9.8 Appendix 8 – GVW Fire Department After-Action Report
Graniteville-Vaucluse-Warrenville Fire Department After-Action Report
Graniteville Train Wreck
January 2005
Summary
On January 6, 2005 at approximately 02:45, two Norfolk Southern freight trains collided in Graniteville, South Carolina. The collision resulted in a catastrophic release of chlorine gas to the atmosphere from a tank car damaged in the derailment. This releases rapidly vaporized to form a dense and highly toxic airborne cloud affecting Graniteville residents and employees of nearby Avondale Mill. Other hazardous materials cars involved in the derailment included 2 additional chlorine cars, 1 sodium hydroxide car, and 1 creosol car.
More than 500 people sought medical evaluation, approximately 70 people were admitted to hospitals and 9 people were killed due to chlorine exposure.
Initial responding agencies from Aiken Country included the Graniteville-Vaucluse-Warrenville (GVW) Fire Department, Aiken County Emergency Medical Services (ACEMS), Aiken County Sheriff's Office (ACSO), Aiken Department of Public Safety (ADPS) and Aiken County Emergency Management Division (ACEMD). Approximately 600 Federal, state and local personnel participated in the response to this disaster.
This report will focus primarily on the actions and observations of the Aiken County agencies involved in the initial response.
Strengths and improvements items will be identified to document the Graniteville-Vaucluse-Warrenville (GVW) Fire Department's ability to recognize, respond to, and control a hazardous materials emergency, as well as to coordinate an integrated response that will protect the health and safety of emergency response personnel, the general public and the environment.
Strengths are those areas in which responders demonstrated exceptional ability or knowledge, or other areas of programmatic solidity. Improvement items are deviations or concerns regarding a particular issue. An improvement item, by itself, does not degrade the response, but the emergency response may be more effective if alternative measures were implemented. Strengths and improvement items will be identified utilizing objectives that are applicable to the agency's response authority.
OBJECTIVE 1: SAFETY
Demonstrate the ability for agency personnel to perform response activities safely.
Criteria 1: Emergency response agency members perform response activities safely.
STRENGTH
- GVW personnel provided specific directions to responders reporting to the Command Post (CP)
Criteria 2: Demonstrate effective scene safety operations through appointment of safety officer position reporting to IC.
STRENGTH
- Safety Officer appointed at CP per pre-established dept policy.
OBJECTIVE 2: PROTECTIVE ACTIONS
Demonstrate the ability to develop and implement appropriate protective actions.
Criteria 1: Determine/implement protective actions and isolate incident scene/area.
STRENGTH
- Response personnel were instructed to clear the area by GVW Fire Chief upon realization of imminent danger.
- Access/egress zones implemented through quick establishment of roadblocks.
- Immediate area evacuated (300 yards)/shelter in place for within 1 mile radius; roadblocks placed Roadblocks established in a timely manner;
- Savannah River Site provided periodic weather updated for Protective Action consideration
IMPROVEMENT ITEM
- Reverse 911 was not achieved in a timely manner due to access available only by Emergency Management personnel. This weakness has been corrected so that Reverse 911 can now be activated through direction from Dispatch supervisor or authorization of Incident Commander.
OBJECTIVE 3: MITIGATION
Demonstrate the ability to properly mitigate, stabilize conditions and gain control over the emergency situation.
Criteria 1: The emergency response agency mitigates the emergency effectively.
STRENGTH
- Responders were thoroughly debriefed when they returned to the CP from operations in the hot zone.
- Logistical support was timely in processing requests once they were established. Additional maps were available at the CP within thirty minutes.
- Railroad consist received at the CP within the first hour.
- Written preplans were used for searches of mill facilities. GVW FD walks down all Avondale facilities annually.
IMPROVEMENT ITEM
- GVW FD did not have adequate resources to conduct decon activities for mass casualty situation.
Criteria: 2: The county EOC provides adequate support to assist in mitigating the incident.
STRENGTH
- Logistical support was timely in processing requests once EOC was established.
IMPROVEMENT ITEM
- Activation and full operation of the EOC was a slow process due to early hour and lack of dedicated facility.
Criteria: 3: Demonstrate effective communications.
- Internal FD communications were successful. Nextel was used as backup communications for privacy of command staff conversations.
- Primary FD communications occurred via E-Tower which was restricted to GVW FD use.
- Dispatcher initiated all-call page for other county Fire Departments to be on standby.
- State of SC provided additional communications capabilities through 800 MHz radio.
- Faxes, phones, etc. available on hazmat units was a key factor in good communications.
- Twice a day briefings with written objectives were conducted at UCP; status of previously established objectives were updated at each briefing
IMPROVEMENT ITEM
- Dispatch should provide more detailed information on location of victims requesting assistance.
- Dispatch should coordinate received information between positions for distribution to all agencies.
Criteria: 4: Demonstrate Command and Control.
STRENGTH
- Recorder position for FD implemented upon activation of the UCP.
- Asst Chief/chief was available on the scene throughout the event.
IMPROVEMENT ITEM
- FD should establish recorder position to assist and document IC activities. Court recorders were provided but not coordinated with IC.
- No coordination between FD and EMS during initial incident response.
- Incident Command System (ICS) process not followed by all responding agencies.
Criteria: 5: Agencies effectively integrate additional support into UC/EOC operations.
STRENGTH
- SC Firefighter Mobilization plan activated and well-staffed.
- Unified Command provided access to all needed agencies. Federal agencies well-integrated and supportive, EPA continually provided maps once the Unified Command Post (UCP) was established.
- Mutual aid agreements in place with SRS and Aiken County.
- Fort Gordon haz-mat resources were briefed to GVW FD approximately 6 weeks prior to incident through a Fort Gordon community support training activity.
IMPROVEMENT ITEM
- Formal mutual aid agreement needed with Richmond County.
- GVW FD personnel need to be briefed on County Emergency Operations plans/procedures.
- Entry teams from other agencies not coordinated with FDIC during early hours of incident.
- Buses used for transport of evacuees were not coordinated with FDIC.
- Better integration of law enforcement and EMS personnel into FD ICS.
Criteria: 7: Appropriate actions are taken to protect and account for emergency responders at the scene.
STRENGTH
- CP relocated due to wind direction considerations (flag provided visual confirmation of wind direction).
- Initial responders notified subsequent responders of danger involved.
IMPROVEMENT ITEM
- Initial FD accountability weak for first 30 minutes due to response from multiple locations; control was regained through radio roll call and telephones.
- Lack of credentials caused some problems with movement of volunteer responders; County produced generic badges with names but no photos.
OBJECTIVE 4: CHEMICAL MONITORING
Demonstrate the ability to minimize exposure and control chemical conditions.
Criteria: 3: Demonstrate command and control of Haz-Mat personnel and activities.
STRENGTH
- Habitability surveys conducted at CP upon arrival of hazmat team. EPA conducted surveys at CP upon their arrival.
- SRS and Richmond County haz-mat resources arrived on scene within a timely manner and were designated by FDIC to be responsible for hazmat operations.
- Hazmat personnel assisted in CP location determination.
- EPA utilized Coast Guard Gulf Coast Strike Team to provide monitoring and on scene response.
- By comparing consist to entry team visual inspection chemicals involved were accurately identified a Written response plan and safety procedures implemented for hazmat operations.
- Briefings provided to hazmat responders by Safety Officer on entry considerations; maps were covered for responders unfamiliar with the area.
Criteria: 4: Demonstrate effective communications.
STRENGTH
- SRS and Richmond County hazmat personnel were familiar with Aiken County personnel and integrated fearlessly into FD operations.
- During UCP meetings, CTEH scientist explained plume models in such a manner that everyone was comfortable.
Criteria: 6: Demonstrate the ability to handle contaminated, non-injured personnel appropriately.
STRENGTH
- Ascauga Lake/Bettis Academy Rd. decon unit established and vital signs recorded.
- Multiple decon centers established on perimeter of affected area.
IMPROVEMENT ITEM
- Decon logs were not accurate due to chaotic state at the scene
- Gross decon performed but quickly overwhelmed; FD did not have adequate resources to conduct decon activities for mass casualty situation.
OBJECTIVE 5: STAFF & ACTIVATE
Activate emergency response facilities in an effective and timely manner based on the type and extent of emergency.
Criteria 1: Activated emergency response members report and perform their assigned duties.
STRENGTH
- Dispatcher initiated all call page for other FDS to be on standby w/o consulting IC.
- Specific directions were provided to responders reporting to the CP
- Community support to provide facilities (Honda Cars/Johnson Motors, Baptist Church) was very beneficial to command and response operations.
OBJECTIVE 6: MEDICAL
Demonstrate the ability to provide appropriate medical care for injured personnel.
Criteria: 1: First responders provide proper first aid care for injured personnel.
STRENGTH
- Initial evacuees treated and vital signs monitored at decon check points established by FD; Additional treatment station established at GVW FD Station 2.
- Medical communications regarding signs/symptoms clear and accurate.
- Hazmat/EMT/First Responder training conducted by GVW FD now includes discussion of appropriate actions to this event.
IMPROVEMENT ITEM
- Development of checklists for mass casualty incidents to record patient information.
Criteria: 2: Demonstrate command and control of the medical emergency.
IMPROVEMENT ITEM
- There was no coordination between FD and EMS during initial event response; effective coordination between FD and EMS occurred several hours into incident.
OBJECTIVE 7: PUBLIC INFORMATION
Develop and disseminate accurate and timely information to the news media and the public.
Criteria 1: Conduct effective news conferences.
IMPROVEMENT ITEM
- GVW FD should establish PIO position for adequate representation at joint press conferences. This would allow for better coordination between ACSO and the FDIC.
OBJECTIVE 8: RECOVERY
Perform recovery activities.
Criteria 1: Develop a recovery plan outline that identifies appropriate recovery strategies.
STRENGTH
- Good coordination with Avondale plant officials in developing recovery plans.
- GVW representative attended daily NTSB briefings.
IMPROVEMENT ITEM
- Development of a recovery checklist may be beneficial for future incidents to address issues such as CIS debriefings, vehicle recovery, and temporary department facilities.
- Designated individual should be identified to coordinate donations and spontaneous volunteers.
PATH FORWARD
- The Graniteville-Vaucluse-Warrenville Fire Department has produced this document in the hopes that other emergency response organizations can benefit from the lessons learned in this incident.
- The Graniteville-Vaucluse-Warrenville Fire Department believes that multiple agency response drills would be beneficial to future responses.
- The Graniteville-Vaucluse-Warrenville Fire Department would like to participate in a roundtable session with other agencies that responded to this incident in an effort to discuss the lessons learned and to strengthen cooperation among agencies.
February 6, 2006
Publication #FHWA-HOP-08-014
