes that EPA is at a crossroads in the scope of its mission.
Lessons learned indicate that to effectively respond to environmental hazards
associated with large-scale biological or terrorist emergencies, commensurate
resources and organizational support must be available to EPA.
1-18
September 2002
-------
Chapter 2
Lessons Learned and Recommendations
Overview
Chapter 2 presents the lessons learned that were drawn from the observations
of the interviewees. Corresponding recommendations were either taken
directly from the responses of interviewees or developed from their
observations.
In this chapter
Topic
See Page
Authority
Mul si-Branch of Federal Government Issue
Multi-Agency Interaction
CF.RCLA and the NCP
Contractual Authority
EPA Non-CERCLA Aulhority
2-3
Operations
Command Structure
Technical Issues
Preparedness
Intra- and Interagency Support
2-6
Communications and Coordination -¦ Internal EPA
On-site Communications
Communication among Regions, Headquarters, and
Sites
2-9
Communications and Coordination ¦- External
Interagency Coordination with the Incident Command
Structure
Public Information Dissemination and Community
Involvement
11
Health and Safety
External Factors
Evolving Internal Procedures
2-13
2-1
September 2002
-------
Overview (continued)
Topic
Sec Page
Resources
2-16
funding Resources
Personnel Resources
Training Resources
Equipment Resources
September 2D02
-------
Authority
A number of jurisdictional issues were raised during EPA's responses to
anthrax releases and suspected releases concerning EPA's constitutional,
statutory and regulator}', and contractual authorities,
Muii j-Br anch of
Federal
Government Although the response on Capitol Hill may itself have been a unique situation,
questions about lines of authority could potentially complicate or delay a
response if an incident were to occur on property under the control of the
other branches of the federal government, legislative or judicial, such as the
Supreme Court,
issue:
Lesson learned
Recommenda-
tion
OSWER, in conjunction with executive branch respcmders and
appropriate representatives of the legislative and judicial branches, should
reach agreement on future responses at legislative and judicial branch
sites. Legal and regulatory issues should be addressed en route to this
agreement.
.Multi-;i»enc>
interaction:
Lessons learned
Tile FRP was not activated to respond to Capitol Hill and did not provide the
structure for a response involving all the various federal agencies
The N'CP is available in the absence of an FRP activation. At the anthrax
response in Florida, the NCP was used to guide the response
EPA was not operating under a traditional response structure and the structure
thai was chosen did not make best use of EPA's experience and established
procedures, resulting in defining roles and responsibilities "on the fly."
Recommend Recommend using already established response structures available
turns
during a muln-agency response when the FRP is not activated, including
defined roles and responsibilities.
Determine who will be accountable for the cleanup m non-1 HP imiltt-
ageney responses.
2-3 September 2002
-------
Authority (continued)
CERCLA and
the NCP:
Lesson learned
Although CERCLA provides authority to respond to biological incidents, the
NCP is not specific about cleanup methods for such incidents.
Recommtn lu
tion
Contractual
Authority:
Lessons learned
Revise the NCP to address specific cleanup methods for biological
agents, such as anthrax.
FPA's current authority to indemnity response contractors could delay
cleanup in future responses where the agency may need flexibility to
implement innovative cleanup methods using contract resources.
lo be effective in carrying out their responsibilities, non-lead region OSCs
involved in a large-scale response must be able, at least on an ernergenev
basis, to direct contractors.
Recommenda-
tions
EPA Non-
CERCLA
Authority:
L ess oris learned
Work to acquire expanded indemnification authority, similar to that of
PL MA and DoD, to implement existing federal law that would enable the
EPA to more readily provide contractor indemnification when necessarv
during unique emergency circumstances.
Develop a contractual mechanism that gives non-lead region OSCs
deliver.' order project officer authority to direct contractors
Remediation oi contamination that requires the use of unusual substances or
methods may require emergency exemptions from other EPA program areas.
However, it is important to note that federal OSCs leading a response do not
have to get permits for on-site work, per CERCLA.
Responders need knowledge of, and access to, the expertise and rcsoua
all EPA program offices.
Recommenda-
tions
To the extent possible, anticipate and develop a process for acquiring
other emergency exemptions thai ma\ he required for biological.
chemical, radiological, and nuclear response activities, and work with the
appropriate offices to implement these processes.
2-4
September 2002
-------
Authority (continued)
Ensure that the capabilities, authorities, and resources of all EPA program
offices are known and available to resporiders.
2-5 September 2002
-------
Operations
The anthrax incidents occurred while EPA's response at the World Trade
Center was ongoing. There were thousands of anthrax incidents, scares, and
hoaxes nationwide. EPA regions responded to many incidents, most of which
were false alarms The operating environment was, in the opinion of
responders, "unlike any previous operating environment" that EPA had faced.
Command
Structure:
Lesson learned
Complex, national-scale responses involving multiple agencies are not
managed most effectively in the absence of a clearly defined and fully
implemented command structure. Some responders observed that the
command structure at Capitol Hill was unfamiliar with federal response
authorities. In other, similar responses, the 1C would be a Federal OSC. In
this ease, the 1C was a private consultant hired by the Capitol Hill Police-
Board and was not initially familiar with the role of the Federal OSC under
the NCP.
Recommenda-
tions
Implement a clearly defined and scalable command structure, such as the
Incident Command System (ICS), based on the National Interagency
Incident Management System (NIIMS). All EPA OSCs will be trained in
the ICS by December 200?. Evaluate using a separate ICS for each site
in a multi-site response.
Ensure that training includes exercises in which OSCs from across the
regions participate together to strengthen teamwork.
Shared operational responsibilities among OSCs worked well on Capitol
Hill. The lead OSC was effective in responding to the press and
Congress, while managing overall site activities. Some responders
observed that more resources should be available to help support the
OSCs in this area. For future nationally significant responses, use a more
formal ICS with Unified Command (UC).
Technical
Issues:
Lessons learned
Adequate expertise was not available in the operational technicalities
associated with responding to anthrax contamination, or other biological
agents. Because there were no established protocols for responding let anthrax
contamination or other biological agents, extensive time and resources were
devoted to the processes of searching for candidate methods, coordinating
logistics, implementing untried procedures, and assessing the efficacy of
candidate methods
2-6
September 2002
-------
Operations (continued)
Without a comprehensive comparison of candidate methods for dealing with
the anthrax contamination and their costs, EPA and contractors may not be
able to use the most efficient response methods.
turns
Rcvommenda- . Develop response teams trained for specific incident types, for example.
three to four people specialized in biological agents. To facilitate inter-
regional cooperation and support, develop cross-regional consistency and
evaluation of skill sets, similar to the USCG Strike Team's qualification
process. A standby list of qualified OSCs and responders (and state
resources) should be available for crisis situations.
Identity and conduct research on potential contaminants for which
vulnerabilities exist, and develop processes for characterizing site
contamination.
Develop biostatisueal or other models for demonstrating when cleanup
levels have been achieved.
Conduct interagency research to evaluate potential decontamination
technologies, their scientific bases, and cost effectiveness, Evaluate
processes for decontamination of personal property.
Document and record the information developed to respond to anthrax
incidents, including best practices, protocols, technologies used at the
various sites, and identify the pros and cons of using them. Ensure that
future responders can access this information, and evaluate plans for an
electronic "field book." to be expanded to address other potential incident
types.
PrrpartiJuvs.s:
Lesson learned
Although the response personnel did a good job of .solving the problems they
faced. EPA was not fully prepared to scale up its efforts to the magnitude
required of the anthrax cleanup, and did no! have sufficient technical
information or procedural guidelines at hand.
Rei-ommcntia- Develop tools, protocols, and procedures required to respond to releases
l'ons of biological agents based on EPA's experience responding to anthrax
Develop and conduct response exercises geared toward other potential
terrorist scenarios in cooperation with other EPA program offices and
appropriate outside agencies,
2-7 September 2002
-------
Operations (continued)
Intra-and
Interagency
Support:
Lesson learned
Review the regional preparedness resources to determine whether they
can he shared with, or expanded across EPA regions.
Support provided to responders from other EPA entities and external agencies
and departments varied in quality and consistency.
Recommenda-
tion
Work with counterparts in other agencies to define roles, assess
capabilities, and develop the necessary technical resources and
knowledge to respond to biological or unconventional contaminants.
2-8
September 2002
-------
Communications and Coordination - Internal EPA
Because of the politically sensitive environment and strong pressure for a fast
response to the Capitol Hill cleanup, internal and external communications
were critical to implementing an effective response. Many of the
communication processes worked well, such as the use of cellular phono
between OSCs and other key responders; daily conference calls: written daily
updates of site activities; and frequent press conferences and updates to
Congress, In other responses of this magnitude. EPA would also consider
implementing a traditional ICS UC structure that would include a Joint
Information Center (JIC).
On-Site
Co mm link a-
ti°ns: A more systematic approach to internal on-site communication* was needed.
A more centralized process for tracking site personnel activities, and progress
Lessons learned toward completion at the Capitol Hill sites would have enhanced coordination
among EPA staff, and thereby improved the efficiency of the response.
To maintain up-to-date information across all components of the response
operation. EPA should look into securing more telecommunications
equipment for on-site responders.
Implement the communications and coordination processes of the ICS for
large-scale responses, and ensure that all responders are fully trained in
ICS.
Clear protocols should be established for standard operating procedures
in responses that require coordination with federal legislative authorities,
or tn politically sensitive situations. Work with the EPA Office of
Congressional and Intergovernmental Relations to help develop
protocols.
Some responders observed that security concerns, such as reporting
confidential information critical to a criminal investigation, prohibited
normal documentation of site activities. A recommendation was made to
develop appropriate reporting alternatives to satisfy both the need tu
share information, and to preserve sensitive information
Ra ommenda-
lions
2-9
September 2002
-------
Communications and Coordination - Internal EPA (continued)
Communication
amon« Regions,
Headquarters,
and Sites:
Lesson learned
Use of EPA "s established systems for inter-office coordination, such as the
National Incident Coordination Team (N1CT). and the Regions! Incident
Coordination Team (RICT), would have made better use of EPA's prior
planning efforts for emergency response situations and coordination within
the Agency.
Recommenda-
tions
Maintain a formal, written communications plan that details the processes
tor internal coordination among various offices that may be called upon
to support responses of political sensitivity and national .security.
Revitalize and ensure the use of EPA's existing communications and
coordination structures such as NIC'T and RICT.
Assume that the NRT and Regional Response Team functions under the
NCP are prepared to facilitate national and regional intcr-agencv
coordination respectively, through enhanced planning, training, and
exercising.
2-10 September 2002
-------
Communications and Coordination - External
Keeping the press and public updated throughout the anthrax cleanup on
Capitol Hill and at other facilities was a key priority for EPA. At Capitol Hill
the U.S. Capitol Police Board elected a spokesperson who held regular press
conferences. The lead OSC participated in the press conferences and kept
members of Congress updated on progress. An effort was also made to
implement CPA's normal community involvement activities for emergency
responses. Lessons learned reflect the need to implement a more formal
communication structure, such as a JIC. typically used tor responses of this
magnitude. Lessons learned also reflect a need to have proper on-site
communications equipment and resources.
Inter agency
Conrdinatjun
w Although a central planning and support station was in operation, greater
familiarity with its existence, roles, and functions, would improve
coordination amonu respondent and thereby increase the efficiency of
Structure: ,, - *
response el I oris.
Lesions learned
Coordination between organizations is critical. Knowing each others* roles,
responsibilities, and capabilities in addressing environmental contaminants,
and creating a structure for sharing information is critical
Rt'( iirnntenda-
liurts
Work with partner agencies 10 clearly define functional and
organizational roles, and improve understanding between agencies
potentially involved in coordinated response actn ities,
Elevate the priority of emergency communication1; *>t rue Hires and
capacities, and ensure fall training m, and implementation of. existing
programs developed for emergency response.
Public
Information
Dissemination
and Commw nm
Invohiment.
/.ovw Icurui'd
In most responses of this size, a JIC is a standard communications structure
within a I'C and is used by EPA lo coordinate information, and to ensure that
public information was disseminated to all interested parties.
In multi-junsdictional responses, EPA would normally work with all
organizations to implement emergency communications and implement
existing outreach programs developed for emergency responses.
2-11
September 2002
-------
Communications and Coordination - External (continued)
Recommenda- . Work with key agencies and organizations to ensure the establishment of
lions
a JiC.
Implement Superfund's standard external communications programs for
emergency responses.
Continue to deploy the Fmergeney Communications and Outreach Team
(ECOT) m support of regions during long-term responses
Provide communicators with appropriate communications resources, such
as mobile telephones, communications-ready laptop^, printers, and fax
machines.
2-12
Septe nber 2002
-------
Health and Safety
In an emergency response, EPA's paramount responsibility is the protection
of health and safety of humans and the environment, EPA's health and safety
experience primarily involves responses to hazardous materials. EPA has no
standard mode or protocols for addressing the special health and safety
concerns associated with the release of a biological agent, such as anthrax. As
a result. EPA re bed on expertise and information from other organizations,
and the approaches to health and safety changed and evolved during this
response.
Although the U.S. government has sponsored anthrax research for several
decades, the av ailability of useful, accurate scientific information for a
response to anthrax in a civilian environment is limited. Anthrax-related
information from other health agencies was not initially as useful as EPA had
anticipated. In the initial phases, there was no organized system that EPA
responders could use to locate the available technologies, capabilities, and
facilities in either civilian or government agencies that ma> have been useful
in the anthrax response. This lack of access to all of the available, relevant
scientific data limited EPA's decision-making regarding operational issues
such as personal protective equipment (PPE). For example, in the first few
days of the response, information such as spore size data was not yet available
to EPA. Once the 1C was set up, and EPA began coordinating with other
agencies who had better information about anthrax and spore si/e, the
necessary data became available and was shared with the responders.
Medical support on site is another key health and safety issue reviewed m this
report. EPA should examine the medical policies, regulations, and laws that
played a roie in providing adequate medical support at the site. This may
involve working with the DoD Directorate of \1iiit3ry Support office, the
USPHS as well as other agencies, and EPA's Office of Administration and
Resources Management, to ensure that E'PA will have the ability to access
adequate and continuous medical support at the beginning of a future large-
scale response.
External
I-";u-K»rs.
EPA responders need access to all available information related to the health
Lessons learned and safety aspects of an anthrax response.
EPA needs faster and greater access to better interagency (both civilian and
military) information on potential biological WMD
EPA's traditional Hazardous Waste Operations and Emergency Response
approach to health and safety {based on chemical hazards j needs to be
2-13
September 2002
-------
Health and Safety (continued)
Recommenda-
tion
Kvolving
Internal
Procedures:
Lessons learned
revisited when responding to biological agents such as anthrax. Additionally,
clear guides on PPE levels for biohazard responses need to be established.
Work with health authorities, such as IMS. to produce medical and
responder guidance on all potential biological threats.
A health and safety plan was available and accessible to all responders on-
site. All responders were directed to review the plan as soon as they entered
the command post. Some responders observed that more information should
be available in the plan that specifically addresses reconnaissance safetv.
Because there were no clearly established protocols for anthrax, there was
some concern among the responders. especially during the first month of the
response,
Responders need a clear understanding of exposure, correct prophylactics, and
location of contamination when they report to duty on site.
Responders from Region 5, where more extensive counter-terrorism training
and drills had occurred, were very helpful in using their training experience to
assist Region 3 in responding to biological agents.
Responders need to be in good health and fitness, and need confidence sn the
adequacy of their medical monitoring. ERT and some (but not all) regions
have special arrangements facilitating gym memberships for exercise.
Responders need sufficient levels of PPE to protect them without hampering
the response.
Mid-course changes in field procedures without sufficient clarification and re-
training were a concern among some responders because of the potential for
human error, safety, and health issues.
Recommendm-
"om * Establish and maintain proper health and safety precautions. EPA should
have sound health and safety protocols for biological contaminants that
have been reviewed by experts in the medical field.
Test and assess effectiveness of PPE against biological agents to
determine level of protection offered by existing Pl'H. Response
2-14
September 2002
-------
Health and Safety (continued)
personnel must be protected and prepared with the appropriate equipment
and medication (i.e.. prophylactic antibiotics).
Resolve any liability issues involved with the prescription of medical
drugs Tor uses considered to be investigative. Speciflcaliv. the CDC"
offered site workers an anthrax vaccine that had not yet been tested for
the accelerated regimen sue workers would have to take. For site
workers to accept the accelerated vaccine regimen. C'DC required them to
sign a liability waiver.
Develop medical protocols for determining the risk to human health
posed by biological contaminants.
Support the convening of a Health and Safety Advisorv committee to
address pertinent issues, and plan for future events and possible scenarios.
Develop a medical surveillance monitoring and provision program for
OSts subject to bio.-counter-ierrorism activities; the current program is
proven only for chemicals.
Develop in each region a team that deals with health and safetv with
available doctors to .support the Site Satetv Otiicer ior WMD incidents,
and other issues as they arise. LPA should develop in-house medical
expertise, and establish a medical monitoring team for biohazards.
Unsure proper training of personnel lo deal with anthrax and other
bioiogicals; regions may need to have a response team readv for these
types of incidents.
Re-evaluate long-standing shortfalls in the Core l;mergenc\ Response
program regarding responder health and fitness for duty, and support
responders in maintaining their physical fitness
2-15
September 2002
-------
Resources
The anthrax response was unprecedented in terms of the amount of resource?,
needed by EPA to accomplish its mission safely and e fleet i vet v. As observed
by the iront-lme responders. availability of resources proved to be
multidimensional, overlapping with operations, communications, and health
and safety issues. In addition, the mechanisms typicallv used bv EPA to
obtain resources had to be exercised and interpreted in wavs not previously
used by EPA in an emergency response. Without established protocols for a
biohazard response or a cost comparison of candidate methods. EPA and
contractors repeatedly consumed valuable resources in scare hum for methods,
coordinating logistics, implementing untried procedures, assessing the
eificacy of candidate methods, and at times repeating the process, if the
methodology did not work.
This section specifically addresses resource issues dealing with funding.
personnel, training, and equipment.
Funding
Resources:
EPA did not have a mechanism, procedure, or source of funding in place to
Lesson learned fmancialk support this magnitude of an emergency response for winch the
FRP had not been activated.
Be able to respond and obtain resources quickly to alleviate the
restrictions on funding and contracts, and depletion of mission funds.
Explore with others how funds could be made available in a non-declared
disaster.
Maintain someone with authority to be on call to answer questions, make
funding decisions, and obtain resources quickly. Appropriate
administrative support to supplement the OSC's 5250K response
spending ceiling and limited contract officer authority is needed on site.
Use resources obtained by EPA to fill gaps in equipment, personnel, and
contractor support.
Personnel
Rt'soiircts:
L ^ Because of the unfamiliar command structure, and the unique circumstances
earne of a response of the magnitude, EPA was not always in control of its
resources, personnel workload, response schedule, or working conditions. A
more traditional command structure, such as the ICS. would have helped
manage resources more formally.
2-16
September 2002
-------
Resources (continued)
Valuable information for response continuity f shift-to-shift and day-to-day)
was lost because the command structure did not establish a clear procedure for
transferring information through the use of log books, rotation reports, ami
pollution reports that would normally be used in other, similar responses
EPA's standard response contracts did not provide for the staffing needs fur
biological emergencies, There were times when there were not enough
qualified contractors available to conduct specialized work.
Insufficient contractor staff with accepted security clearance hindered the
response effort.
Recommenda-
tions
Maintain Agency control over its work load planning so that resources
can be appropriately scheduled.
Determine way*. for regions to support their ongoing programs while
sustaining a long-term response effort. Similar to the USPHS, EPA may
consider the use of a volunteer service as backup, to respond to
concurrent regional emergency events when regular personnel may be on-
scene at a nationally significant response.
Review EPA's process for acquiring qualified contract personnel to
access contractors that match the specifications of jobs EPA needs to
have done. This must include technical and medical experts m the area of
bioierrorism who can be on-site as needed.
Work with other response agencies to ensure, ahead of time, that IIP A
security clearances for contract personnel are recognized in order for
EPA response contractors to gain access to critical response information.
Depbv adequate medical staff on-site to monitor the health of
responders.
Resources:
Lesson learned
EPA was well prepared and trained for an emergency response, but not well
trained or prepared to handle the unfamiliar and unique aspects of a
btohazard, or specifically, anthrax response.
2-17
September 2002
-------
Resources (continued)
Provide more training for responding to a biological incident to OSCs, and
ERT. While it may be unrealistic to focus the training on all possible
biological agents, training should address responses to the most probable
agents and the range of threat characteristics. Before training can occur,
however, adequate protocols for dealing with biohazard remediation must
be developed and implemented.
Coordinate interagency training to ensure broad familiarity with KPA's
capabilities in emergency response.
Provide OSCs with ICS training and certification.
Tram teams of OSCs intensively in specialized response efforts, and
enable them to act as technical advisors when the response is larger than
the team can handle.
Tram remedial project managers (RPMs) and site assessment managers as
back-up for OSCs so they can temporarily maintain continuity of ongoing
removal actions on-eall if OSCs are responding to national emergency
situations.
Provide additional staff exercises for emergency operations, specifically
regarding emergencies of a biological nature
Lquipnivnt
Kovntirircs:
f,csM>/is learned
The lack of real-lime analyses, compounded by the lack ol cleanup levels,
hindered response.
EPA docs not have an inventory of the equipment needed lo sample microbial
agents or to perform disinfection. It also does not have a database of possible
sources of equipment as it does for chemical responses-
Planning of health and safety resources had not included mechanisms to
procure antibiotics or prophylactics for responders or the appropriate PPE
needed during the disinfection stage of the operation.
OSCs should have access to their own PPE: they should not have to "dram
up" PPl: at the beginning of each shift ot borrow it from other agencies,
Responders need adequate, reliable communications resources,
September 2002
-------
Resources (continued)
Recommenda- . Provide responders with access to an on-site lab for the testing and
tinns
analysis of samples for "real time" emergency response. A nationwide
network of laboratory capacity for microbial testing, including adequate
in-house capabilities, needs to be provided.
Establish an emergency inventor)' of the equipment and protocols needed
to respond to bioterronsrn, including state resources, or at least a database
of sources of the needed equipment and protocols.
Provide responder with access to a sufficient amount of equipment to
minimize reuse and to address all activities that would compromise
worker health and safety regardless of the PPE level chosen.
Maintain a minimum communications infrastructure for example, two-
way radio capability cell phones and full-time network computers are
tools that can he implemented quickly. The use of remote television
capability should be explored.
2-19
September 2002
-------
Chapter 3
Conclusions and Cross-Cutting Recommendations
Conclusions
Using nioiv lhan 3d years of experience in responding to hazardous subMance
releases. EPA planned, tested, and implemented the first ever cleanup of
several large, anthrax-contaminated buildings in a mailer of three months,
while responding to other anihrax incidents and hoaxes, and continuing
activities at the World Trade Center.
j |owevcri f-.PA's current challenge is evident. Managing adequate reMHirccs
in terms of personnel, funding, equipment, and training, to meet the evolving
requirements of its counter-terrorism role are all issues that must be addressed
to maintain the level of commitment EPA has in protecting human health and
the environment.
If EPA is to continue responding to large-scale incidents requiring muhi-
agencv involvement, it must take actions to surmount these challenges before
another incident occurs. The cross-cutting recommendations and supporting
steps identified in Chapter 3 of this report were designed to meet these
challenges,
EPA considers the anthrax cleanup a success. Using the Agency's well-tested
problem solving approach to emergencies, EPA met and resolved the
following challenges:
EPA was able to clean up the anthrax on Capitol Hill efficiently and
safely, while having to adapt and operate within a command structure that
used new approaches to organizing an emergency response.
Because of the circumstances and location of the anthrax response on
Capitol Hill, EFA worked within the established command structure
facilitating the management of its response activities and personnel, while
also communicating and coordinating effectively with the other agencies
and organizations.
Although highly trained and experienced in bazatdous substance
responses. EPA respondcrs had only limited technical information and
experience for cleaning up biological contaminants. Despite these
challenges. EPA was able to implement a plan of action based on sound
science.
3-1
September 2002
-------
Conclusions (continued)
* Betore cleanup activities could begin. EPA, along with others, worked to
access the technical and medical expertise necessary to identic
appropriate health and safety procedures, and implement safeguards for
the biological response.
Alter evaluating the lessons learned and interviewees' recommendations, the
most significant issues were identilied as overarching challenges that "cut
across at least lour of the iive area categories of focus: authorities,
operations, communications, health and safety, and resources. Sev en
recommendations addressing these challenges encompass the more specific
recommendations described m Chapter 2.
hnhance capability to efficiently scale up emergency response, and
develop specialized response skills for unfamiliar threats.
Steps to enhance scale up capabilities include (he fallowing:
F.nsure that EPA responders are familiar with and well trained m a
standardized ICS as an internal response management structure (such as
the ICS MUMS).
Define the scope of EPA's and other agencies' roles, responsibilities,
capabilities, and authorities prior to the initiation of major response
activities, and ensure that each is understood clearly by HP A respond ^
contractors, and personnel from partner agencies.
Establish a J1C to help lead OSCs with the public/external relations and
political interaction Junctions in a large-scale response in order to protect
the response management role of the lead OSC.
Develop and implement an agency-wide coordination plan lo best use
support staff and resources from across the regions when needed.
Provide a coordination structure for staff rotation in a large-scale
response, and minimize impact on ongoing programs.
Develop a database that includes available EPA. contractor, and
local/state expertise m order to match the best available resources So
specialized response needs.
In this chapter
Recommenda-
tion #1
3-2
September 2002
-------
Conclusions (continued)
Recommenda- Develop, with the Office of Homeland Security, a response coordination
twn structure to be followed in a multi-federal agency response to a terrorist
incident for which the FRP is not activated.
Such an interagency coordination structure must:
» involve liPA leadership working with counterparts in other agencies or
departments to clearly define roles and responsibilities in a non-FRP
multi-federal agency response.
Institute periodic interagency emergency response training and exercises
to ensure preparedness and mutual familiarity with EPA and other
agencies' roles, responsibilities, and capabilities,
Plan with the FBI and other law enforcement agencies for scenarios
involving concurrent crisis and consequence management. Hnsure
appropriate interagency cooperation on evidence gathering and health and
safety protocols ior cases in which investigation and emergency response
must occur simultaneously.
Resolve funding and cost recovery issues m the absence of the
declaration of a national emergency under the FRP.
Recommenda- Improve response capability and develop in-house expertise on biological
tum M agents and other WMD.
Steps to improve response capabilities for biological agents and WhiD
include the following:
Coordinate closely with other federal agencies.
Research biological agents for which potential threat of terrorist or
criminal contamination exists, and identify and develop a database for
technologies and methods for detection, sampling, and cleanup.
Identify nationwide resources and a capacity for sampling and analysis of
biological and new or unconventional agents, including the development
of interagency and public-private networks (e.g., with CDC. FBI. DoD,
universities and/or commercial labs, etc.), to facilitate sharing of best
available science and laboratory resources in emergency responses.
Document all relevant data developed m responding to anthrax incidents
for use in developing protocols for responding to biological agents or
3-3
September 2002
-------
Conclusions (continued)
WMD, including appropriate procedures for site characterization and risk
assessment.
Develop and train response teams for specific emergency scenarios (e.g..
3-4 people specialized in biological agents). Training should involve an
evaluation of skill sets thai is consistent across regions (similar to USCG
Strike Teams' qualification process) 10 facilitate cross-regional
cooperation.
Knhunce safeguards to L-uiurt that responder health and safety is jjivon
precedence among competing priorities, especially in niul{i-a»enc> led
responses.
Steps to safeguard respander health and safety include the following:
Support the efforts of a recently convened Health and Safety Advisory
Committee to address unfamiliar health and safety issues associated with
responding to biological or unconventional agents,
« Establish and enforce clear limits on hours spent by on-site personnel in
high stress or high risk capacities. Take steps to safeguard the ability of
EPA personnel to make hazard level determinations and appropriate
health and safety decisions independently of external pressures or
deadlines.
Examine current response contracts to resolve funding to cover the costs
of contractor medical monitoring and health needs, including physicals,
blood work and other lab tests, vaccines, antibiotics, etc. Ensure timely
reimbursement of contractor's out-of-pocket medical expenses where
appropriate,
Monitor research on efficacy and long term effects of prophylactic
antibiotics against biological agents. Monitor and, where appropriate,
conduct followup studies, especially on responders treated with
prophylactic antibiotics for extended periods of tune.
Expand the routine Medical Monitoring Program to address health issues
specific to biological agents, and ensure that responders undergo pre-
entry and post-exposure medical testing for pathogens or biotoxinv
Rt'ctnumcnda -
tion *r4
3-4
September 2002
-------
Conclusions (continued)
Reaimmenda- Revisit, and revise as needed, F.PA's existing internal emergency response
li'mi coordination authority, plans, and structures.
A it ions to update existing plans and structures include the following-
Revitalize and then ensure the use of EPA's existing intern;)!
communications and coordination structures, specifically the N'ICT and
RJCT. which reflect prior planning efforts for inter-office coordination
during emergency response.-,
Clarify the role of ERT personnel as Science Support Coordinators to
OSCs, to make best tree of ERT expertise.
Ensure that the special capabilities. authorities, and resources of all EPA
program offices are known and available to responders.
Clarify jurisdictional issues with regard to EPA's emergency response
authority at a site under the control of the legislative or judicial branches.
Recommeiula- Hievate priori!) of emergency communications structures am! capacity,
uon fib atKj implement existing communications programs developed for
emergency responses.
Steps to strengthen the effectiveness of emergency communications include
the following:
Implement the Superfund's required community involvement activities
and best practices for emergency response communications. Required
activities include implementation of a robust community involvement
program; establishment of a JIC; development of a communications
strategy; and deployment of the ECOT.
Work with key agencies and organizations to recommend establishing a
JIC for all major responses to coordinate external communications, and
ensure that information is available and communicated to the press and
the public.
Ensure that OSCs and Community Involvement Managers are aware of
and able to deploy ECOT when long term communications support ts
needed throughout a response.
3-5
September 2002
-------
Conclusions (continued)
Work with EPA's Office of Public Affairs fOPA) to develop national
guidance on media policies during emergency responses of national
significance. The guidance would be used to help OERR develop the
appropriate information needed for OP A to disseminate information to
the public from a national forum.
Acquire equipment, lab capacity, funding and trained personnel
sufficient to support tPA's role in responding to biological agent1. uiui
other WMD.
Steps to secure adequate response resources include the following:
Identify and seek dedicated funding for advancing counter-terrorism
efforts, commensurate with EPA's counter-terrorism role
Invest in enhanced field and lab analytical capacity for sampling and
analysis of new agents, equipment needed to perform appropriate
decontamination, and specialized PPE. Develop interagency and
public private networks to maximize available resources.
Develop and provide training m emergency response to btohazards and
other WMD. and in the operation of multi-agency responses. Provide
training to OSl's in management skills needed for large-scale responses
as well as for working effectively as part of a team.
Review existing contracts to determine how- best to acquire expertise for
biobazard and WMD responses. Establish contract mechanisms to
adequately indemnify contractors and to provide non-lead region OSCs
emergency authority to direct contractors.
Acquire and maintain adequate emergency communications infrastructure
and electronic equipment, including fully equipped laptop computers,
two-way radio cell phones, fax machines, and remote closed-circuit
television capacity.
Recommenda-
tion H ~
3-6
September 2002
-------
Appendix A
Report Methodology
A-l
-------
Appendix A
Report Methodology
Introduction EPA Administrator Christine Todd Whitman charged Assistant Administrator,
Marianne Lament Horinko. OSWER, to chair an effort to draw lessons
learned from the wide-ranging EPA activities following the events of
September 1J. The resulting report. Lessons Learned in the Aftermath of
September 11, 2001, developed by OERK, was released on February 1. 2002,
Due in part to the relevance of the initial report, this second lessons learned
report was commissioned on March 6, 2002, to address challenges faced
during EPA's activities in responding to nationwide anthrax from October
2001 to February 2002, and to propose recommendations for enhancing
response capabilities in the future.
Process The process for this effort involved the following steps:
Request names of EPA personnel representing a cross-section of
individuals involved with all aspects of EPA's anthrax related activities
from EPA offices.
Conduct interviews, of identified EPA personnel regarding key aspects of
actions taken and experience responding to anthrax,
Synthesize raw data from interviews and identify common themes,
perspectives, and patterns.
Develop lessons learned for major response aspects; operations,
authorities, health and safety, communications, and resources.
Collaborate to identify cross-cutting issues and overarching
recommendations which encompass several, or all of the major response
categories.
Develop first draft of lessons learned report.
Circulate first draft to Assistant Administrators (AAs), Regional
Administrators (RAst. and contributing interviewees for feedback.
Review comments from AAs, RAs. and contributing interviewees, and
incorporate additions or edits where appropriate.
Present final Anthrax, Lessons Learned to EPA Administrator,
A-2 September 2002
-------
Report Methodology (continued)
Data collection tor this study was designed to solicit input tor the time period
following the initial identification of anthrax contamination at the AMI
Building in Boca Raton, Florida on September 25. 2001, to include anthrax
response activities through February. 2002.
The greatest intensity of EPA activity over a duration of time, however, was
from October ];>, 200] when anthrax contamination was confirmed in the Hart
Senate Office Building, until January 22, 2002 when the building was cleared
for reoccupancy. It was also during this period that other Congressional
buildings were sampled and cleaned, and that the vast majority of anthrax
cross-contamination was discovered in other federal and postal facilities, and
mail rooms in several states.
Time periods of
interest
Information information for this study was gathered from the following sources:
sources
» Sixty-seven interviews with EPA personnel, representing input from all
EPA regions and headquarters, including responders and EPA
management at all levels. (All regions responded to anthrax
contamination either in the region, or by contributing rotational personnel
in support ol the Region 3 Capitol Hill response.)
Other resources such as internal reports, summaries of events, and
documentation from the Emergency Operations Center (HOC), including
the following:
> Meeting and conference call summaries from Capitol Hill and
Regional responses
Press releases
Situation, Incident, and Pollution Reports (where existing)
~ FPA regional offices' lessons learned
* External groups' lesions learned reports
A-3
September 2002
-------
Report Methodology (continued)
ORGANIZATION
TITLK, OR I-TNOTION SFRVKD IN ANTHRAX
RESPONSE ACTIVITIES
Upper Management
1. HQ
Administrator
2. HQ
Special Assistant for Homeland Security
3. HQ
Deputy Administrator (DA)
4, HQ
DA Chief of Staff
5. HQ - OSWER
Assistant Administrator, Office of Solid Waste
and Emergency Response
6. HQ
Chief Adviser for Bioterrorism Issues
7. R3
Deputy Regional Administrator
Middle Management
X HQ - Oi-RK OPC
Center Director
9. HQ - OERK CIOC
Program Manager
10, HQ-OPA
Public Affairs Specialist
11. HQ - OERR
Senior Process Manager
12. HQ-OSWER
EOC Regional Coordinator
n. iiq-opp'is
Program Manager
14. HQ-OGC
General Counsel
15, HQ-USPHS
Program Officer
16. ERT (R2)
Center Director
17. R1
Removal Manager
18, R3
Technical Manager
19. R3
Chief, Removal Branch (Acting)
20. R3
Congressional Liaison
21. R3
Associate Regional Counsel
14. R3
Community Involvement Coordinator
15. R3
Removal Manager
September 2002
-------
Report Methodology (continued)
ORGANIZATION
TITLE, OR FUNCTION S FRY FT) IN ANTHRAX
RESPONSE ACT IYITILS
16. R3
Section Chief. Removal Branch
17, R3
Chief, Removal Branch
18, R3
Division Director
19. R4
Chief, Removal Branch
20. R4
Section Chief
21. R5
Public Affairs Specialist
22. R5
Chief. Remov al Branch
Front Line Res ponders
23. R1
osc
24. RI
osc
25, ERT
Veterinary Medicine Officer
26, ERT
OSC Technical Support
27. ERT (R2)
Environmental Engineer
28. ERT (R2)
Engineer
29. R2
OSC
30, R3
Federal Facilities Branch RPM Technical
Specialist OSC
31. R3
Lead OSC
32, R3
Community' Involvement Coordinator
33, R3
OSC
34, R3
osc
35. R3
Regional Response Coordinate
36. R3
OSC
37. R3
osc
38, R3
osc
39. R3
Regional Counter-Terrorism Program
Coordinator
Ao
September 2002
-------
Report Methodology (continued)
ORGANIZATION
TITLE. OR I- I NC'TION SERY'ED IN ANTHRAX
RESPONSE ACTIVITIES
40. R3
osc
41. R3
osc
42, R3
osc
43, R4
osc
44 R4
osc
45. R4
osc
46, R4
osc
47. R4
osc
4X. R5
osc
49. R5
osc
50. R5
osc
51. R5
osc
52. R5
osc
5?. R6
osc
54. R7
osc
55. R7
osc
56. RS
osc
57. R9
osc
58. RIO
osc
5«. RIO
osc
60. RIO
osc
\
September 2002
-------
Appendix B
Sample Interview Questions
B-l
September 2002
-------
Appendix B
Sample interview Questions
Intervieweg Office 'Title Date
Interviewer
Questions for Anthrax Interviews with Headquarters ami Regional Management Personnel
A. Authority {Laws/Regulations}
1, Under which laws and authorities did you respond0
2. Did you have authority appropriate for the response actions thai were required"?
3, Did von encounter any problems or issues related to your authority or the authority of other
parties involved in the response'? If so, how were the problems or issues resolved?
4. What law regulations could be strengthened to provide the adequate authority1?
B. Operations
1. What, specifically, was your role in the response'? What actions did you take to earn' out
your responsibilities'?
2. Describe the operating environment. What were the issues that you faced?
3. What were the cleanup technologies, specific to your sue/facility, used in the anthrax
response'?
4. What were some of the issues associated with the technicalities of remediating the anthrax?
5. Were there any technologies that would have been helpful to you if they were available
during the response operation in terms of analytical methods, monitoring, etc.''
6. Mow prepared was your organization to respond to the anthrax incident! s)'?
7. Hid you receive the support you required to carry out your responsibilities?
B
September 2002
-------
Sample Interview Questions (continued)
C. Communications/Coordination
/nternal Communication/Coordination
1. Describe the structure for ensuring that HQ, Regions, and EOC operations were kept
updated on response progress. How well did this structure work? What could be improved?
2. Was a Joint Information Center (JIC) established*? If so, talk about how the J1C functioned.
If not, describe the decision-making process for not having a JIC. Describe what was
implemented in lieu of a JIC.
3. How were you notified of the anthrax incidents)?
4. Describe the process for information gathering. Was there an organized structure for
obtaining information from key personnel responsible for the response? What worked and
what could be improved?
5. Did you receive the information you required to carry out your responsibilities initially? As
the response activities progressed?
6. What information requests, including reporting requirements, were made of you''
7. What EPA groups did you communicate, coordinate with? What was the nature of the
communication? Was it successful''
8. Were there any significant challenges that kept you from communicating internally?
Describe the challenges and offer suggestions for improving internal communications.
lixtern al ( omntu nicution/Coordinution
9. Which organizations, outside offfPA, did you coordinate with'*
10. What was the nature of the coordination/communication with outside organizations? Was it
successful?
11. How were crisis communication, public information, or media relations decisions made and
communicated?
12. Were there any significant challenges that kept you from communicating externally?
Describe the challenges and offer suggestions for improving external communications.
September 2002
-------
Sample Interview Questions (continued)
Community Involvement
13. Was there a formal communications strategy that outlined who the key audiences were and
how the agency would involve them during the response'.'
14. What were some of the challenges of conducting community involvement activities during
the response'.1 How could those challenges have been resolved0
D. Health and Safety
L Was the health and safety planning sufficient to address the activities of your organization in
response to the anthrax incidents)?
2. How were you involved in hazard and risk management decisions?
3. Was the level of training you and your organization had received sufficient to prepare vou to
address the health and safety issues associated with the anthrax incidental?
4. Describe the challenges you faced and what specific recommendations you would give.
E. Resources: Technical and Administrative
1. What resource issues did you face in carrying out your responsibilities?
2. I low did you handle resource (personnel, equipment, funding) shortfalls?
3. Did responding to the anthrax incident(s) require you to make adjustments in other program
activities?
F. Overall Significance and Impact
1. Please indicate your degree of satisfaction with llPA's abiluv to respond to the challenges
presented in each of the areas previous!v discussed:
Very
Satisfied
Reasonably
Satisfied
Satisfied
Di satisfied
Very
Dissatisfied
Authority
5
4
3
2
1
Operations
5
4
3
2
1
Interna] (EPA)
Communications
5
4
3
->
1
B-4
September 2002
-------
Sample Interview Questions (continued)
Very
Satisfied
Reasonably
Satisfied
Satisfied
Dissatisfied
Very
Dissatisfied
External
(other agencies)
Communications
5
4
3
*>
I
Community
Communications
5
4
3
2
1
Health and Safety
5
4
3
2
1
Resources
s
4
3
2
1
2. What do you believe to be the most significant problems or challenges facing the Agency in
the case of anthrax contamination .' (List no more than five.)
Questions for Anthrax Interviews with OSCs and Other Response Personnel
A, Autliorin 11 aus Regulations)
1, Under which laws'regulations did you respond?
2, Did you have authority appropriate for the response actions that were required?
3, Did other parties act under other authorities, laws or regulations'? If so, what were they?
4, Did you encounter any problems or issues related to your authority or the authority of other
panics involved in the response? if so, how were the problems or issues resolved?
5, What law/regulations could be strengthened to provide the adequate authority''
B. Operations
1. What, specifically. was your role in the response? What actions did you take to cam out
your responsibilities?
2. Describe the operating environment. What were the immediate issues thai you faced?
3. What were lite cleanup technologies, specific to your site/facility, used in the anthrax
response?
B-5
September 2002
-------
Sample Interview Questions (continued)
4. What were some of the issues associated with the technicalities of remediating the anthrax'.1
Were there any technologies that would have been helpful to you if the v were available
during the response operation in terms of analytical methods, monitoring, etc.?
5. How prepared was your organization to respond to the anthrax incident!sT?
6. Did you receive the support you required to carry out your responsibilities?
C. Communications/Coordination
Internal Communication/Coordination
1. Describe the structure fur ensuring that HQ, Regions, and HOC operations were kept
updated on response progress, iiow well did this structure work'.' What could he improved?
2. Was a Joint Information Center fJIC) established'.' If so, talk about how the J!C functioned.
If not. describe the decision-making process for not having a J1C. Describe what was
implemented in lieu of a JIC.
3. How were you notified of the anthrax incident! s)
4. Describe the process for information gathering. Was there an organized structure for
obtaining information from key personnel responsible for the response? What worked and
what could be improved?
5. Initially, did you receive the information >'011 required to carry out your responsibilities? As
the response activities progressed?
6. What information requests, including reporting requirements, were made of you'.'
7. What EPA organizations did you communicate coordinate with'.'
8. What was the nature of the communication, coordination'.1 Was it successful?
9. Were there any significant challenges that kept you from communicating internally'1
Describe the challenges and offer suggestions for improving internal communications.
External Communication/Coordination
10. Which organizations, outside of EPA. did you coordinate with?
I L Was there a clear structure for keeping external audiences updated'.'
12. What was the nature of the coordination/communication? Was it successful?
B-6
Septc Tiber 2002
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Sample Interview Questions (continued)
13. How were crisis communication, public information, or media relations decisions made and
communicated'1
14. Were there any significant challenges that kept you from communicating externa!ly".'
Describe the challenges and offer suggestions for improving external communications.
Community Involvement
15. Was there a formal communication* strategy that outlined who the key audiences were and
how the agency would involve them during the response'1
16. What were some of the challenges of conducting community involvement activities dunng
the response? How could those challenges have been resolved?
D. Health ;md Safcl>
1. Was there a written HASP for employees involved in the response?
2. Was the level of training you had received sufficient to prepare you to address the health
and safety issues associated with the anthrax incident!s)''
3. Was the site evaluated to identify specific site hazards and to determine the appropriate
safety and health control procedures?
4. Were appropriate procedures implemented to control exposure to hazardous substances
before clean-up work began?
5. Were you or are you covered under a medical surveillance program?
6. Did the site manager use engineering controls, work practices, and PPE appropriately to
protect employees from exposure to hazardous substances and safety and health hazards?
7. Were decontamination procedures developed, communicated to employees and implemented
before any employees or equipment entered areas on site where potential for exposure to
hazardous substances exist?
8. Was a written site emergency response plan developed and implemented for the site, and
made available to you?
9. Describe the challenges you faced and what specific recommendations you would give.
E, Resources: technical and Administrative
1. What resource issues did you face in earning out your responsibilities?
September 2002
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Sample interview Questions (continued)
2, How did you handle resource (personnel, equipment, funding) shortfalls?
3, Did your response activities require you to make adjustments in other program activities'.1
F, Overall Significance and Impact
L Please indicate your degree of satisfaction with EPA's ability to respond to the challenges
presented in each of the areas previously discussed:
Very
Satisfied
Reasonably
Satisfied
Satisfied
Dissatisfied
Very
Dissatisfied
Authority
5
4
3
2
1
Operations
5
4
3
2
I
Internal (EPA)
Communications
5
4
3
2
1
External
{other agencies)
Communications
5
4
2
I
Community
Communications
5
4
3
*>
1
Health and Safety
5
4
3
2
1
Resources
5
4
3
1
2. What do you believe to be the most significant problems or challenges facing the Agency in
the case of anthrax contamination? (List no more than five.)
B-8
September 2002
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