DELTA FIRE-GENERAL MOTORS RADIOLOGICAL DISPERSIONS DEVICE EXERCISE (MAY 13, 2003) – LESSONS LEARNED

Lou Brandon

Michigan Department of Environmental Quality

INTRODUCTION

In Early 2003, the Delta Township Fire Department guided the planning of a county Weapons of Mass Destruction (WMD) exercise towards a Radiological Dispersal Device (RDD) event because that was what they knew least about. General Motors (GM) provided an unused factory and numerous support staff. To support firefighter rescue activities and use the building, it was desired to detonate the device inside of the factory. With the assistance of the Michigan (MI) Department of Environmental Quality (DEQ) and the Lawrence Livermore National Laboratory (LLNL) Hotspot Program, a scenario was developed with a large 6000 curie Cs-137 source to test response capability in a relatively extreme radiation environment and to provide perspective on relative hazards. Upon detonation, the factory became extremely contaminated and structural damage provided for leakage and an off-site plume. Many wounded remained in high radiation fields awaiting rescue. The response effort included multiple county law enforcement and firefighter units, Sparrow Hospital, the MI National Guard 51^st WMD Civil Support Team (CST), the MI DEQ and other state agencies involved in the activation of the State Emergency Operations Center (SEOC), and the Federal Bureau of Investigation (FBI). As a first initiative by most of the planners for an exercise of this scale, this event came together remarkably well, but many aspects did not go as expected. Fascinating insight is gained from the experience of demanding that many agencies work together in a foreign and hostile environment where the lives of those stranded are more at risk as each minute passes. This exercise has greatly enhanced the capability of our local organizations to respond and work together in a radiological emergency.

Delta Fire kept the nature of the incident (chemical, radiological, biological) guarded and most players did not know what to expect. From DEQ’s experience with nuclear plants using the Drill 1, Drill 2, Exercise sequence, Drill 1 is where most problems arise. This scenario, a first attempt for many players who had not interfaced with other responding agencies, was expected to reveal weaknesses and ultimately strengthen response capability.

THE SCENARIO

To simulate an indoor environment with Hotspot, a low wind speed of 0.1 m/s and an inversion layer of 10 m was used. Wind direction was modified to 210 degrees from 235 degrees to align with the building layout. Considering leakage or a roof collapse, this plume also provided external mR/h values in the building vicinity. Gamma rates were assumed to be fairly constant over time within the building and dependent on distance from ground zero.

In Michigan, about a dozen facilities are authorized by their Nuclear Regulatory Commission (NRC) license for more than 1000 curies of Cs-137 and five are authorized for about 6000 curies or more. Cs and Co comprise the highest activity sources and metallic cobalt is generally much less dispersible than Cs. In the US, there exist about 70 large irradiators (10K to 15M curies, Co-60) and 284 smaller irradiators (less than 10K curies, mostly Cs-137 and Co-60), all well regulated. What is the possibility that a large source from a third world country could be smuggled across a U. S. border crossing? Even if it is possible, technical challenges remain to effectively disperse a large radiological source.

The DEQ has guided that first responders to an explosion should assess the presence of radiation, if they can. Premise: For a dirty bomb event, the radiological impact will generally be low enough that first responders can enter the affected area for lifesaving purposes and exit quickly without being overly concerned about excessive exposure or dose. This scenario was about to challenge the premise which has provided the basis for guidance to first responders within the state.

PROGRESSION OF EVENTS WITH COMMENTARY

8:45 A.M. Detonation Occurs

Sixty victims are staged 20-100 yards from the blast and are now in radiation fields of 20-225 rad/h. 400 - 500 rad is sufficient to provide a lethal dose where 50 percent of those exposed will die within 30 days without medical intervention. The first responders did not yet know that the incident was radiological. Due to the detonation within the building, much of the contamination was contained. This created a radiation field that was more intense than if the source had been more widely dispersed. The (GM) on-site emergency response team rushed to the blast scene and advised those who could walk to exit. About 35 of the victims walked out. The GM team had been advised to look for fluorescent material in a darkened building (glow sticks were intended to be staged, but never were) as an indication of a strong radiological source. Seeing none, they advanced further, but did not remain nor attempt rescue in the building. The GM teams had no radiological detection equipment (estimated dose 1.5 rem for each GM responder).

Now the stage was set for off-site first responders to apply their radiological skills during a rescue. First responders are aware that an explosion implies potential radiation, secondary devices, and potential perpetrators. The Lansing firefighters had electronic dosimetry. Delta Fire had ordered but not yet received alarming dosimetry. They had a few old and new meters available to monitor for radiation.

9:15 A.M. First Firefighter Entry

Two firemen, with respirators, entered the building with a CDV-700 meter and bullet probe. The controller (at an alternative entrance) met them in a radiation field of about 50 R/h. Assessing the location, he called out this rate then noticed their meter and told them the meter was off-scale. The firemen reported a 50 R/h reading via radio and immediately left (estimated dose 1.25 rem). The CDV-700 meter could indicate a maximum of only 50 mR/h. The firemen had available an ADP 2000 meter capable of 100 R/h and CDV-777 ion chambers capable of 50 R/h. Play could have been enhanced by providing readings to these firemen when they first entered.

Early comments by controller, Major Hinga, 51^st WMD Army National Guard

Field personnel need to confirm that they have the correct information. There was confusion at the operator level as to whether the first entry team had readings of 50 mrem/h or 50 rem/h. Fire department personnel did a good job of monitoring and knew their equipment. The entry team immediately realized the potential for radioactive contamination and did a good job of monitoring each other. The team also made the correct decision to reduce the spread of contamination by staying in place while awaiting further instructions. The entry team needed to be equipped with a better RADIAC (radiation meter). The one used on initial entry was an old Civil Defense model. These machines are reliable for establishing that radiation is present. However, these meters can’t read above 50 mrem/h. Without knowing just how much higher the radiation levels might be, the Fire Department made the correct decision to not risk the safety of their members until a more accurate survey could be accomplished. This delayed further search and rescue operations by several hours and would have resulted in additional deaths among the initial blast victims. If the department had used better meters, they would have found that levels were high, but tolerable, for quick search and rescue entries into the outer edges of the effected areas.

Some confusion at the command level resulted in the unnecessary spread of contamination. The entry team was instructed to move to an open area further south along the building to await hasty decontamination. They were then directed to return to their original location for hasty decontamination where the two firemen were hosed down in the parking lot near a storm drain. They, then, removed and left their gear in piles. Major Hinga recommends that a location for hasty decontamination and identification of personnel to perform the hasty decontamination be established before the team makes first entry so that they can be decontaminated more quickly and efficiently. An ongoing concern for consideration is whether contaminated water should be contained during the decontamination process.

The GM victims and the GM EMT personnel were not made aware of the radioactive contamination for almost a full hour after the Fire Department first became aware of the contamination. This caused the GM EMT personnel to treat contaminated casualties while keeping their Self-Contained Breathing Apparatus (SCBA) gear unused at their side. This potentially would have unnecessarily exposed the GM EMT personnel to radioactive dust from the patients. The victims went through an emergency or ‘hasty’ decontamination, being sprayed with fire hoses over a lawn area. Respiratory protection was not used at this stage of decontamination for the public or the emergency workers (EWs). The hasty decontamination personnel were very thorough in performing their duties. They covered all surfaces of the body (except for missing the bottoms of the feet of the first two decontaminated) and were conscious of the potential for contaminated runoff. The team did a good job of monitoring each person for contamination and segregating those with high levels of remaining contamination from those with low levels of contamination. The people working the line were very ingenious in acquiring towels, blankets, and other items to keep the victims warm after they were passed through the hasty decontamination. The team did a good job monitoring themselves and their equipment during recovery operations after the hasty decontamination was no longer required. The regular decontamination was set up quickly and everyone seemed to know what they were doing. Victims were directed to one of three decontamination tents for monitoring and further decontamination (EWs used respirators). The decontamination personnel knew their jobs and performed them thoroughly. Personnel on the line did an excellent job of monitoring individuals after decontamination and did a good job of processing themselves through decontamination before they left the area.

Areas for improvement: Management needs to put more planning into how to keep victims warm and protected after hasty decontamination. Planning also needs to be done as to how to perform hasty decontamination in very cold weather. The people performing hasty decontamination should wear respiratory protection. The personnel operating the regular decontamination line all wore respiratory protection, but across the street the people performing hasty decontamination were unmasked. The decontamination line should be placed closer to the hasty decontamination line to reduce the spread of contamination as victims move from one line to the other.

Early comments by controller, Don Parry, CHP

There seemed to be some problems from a training, procedure, and equipment point of view and there appeared to be room for improvement in these areas.

Training: While some type of radiation survey was performed on most, if not all, potentially contaminated victims and emergency workers, the choice of survey instrument was, at times, inappropriate for the task. Below are listed some of the various instruments that I saw used during the exercise along with my description of how they were used and how they should be used. The CDV 700 is a survey instrument with a relatively low scale and is best used for a quick decontamination survey of people and equipment to detect gross levels of contamination. I saw it used in the exercise as an area survey meter inside the building. Since the top scale on the meter is only 50 mR/h, it measured to be off-scale very quickly in the scenario and did not give a very good assessment of the radiation hazard from an external radiation field. The CDV 777 is a high range ion chamber that should be used to assess levels of external gamma radiation to decide how long workers could be present in the area and remain below limits. I saw this meter used for decontamination surveys. The Victoreen Model 190 is a survey meter with a thin window detector and would be appropriate for a final decontamination survey to determine if individuals are free from contamination. I saw it being used on the “dirty” side of the decontamination showers, which isn’t a bad choice, but since it was the only thin windowed chamber available, I would have used it on the clean side and used the CDV 700 on the dirty side. It appears that some personnel may need some instruction on the different types of instruments available and on their correct use.

Procedures: Survey techniques could be improved. Operators should perform surveys generally much slower than I observed. Survey meters should have speakers or headphones and these should be used since they allow better detection of areas of contamination. Equipment and probes should be covered with plastic to protect from water and from becoming contaminated when surveying contaminated patients. Operators should be careful to not touch contaminated persons with the probe and, if they do, they should know to check the probe for contamination afterwards. Again, having the probe placed in plastic would make decontamination easier.

Equipment: In general, I saw very few thin window detectors which would be the best choice for final decontamination surveys. The CDV 777 is a good high range meter, but it should not be used for decontamination surveys. The CDV 700 is a good durable survey meter which is good for determining gross levels of contamination, but should not be used for area surveys or final decontamination surveys. Ideally, meters should have digital readouts and be auto scaling. Meters with plastic cases would be easier to decontaminate.

9:30 A.M. Firefighters are ready and raring for rescue.

The first walkout victim arrives at the hospital. This victim arrived before the controller (poor controller planning). Sparrow Hospital is disappointed with the pre-patient event notification, but the hospital appears well prepared. They had no prior knowledge of this type of event. Their additional shift of staff was not challenged until much later. They have one decontamination room. They contacted the Radiation Emergency Assistance Center (REAC/TS) at Oak Ridge and coordinated care with doctors there.

Local law enforcement and Delta Fire arrived first and formed a unified command (UC). The FBI is now involved in decision-making. Michigan State Police (MSP) soon joins the UC. The UC should be facilitating both crisis and consequence management. The FBI should coordinate the crisis management team and the Department of Homeland Security (DHS)/Federal Emergency Management Agency (FEMA) should coordinate the consequence management team (FEMA did not play in this exercise as TOPOFF II occurred on the same date). The Incident Command (IC) System consists of Command (united), Liaison Officer, Press Information Officer, Safety Officer, Operations, Planning and Intelligence, Logistics and Finance/Administration sections. The operational control of assets should be retained by designated officials representing local, state, and federal agencies.

The SEOC is activated and the MSP Mobile Command Vehicle arrives shortly thereafter on site. The DEQ and other state agencies have pre-staged responders at the SEOC to facilitate play. The 51st CST is also pre-staged in the vicinity of the GM factory.

9:45 A.M. One hour has elapsed - a SEOC briefing announces a 50 R/h reading made at the scene 30 minutes earlier.

One hour has elapsed. DEQ, after notification by the DEQ Emergency Management Coordinator (EMC) at the SEOC, calls a brief meeting. They then dispatch one field team and a team consisting of two Field Team Center Coordinators (FTCCs), a health physicist for dose assessment, and a public information official. Usually MSP would make the DEQ contact and it is not clear why it was not made earlier. DEQ responds in real time and the field team has to pick up equipment several miles away. By the time the DEQ team responded, the plume had essentially passed and contamination from deposition was the primary off-site concern.

Both radiological and meteorological data provided good perspective. The wind happened to be blowing toward our equipment bay and very early detection and radionuclide determination could have been made and communicated earlier if the field team had measured en route to the site about seven miles away. The other DEQ team considers contacting the incident commander en route, but has no phone number. The 51st CST is also en route (actually pre-staged). Media personnel begin wandering through contaminated areas as GM employees begin providing tours without regard to areas of play. Some victims inside have now received a radiation dose of 335 rem. A secondary explosive device has been identified in a vehicle close to the building and made safe. IC is facing tough decisions, a chaotic command environment, and further complications.

The 51st CST arrives with both off-site and on-site monitoring capability along with many specialized radiological resources. The 51st CST sets up decontamination resources in an area to the east, slightly upwind, as directed. The large loading dock doors are the only barrier between this decontamination area and the highly contaminated area housing the remaining casualties within. Opening the doors may have shed a lot of light on the accident scene, but probably would have allowed contamination to flow into the 51st CST decontamination area. As the 51st CST prepares to survey inside, a perpetrator is spotted on the roof. This turns out to be a photographer and the rescue is unnecessarily delayed about an hour and a half.

Communications were established between this site and the SEOC, both through IC and through DEQ. DEQ passed information back and forth timely, and SEOC decisions were conveyed to field teams. Teams were instructed to monitor 360 degrees around the building. Technical data was attempted to be conveyed to the SEOC by phone rather than by fax (thought not readily available, but it was) and resulted in confusion and delays. Within DEQ, there was a need for greater teamwork at the SEOC, especially since one player was very new. An area was set up on site for press and public information personnel but, possibly due to the cool breeze (and GM tours), was not used. An IC controller may have aided in facilitating play and avoiding diversions.

The DEQ team logs in at incident site at 10:40 A.M. DEQ is informed upon arrival that they can stage, but that since a perpetrator was spotted, they would not have been allowed to move into the scene if it were a real event. They find the MSP mobile command vehicle jammed full of people. The Delta Fire IC vehicle is also packed. DEQ needs power and a fax. DEQ periodically interfaces with UC, but rather than integrate into the IC structure and provide much needed radiological insight, they decide to work independently in their van beside the command vehicles and focus on the off-site response. The intended dose modeling programs (laptop never turned on) are not used. Dose assessment becomes based entirely on a one page RDD guideline that was prepared in advance. Good practice would preclude protective action decisions from being made on just one assessment instrument or one meter reading.

10:45 A.M. Two hours elapsed – what are the priorities?

A Special Weapons & Advanced Tactics (SWAT) team arrives but does not inform the IC that they had arrived. They have no dosimetry but begin to enter the building in an attempt to clear the area. Inside, four GM employees now have lethal doses and four more have very high radiation doses.

Victims/patients that had initially walked out were reprocessed through the decontamination line if any contamination was still present. Personnel on the line began to correctly deduce that victims had internal contamination in the lungs/throat after radiation was still present in the chest and neck area after several attempts at decontamination in those areas were unsuccessful. Decontamination and Emergency Medical Service (EMS) personnel made an excellent decision to reduce the potential spread of contamination by placing surgical masks on victims showing internal contamination. Firefighters were receptive to controller guidance on decontamination meter use. One explained that his meter, an ion chamber, was all that was available. Both the 51st CST and DEQ personnel were close by and could have assisted decontamination with both guidance and equipment. The DEQ team understood that much of the SEOC play for this drill was dependant on off-site data being provided by the field team and assumed that rescue was better addressed by fire and 51st CST teams. It was learned later that the 51st CST team is not oriented for rescue. One falsely reassuring comment provided to DEQ during play from a county official indicated that no problems were evident in the decontamination area.

11:04 A.M. DEQ reads 850 uR/h (1 m AGL) about 1.2 miles downwind.

Cs-137 is identified with no alpha radiation present by 11:22 A.M. The DEQ team takes an air sample, but no evident soil samples. DEQ guidance sheets prepared in advance for radionuclides of concern indicated that a limit of 450 uR/h would identify a relocation concern for Cs-137, if residents remained there for a full year. Field teams and the DEQ on-site support team were fully focused on the off-site concerns as we normally do for nuclear power plant drills. In this case, the greatest concern was on site, in the building, at least until casualties were removed.

Decontaminated patients begin arriving at the hospital about 11:30 A.M. They comment that they have already been decontaminated about four times. They are still internally contaminated. The patients were registered, tested for chemical contamination, and grouped in the cancer center. It was intended that some very contaminated victims be sent to the hospital which eventually occurred after 1:30 P.M. By this time, the drill had ended and the hospital was in debrief mode and did not play further. The Metro teams demonstrated that they can play an important role in reducing the hospital’s contaminated patient workload. The ‘walking well’ would be another large population group that the first responders can help process to keep the hospital’s patient burden lower.

At the SEOC, the players are being challenged and make protective action decisions. At 11:40 A.M, the State secondary complex (upwind) is sheltered. The 496 Expressway, two miles downwind, has been shut down. The Michigan Department of Agriculture (MDA) has embargoed foods in the area and issued advisories. Public relocation concerns are recognized within a mile downwind, but are non-immediate.

11:45 A.M. Three hours have elapsed - eight GM employees now have a lethal dose.

Eleven more have very high radiation doses. DEQ team now has data points (10 x background) to begin characterizing the deposition pattern. Conveying this to the SEOC presents numerous problems as procedures were bypassed and roles and responsibilities strayed from those expected. Rescue has been held up by law enforcement due to an observed perpetrator on the roof who is eventually shot. In a situation like this, are there alternatives for an earlier rescue?

The 51st CST enters the southwest corner entrance with two team members at 12:05 P.M with level A personal protective equipment (PPE), and small mobile response vehicle. Their turn back value has been reduced by an administrative decision from 5 cg/h (rads/h) to 1 cg/h. It is obvious that they are thinking in terms of ‘as low as reasonably achievable’ (ALARA) rather than lifesaving dose limits. They reach their limit inside the door and their chemical detector also reads high (from the smoke simulator?). They exit. Their turn back limit is raised and the 51st CST reenters and proceeds to a 5 cg/h (rad/h) level for about 30 seconds. They exit to try another entrance.

For this exercise with Cs-137, an effective beta and gamma emitter, a roentgen (R measured in air) is about equal to a rad or centi-gray (cg)(energy to a person) and is also about equivalent to a rem (dose to person). The 51st CST proceeded slowly with much caution. At 12:30 P.M, dose rates inside are artificially reduced by the controller to facilitate play for the 51st CST (now with 17 cg/h limit) to enter and find some victims. Their suits were fogging up and the room was very dim with smoke-like haze. Progress was continuously impeded by high rates.

Areas for improvement: Better communication and coordination needs to take place between the 51st CST survey element and the IC System operations element. Errors in communication/coordination caused confusion as to the planned location for the 51st CST’s initial entry. This confusion resulted in entry delays and caused the 51st CST analytical and decontamination elements to be improperly positioned.

12:40 P.M. Almost four hours elapsed – can the rescue begin?

About 15 firemen, with standard gear, respirators, and rescue sleds, enter behind two 51st CST lead personnel. They ignore the 51st CST lead when bodies are observed and run to victims. Two men run through the middle of the debris pile (2000 R/h) to rescue two victims on the other side. GM employees are removed by sled, wheeled chairs, and assisted support. It appears that two to three trips were made by each fireman. Ideally, the firemen should have followed the 51st CST who were identifying the zone of relatively safe radiation levels. Interestingly, the scattering of firemen actually allowed many more casualties to be rescued in a short period of time than they could have otherwise. This provides good reason to re-think our approach, especially with resulting firemen doses (except for two) well within their 25 rem lifesaving limit. Some victims would probably have died from their severe medical injuries over the long delay. Most, after inhaling contaminated smoke and dust for four hours had severe internal contamination.

Major Hinga comments on Search and Rescue Teams

Firefighters did a good job in organizing and planning the team composition and equipment prior to entry. It was an excellent job of locating and extracting victims quickly and SAFELY.

Areas for improvement: The 51st CST and the Rescue team needed to develop a joint plan before entering the contaminated area where search and rescue needed to be performed. The lack of a joint plan caused 51st CST members to briefly attempt to egress victims instead of staying focused on their survey mission. It also caused firefighters to initially proceed in the wrong direction after entering the building, entering areas that had not yet been monitored, and subjected the rescuers to dangerously high levels of radiation. Rescue team members need to be monitored for contamination after entering a contaminated environment. After they have entered a contaminated area, firefighters need to keep their SCBA masks on until after they have processed through decontamination. All the players at the operator level (both responders and victims) did an excellent job of carrying out their assigned tasks and cooperating with members of other agencies. GM did an excellent job of organizing their people and providing logistical support to the exercise.

Victims could be removed in as little as two minutes.

Firefighter total doses ranged from 1-30 rems per rescue trip (average 4.3 rems). Victims total doses ranged from 230-1341 rem (9 were lethal doses). With modern medical intervention techniques, many with lethal doses could still survive. The estimated dose for the two 51st CST members was about 19 rem. This duo remained primarily in the building and assisted the firemen rescue until about 1:00 P.M. Had this team, leading the firemen, been in lifesaving mode, they may have cut the response time to less than 30 minutes. Their original dose limit was 2.5 cg or 2.5 rad or rem. EPA guidelines suggest that 25 rem is appropriate for lifesaving and some discussion (Dr. John Poston, Chair, NCRP 138) suggests 50 rem as possibly more appropriate. DEQ normally thinks in terms of our 1 rem/day limit. Although we did not participate in the rescue, this is the first time we’ve been this close to an incident where thinking in terms of the 25 rem/y was probably more appropriate. How many on site shifted into this mode of thinking? First responders demonstrated effective transfer of highly contaminated GM employees from the defined hot zone to decontamination areas with a long rope and sled. Teamwork was evident throughout the exercise.

CONCLUSIONS AND FURTHER CONSIDERATIONS

More lives could have been saved in this scenario with a more efficient response. Direct contact from IC to DEQ Hazardous Waste and Radiological Protection Section (HWRPS) or another radiological authority was possible. Similarly, DEQ communication with the IC en route was possible and greater integration on-site to characterize, assess, and prioritize radiological perspectives would have been of great benefit. The DEQ HWRPS, and possibly the 51st CST, can play a more active role in advising the IC. One concept for lifesaving in a hot environment might be a deep 2 minute surveillance mission to quickly assess the hot zone with appropriate lifesaving limits. Once radiation levels are measured, limits can be reviewed, and stay times calculated. The available ADP 2000 meter could read up to 100 R/h. Most victims were in a radiation field much less than this (103 R/h for 3). Responders can pursue avenues for quick and efficient rescue with dosimetry. (Would firemen have responded more efficiently without the multi-agency assistance?)

Additional considerations include ensuring that meter readings are accurate. General guidance necessitates verification of readings with a second instrument, if possible. In this case, dosimetry can provide verification after the first rescue run. The DEQ general guidance for a dirty bomb incident, supported by this exercise, is that first responders should be able to perform lifesaving activities without regard to radiation concern as long as they get out of the hot zone quickly. With radiation detection equipment, the incident can be characterized, but even high radiation readings should not preclude the possibility of a quick rescue with no significant long term health effects for the responders. Detection of radiation should not unnecessarily bog down the progress. DEQ has the capability to help size up an incident, determine possibilities, and provide dosimetry, if necessary. There was a moment during play about 11:00 A.M. when I, as a controller, briefly spoke with the IC. The view was that the rescue may not be attempted at all due to high radiation rates. It was pointed out, and this point could have been made much earlier by on-site radiological experts, that in a 50 R/h field, 30 minutes are available before the lifesaving limit is reached. Many victims were in lower radiation fields than this. I was thoroughly impressed to see many individuals rescued on a plastic sled with total time in the building being only about 2 minutes per trip.

Other important alternative approaches include: 1. Victims could have been communicated with from various low radiation rate doorways by calling to them. 2. If the victims were unable to be rescued, their internal dose could have been reduced by ventilating the building (at the cost of slightly contaminating the environment). 3. Large delivery doors were in the vicinity of the blast and could have been opened (if the desire for first responders to have to work in a dark smoky building was ignored) and responders would have had visual access to many victims (actually those in the hottest zone). 4. Remote approaches like using a robot to measure dose rates or first responders throwing a rope are possibilities that could have been used in this case. Radiological authorities should have been continually emphasizing to the IC that the victims were in a very hot zone and providing possible solutions. The IC had a lot to think about operationally and was depending on DEQ and others for radiological guidance. As the number of agencies increases, it becomes more difficult to interface with each one sufficiently. Priorities and initiatives need to be identified, verified, and communicated amongst major and minor players. Players with needs should vocalize them to expedite the response with other agency resources or personnel. Examples of needs that could have been expressed and met included workspace, AC power, extra meters, dosimetry, a fax machine, health physics support, possibly more field teams, portal monitors, and SEOC support personnel.

A multi-agency response implies that extended resources are likely available and a coordinated response means working with and interfacing with each other.

Areas for improvement: A better understanding of the process to activate the 51st CST was needed. It appeared that the IC initially had difficulty contacting the 51st CST for assistance. Additional radiation education of first responders is needed. Some seemed confused as to safe levels of exposure, the difference between being exposed to radiation and being contaminated with radioactive particles, and the differences between total dose and dose rate. Local, state, and federal agencies had varying levels of radiological expertise and were available at both the incident site and at the SEOC. The locals could have used more guidance and support as they addressed decontamination of the public. The 51st CST assisted with the rescue by local firefighters, but rescue is not their business. DEQ could have assisted with on-site assessment. DEQ was assisted in off-site monitoring by the 51st CST. This aspect was simulated, but quite possible. Coordination between local, state, and federal radiological entities at the SEOC also had room for improvement.

Within the DEQ, it was observed that the most natural response is to do things as we have in the past. At times, there was a tendency to work somewhat independently of other efforts without assessing the big picture. Emergency situations are very challenging. Time doesn’t wait and second chances are rare. It should not be assumed that the other guys always know what they are doing. Strengths and weaknesses were abundant, and will be in the future. By working together and checking each other’s procedures, many weaknesses can be recognized earlier and set straight. What are the priorities? Is everything under control? In the end, most of the debrief comments were very positive. The FBI commented that the crime scene should not prevent attention to the injured. So why did it take so long to rescue the GM workers? At least we can say that the scenario provided everyone with an adequate challenge. This exercise has been a learning experience at many levels and the lessons learned can be of benefit to others. Probably the most important lesson learned was that response agencies need to practice working together to maximize their efficiencies. This was a successful exercise because we have learned so much and come so far. The agencies involved are much better prepared to work as an integrated team and we continue to work more closely together now than in the past. Other than a real emergency, there is no substitute for an exercise to genuinely test response capability, especially a multi-agency response. A challenging scenario can be designed for success with careful planning and can maximize lessons learned. The first responders’ willingness to fully test their response capability in the interest of founding a stronger and more united base, to build more confidence and competence in fellow responders, and to reassure the public, is to be commended.