Lessons Learned:

Followup On the Army Corps of Engineers (ACOE) Dalles Spill

 

Background:  The Dalles Dam After-Action Report was commissioned to be an independent review of Ecology’s internal processes and policies in response to this spill.  The author of the report was asked to focus on three questions:

 

• Delay: Was there delay in launching the Ecology (WDOEO Level 3 overhead team? 
• Unified Command: Did unity break down in the Unified Command? 
• Information Flow: Was there adequate information flow from on-scene staff to headquarters and stakeholders?

 

There were 21 lessons and 50 recommendations listed in the Dalles Spill Report.  Each are listed below along with the actions and implementations that Ecology or others have taken since the spill of January 15, 2004.   

 

Lesson:  Even well intended estimates of spill volume based on observations of floating oil should not be accepted unless they are confirmed by valid mass balance computations beginning with a recognized total potential amount released.

 

Recommendation:  All investigators, including the first person on-scene, until a designated investigator arrives, should be directed to immediately ascertain the potential volume and insist on referring to this potential in all communications until a better estimate is derived through mass balance computations.

 

Recommendation:  All investigators and potential first responders should be familiar with standard mass balance computations, volume estimating methods, and standard volume-mass conversions.

 

Recommendation:  When the volume spilled is unknown or uncertain, the response team should be sized based upon the potential, until more reliable information is available.

 

Actions: 

• Volume estimate training and standard mass balance computations are a regular part of spill response and investigation training.  Our latest training occurred at the September Chelan Training where a review of the Guidelines for Determining Oil Spill Volume in the Field occurred. (Reference manual developed for Ecology in 1996 with corresponding training for Ecology staff.)  
• By management directive and as noted in the Program Standard Operating Procedures and Operations Manual in the Notification Section, all spills will be responded to according to their potential volume/impact until reliable information (mass balance) may cause a need to increase or reduce response resources.
• All Ecology Spills Program investigators are well trained in mass balance computations, volume estimate methods, and standard volume-mass conversions.
• Ecology’s new Incident Management Assist Team (IMAT) dispatch procedures include sending an investigator to any significant spill of oil or hazmat.  The IMAT is an overhead team of trained Ecology staff to manage spill responses.
• During the Dalco Passage spill, Ecology investigators were immediately dispatched to investigate the source of the spill and gather other pertinent information.  Field observations and disposal numbers were all used in estimating potential spill/recovery volume estimates.  Spill volume estimating was difficult in the Dalco Passage spill because there was no identified responsible part.  There were additional lessons learned about spill volume estimates during that incident.
• It is now the policy of the ACOE to report spills with both estimates of quantity spilled (by observation and/or initial calculations) and potential quantity from the identified source. 
• Until firm spill quantities can be determined, all ACOE responses are measured by the potential volume from the identified source.                 

 

Lesson:  On-scene responses to spills from dams, which are presently mandated by WDOE policy, should initially focus on the potential of any oil released downstream, since the dam structure itself will often contain and concentrate upstream spills.

 

Recommendation:  Whenever any quantity of oil is reported as being released or observed downstream from a dam, an immediate priority should be given to a visual survey of the reach below the dam, the potential implementation of downstream Geographic Response Plans (GRP) strategies and the identification and control of the source of the downstream pollution. Note: GRPs are pre-identified sensitive resources with response strategies defined ahead of a spill.

 

Actions:

 

• Each of these points is consistent with existing policies.  Each is practiced regularly during drills testing spill preparedness.
•  During the July 21, 2004 response to the Navy F-18 jet crash in the Columbia River, down stream assessments and over-flights were conducted by multiple federal and state responders.  Appropriate GRP strategies were deployed downstream of the crash site.

 

Lesson:  It is contingent on WDOE to make provision for rapid assessment and response to downstream spills independent of the actions of ACOE or other potential spillers.

 

Lesson:  In considering delays associated with this or any river spill response, it is the recognition of downstream threat and the deployment of observers and GRP strategies that appear to be the most crucial potential delays in terms of protecting State waters and shorelines.

 

Recommendation:  If there is any oil reported below a dam, WDOE responders must work closely with the ACOE in assessing the amount of oil spilled and in controlling the source, while also immediately calling for independent visual surveys of the reach below the dam and immediately activating State contractors to begin preparations for deployment of GRP strategies below the dam.

 

Recommendation:  All potential field observers and first responders should receive training in the identification, standard classification and volume estimation of floating oil.  Whenever possible, responders should be sent out with experienced observers for training, calibration and/or confirmation.

 

Recommendation:  Without a mass-balance confirmation, all estimates of spill volume based on observations of floating oil, even from trained observers, should be given as a range of volumes, often as being within an order of magnitude, thus more accurately portraying the inherent uncertainties.

 

Actions:

 

• This remains an issue and warrants further training of Ecology staff.  The initial spill volume in the Dalco Passage spill was not given as a range.  Throughout the response as waste disposal tracking was conducted, it became apparent that the spill size may have been larger than the volume originally estimated and provided to the public.
• Since the Dalles spill incident, ACOE personnel conduct downstream surveys of collection areas identified during the January 15 spill when ever spills occur at the Dalles Project.  Also, when other significant river spills occur, Ecology’s Vancouver Field Office personnel would again be dispatched, along with an over flight, to move up river searching for the leading edge of the spill. 
• Over-flights are a regular part of Ecology responses to oil spills and are conducted when needed and when safety allows.
• At the July 21, 2004, Navy F18 jets Columbia River crash and spill, the responding contractor (NRCES) was directed to boom the mouth of the John Day River, down stream of the spill, before arriving at the command post. This was done as a preliminary precaution.
• The Spills IMAT policy has since been developed and implemented.  Significant spills are responded to according to their potential. The Spills program has adopted an aggressive response posture to deploy assets early into a spill and recall them once an adequate response has been provided by the spiller.  There are some positions that will not be relinquished by Ecology, such as the State On Scene Coordinator (SOSC), Environmental Unit Lead, Liaison and Public Affairs representatives.
• All Spills personnel have been trained in Field Observation techniques during the 09/04/2004 Program Training Event.  There will be a continuous focus on development of field observer tools and staff training.         

 

Lesson:  It is presently unclear what constitutes a shift from a Level 2 to a Levels 3 classification.  The question of delay in the launch of the Level 3 overhead team seems to be referring to timing of the responders who arrived Saturday morning.

 

Recommendation:  If criteria are developed for changing response levels, they should include not only existing on-scene staffing, but also the ICS training of the on-scene staff and any potential efficiencies to be gained by relieving the spiller’s staff, thus allowing them to focus on critical operational responsibilities with which they may be more familiar.

 

Recommendation:  Given that the WDOE Levels are not commonly understood and have no operational meaning outside of WDOE, it is recommended that they not be referenced in any external communications.

 

Recommendation:  The term "Overhead Team" has specialized meaning within WDOE but can be confusing or misleading for other responders.  "Overhead" is often viewed as a negative term referring to potentially extraneous staffing or costs, particularly in the response industry.  It is recommended that Ecology change the internal and external name for this team to something like Washington Incident Command Assistance Team.  This is similar to the Incident Management Assistance Team nomenclature used by the Coast Guard and industry, but provides a more unique Washington State identity.  This may also help built an esprit-de-corps within the State team members. 

 

Recommendation:  The term "After-Hours Responders" also has specialized meaning within WDOE that is seemingly obvious to insiders, but may be counterintuitive to other responders, particularly because it can refer to people who have other known roles in a response.  These responders are filling specific roles when they are on-call.  It might be less confusing and generally better to just refer to them in terms of the position they are filling, either while on-call or in their normal response assignment.

 

Actions:

 

• Levels of response are now included and defined in our Spill Response Operations Manual and activation has been practiced during drills and at the Dalco Pass spill.  These levels have also been shared with our response partners and stakeholders across the State.
• The Response Levels were reviewed in the Policy component of our recent Spill Response Training Workshop in October. 
• By carefully explaining to a spiller what constitutes each of the Response Levels initiated by Ecology, it is felt that the spiller can then know what to expect from Ecology responses and thereby assist in decisions regarding staffing levels. (These levels are now understood and even used by the Corps after we conducted ICS training for them after the Dalles Project spill.)  We will continue with the use of Response Levels and the associated terminology both inside and outside of our agency as they are very useful tools.    
• Incident Management Assist Team is now the official name of our ICS management response team.
• A successful Level IV activation and implementation of the IMAT occurred during the Dalco Pass spill.

 

Lesson:  Allowing WDOE staff to make time critical decisions based on their instinct can be disconcerting but it can also be an opportunity to take advantage of experience to make the response more effective and build or establish trust.

 

Lesson: Decisions based on instinct, intuition or "gut reactions" often have maximum beneficial impact when implemented early in emergency response, but they can also be hard to defend if they prove wrong.

 

Recommendation: Experienced WDOE personnel should be encouraged to voice their instinctual reactions and recommendations knowing that these will be received and considered in any associated decisions.

 

Recommendation: Because instinct and intuition are built on individual experience, it is recommended that WDOE develop a method of capturing individual experience so that it can become part of an organizational memory, which can then foster institutional instinctive response actions.  To this end it is recommended that WDOE build a database of incident histories, which can be maintained and accessed, to allow for the effective sharing of experience.

 

Actions:

 

• The above mentioned data base is being developed with inclusions of the Dalles, Foss, and Dalco Passage lessons learned.
• Instinctual reactions and recommendations are communicated throughout a spill incident and are always considered when making decisions.
• The Washington State Department of Ecology is fortunate to have some of the most experienced, best trained and talented response personnel in the world.  This talent is recognized by professional response organizations from across the nation during drills and related professional events.
• We have emphasized considering “potential” when making go/no-go decisions and Program Management has encouraged and pledged support for responders to “error on commission” or “over respond”.          

 

Lesson:  An Ecology Response Support and Information Center (called RSIC here, but also known as War Room or Situation Room, or EOC, etc.), should be established in the Spills Program headquarters office. This would be a space where maps, photographs and response documentation can be posted and would need access to communications capabilities so that needed support can be coordinated and delivered.  This would also function as a single location for headquarters staff to track the status of field responses, maintain contact with field teams, and receive a briefing prior to deployment.

 

Recommendation:  A primary HQ Support Coordinator (referred to here as HSC) should be identified for each incident. This person should have sufficient authority to activate needed State resources and interact with other appropriate State and Federal agency managers.  The HSC would be responsible for interacting with the on-scene responders (Away Team) and for providing/directing "home team" liaison, resource ordering and technical support services from headquarters for the team in the field. 

 

Recommendation:  It is recommended that Ecology develop and publish standard operating and staffing procedures for a headquarters RSIC.  These procedures should include a checklist for the HSC, focused on consistent, clear communications with field responders and Ecology headquarters support and management staff.

 

Recommendation:  The SOSC and HSC should consider and discuss the activation of other contract cleanup resources needed to address oil in the river while ACOE resources and contractors are focused on the dam.

 

Recommendation:  All Washington State responders should receive DRILLTAC training prior to deployment. (Note: DRILLTRAC is the comprehensive training and competency program that is required of all Ecology staff.

 

Recommendation:  As soon as possible after a SOSC is on-scene at a response, an administrative support person should be dispatched to serve as UC recorder, command post coordinator and to assume other responsibilities as needed.

 

Recommendation:  As soon as WDOE staff arrives at the command post, they should establish the use of the ICS-211 check-in forms if they are not already in use, and maintain this practice until all have completed Demobilization forms.

 

Recommendation:  Caches of cleanup equipment, which are maintained by various companies along the Columbia River, should be identified and contracts established prior to being needed for spill response.

 

Actions:

• Space has been designated as our Headquarters Situation Room to be used for coordination at larger spills.  (This room was used during the initial phases and throughout the Dalco Pass spill response.)
• A Headquarters Support Coordinator has been established.  We have, to various degrees used the HSC on numerous drills, spills and incidents since The Dalles Spill.  Most recently the Dalco Pass spill.  
• All full-time SPPR personnel have received DRILLTRAC training specific to their assigned roles and have been regularly drilled in their respective positions, most recently at the Chelan Level IV drill.   
• ICS form 211s are regularly used at drills and were used throughout the Dalco Pass spill.   

 

Lesson:  The ACOE assessment report includes recommendations that ACOE:

• "Pre-stage boom at Bingen marina, Spring Creek Fish Hatchery and Dalles Boat Basin.
• Oil spill training of crews should include hands-on inland water oil spills training.
• Oil spill equipment should be staged and ready to be used
• [Develop the] Ability to perform an oil spill inventory [i.e. mass balance] earlier than 6 days into the event.
• Pre-stage containment boom on open trailers and absorbents on closed trailers.
• Deploy containment boom up and down stream of units during annual or other oil spill risk maintenance.
• Should evaluate the command and control process, communications and interactions with external entities,"

 

Recommendation:  Until an ACOE is capable of fielding an ICS trained regional or district incident management assistance team, WDOE should consider immediately deploying a full incident management team to maximize the potential for protecting State resources at risk whenever there is an incident at a facility.

 

Recommendation:  If the responsible party is unfamiliar with the operation of the Unified Command and standard ICS processes, it is critical that trained WDOE staff work within the incident management structure while maintaining standards and procedures.

 

Recommendation:   management should continue to be encouraged at the highest levels to purchase and warehouse response equipment at each of their dams and to ensure training for their on-site staff in the rapid and safe deployment of the cached response resources.

 

Recommendation:  If possible, WDOE should provide or recommend training for personnel at regional training sites accessible to the staff from the dams.

 

Recommendation:   management should be encouraged to reestablish the District Emergency Response Team (DERT) for rapid deployment of operational resources and mutual aid during incidents at dams.  Additionally District staff should be encouraged to develop a district incident management assistance team to take over command post functions, freeing the facilities staff for operational assignments.

 

Actions:

 

• We have provided the Corps with basic ICS training and have encouraged them to seek further training. We have also encouraged them to field a District Emergency Response Team for both response operations and filling ICS roles.
• The Corps has purchased some response equipment (booms/pads) and has deployed them during a number of smaller spills at The Dalles Project.  No large scale equipment purchases or pre-deployments have occurred.
• Other Corps Projects have recently conducting spill response training.  (Little Goose and Lower Monumental in October 2004)    

 

Lesson:  The WDOE Public Affairs staff needs to be contacted earlier and kept in the communications loop from the HQ office, with expectations clearly expressed.

 

Recommendation:  Joint Information Center (JIC) expectations and responsibilities should be clearly established and notification and deployment protocols should be developed and mutually approved.

 

Recommendation:  JIC personnel should be encouraged to contact other potential JIC members and develop protocols for working in a "virtual JIC" via email or designated web pages.

 

Recommendation:  WDOE Public Affairs staff should be trained in ICS before any field deployment.

Actions:

• The communications Workgroup of the Regional Response Team/Northwest Area Committee has recently been reactivated and expanded and is addressing off-site coordination issues.
• During the Dalco Passage Spill, Ecology Public Affairs staff supported by U.S. Coast Guard Personnel were involved in the spill from the initial response.  Ecology Public Affairs staff established a JIC at the Command Post and staffed the JIC throughout the response.
• Ecology Public Affairs staff received training in ICS under the DRILLTRAC Program.

 

Lesson: Both the Safety Officer and Liaison Officer positions should be thought of in the context of a unified response as requiring agency-specific staffing similar to the JIC staffing under the Information Officer.

 

Lesson: Liaison with Washington State government agencies and officials should be handled within the WDOE/SPPR senior staff as the specific contact dictates.

 

Lesson: When responding with the ACOE or other non-plan-holders where reimbursable funding is doubtful or subject to later litigation, WDOE staff is responsible for providing its own Logistics and Finance support in order to fulfill its environmental protection and investigation mandates.

 

Recommendation:  Designated State of Washington personnel should be assigned to work within the unified command Liaison and Safety offices, similar to the way the JIC works.  These positions would focus on issues, policies, mandates and communications specific to Washington.

 

Recommendation:  A designated State of Washington Safety Officer should be assigned to each incident, either functioning on-scene or remotely in conjunction with on-scene safety personnel.

 

Recommendation:  Safety of responders and the public should be the top priority and should be emphasized in any published policies or procedures and should frequently be revisited in communications with the deployed staff. 

 

Recommendation:  Policies concerning any approved participation of volunteers, NGO personnel, media representatives and other non-State personnel, or untrained State personnel, in field or command post operations, should be clearly addressed and published.  These published policies and procedures should be focused on the safety of all participants.

 

Recommendation:  Field personnel should be empowered to make whatever decisions are necessary in the field to protect the safety of responders and the public.

 

Recommendation:  If it is not already required, it is recommended that all potential WDOE field observers be certified as having received training in fixed-wing, helicopter and boating safety before being allowed to embark on any State-owned or State-leased vessels or aircraft. 

 

Recommendation:  A designated State of Washington Liaison Officer should be assigned to each incident, either functioning on-scene or remotely in conjunction with the on-scene Liaison Officer and staff.

 

Actions:

 

• The Liaison and Safety positions are now staffed by Ecology personnel as a regular part of drills and spills and Northwest Area Contingency Plan policy changes reflecting agency involvement is under development.
• Ecology responders worked in the Liaison position during the Dalco Pass spill response.     
• Safety is ALWAYS the top priority during any Ecology response of any size, complexity, and duration. Ecology provided Safety support throughout the Dalco Passage response including input into the initial Health and Safety Plan.
• Logistics support was provided by Ecology throughout the Dalco Passage operations. Ecology personnel have been training through the DRILLTRAC initiative to fill this role, and it was successfully implemented during the Dalco response.         

 

Lesson:  Other responders, including Federal and other state agencies, cannot relieve WDOE of its mandate to protect state waters, but must be informed of the requirement and the intent to fulfill that requirement within the Unified Command structure.

 

Lesson:  It is important that the SOSC and staff maintain a good working relationship with other members of the Unified Command and unified response.

 

Recommendation:  If budget and staffing allow, it would be best to respond early with a larger team to assist in initial setup and situation scoping.  As soon as it becomes clear that any staff is not needed, they can be released.  This overstaffing of the initial response can also be viewed as providing training opportunities for both new and experienced staff.

 

Recommendation:  If section chief and unit leader positions are to be filled, deputies should be assigned as soon as feasible.

 

Recommendation:  WDOE responders should be prepared to deal with less than ideal command posts environments, which may include having to provide their own food, lodging and transportation. 

 

Recommendation:  Unless space constraints require a command post shift, it is best to avoid this disruption if at all possible.

 

Actions:

 

• Since the completion of DRILLTRAC training, clearly defined roles and positions have been identified and assigned within the IMAT.  These roles and positions have been exercised at many drills and spills, most recently during the Level IV response to the Dalco Pass spill.   
• Deputy SOSC and Deputy EUL positions are now a regular part of our drills and IMAT responses.  Other deputy positions are filled on an as needed basis.
• The Headquarters Support Coordinator will assist the SOSC and other response staff deal with possible challenges within Unified Command by providing outside communications with other involved agencies at a higher management level.
• Ecology Command Staff have been directed to request a Planning Chief and Deputy Environmental Unit Leader whenever an Environmental Unit Leader is requested during an IMAT activation.
• Unified Command operated very effectively during the Dalco Passage Spill.  This is a direct result of training during DRILLTRAC and practicing roles and responsibilities during drills and exercises.            

 

Lesson:  Crucial information concerning PCB concerning provisions in the Model Toxics Act requiring action on releases of oil with >1ppm of PCB would have been important during the Dalles Project response and should be compiled and made available online for all WDOE responders.

 

Lesson: The concentration of specific (potentially toxic) components of released products may change with weathering, evaporation and natural dispersion/collection, and may differ dramatically from the information given on generic, or even specific, material safety data sheets (MSDS) or other analytical reports.

 

Recommendation:  Fact sheets concerning mandated action levels with appropriate State regulatory references should be compiled for selected toxic substances and hazardous materials, and should be made available in printed and online formats for State responders.  This information would supplement available generic MSDS or hazardous chemical database reports and would focus on specific Washington State concerns and mandates.

 

Recommendation:  If the spilled product is reported to contain any toxic substance, samples should be taken at the spill sites and if possible from the weathered product in the field. The samples should be transported for analysis at the earliest possible date to confirm the safety of responders and the public.  This is recommended regardless of the presence or absence of any "fingerprinting" concerns.

 

Actions:

 

• Part of the function of the HSC is to access technical information and pass it on to the SOSC during spills.  Additionally, the Safety Officer is responsible for early characterization of the spilled product to ensure that protective equipment and measures are adequate for the hazards encountered.
• During the Dalco Passage spill, oil samples were collected from the water to confirm the material identity and existing safety measures were validated.

 

Lesson:  Communications and computer equipment needed to send, receive and track critical response and status information was needed.

 

Lesson:  An easy and widely available access to the internet is needed for use by all WDOE field responders regardless of the location.

 

Recommendation:  Needed communications and computer equipment should be procured and deployed for use by field responders.  This equipment may include: laptop computers, combination printer-copier-scanner machines, data sticks, and appropriate mapping, photo handling and communications software.

 

Recommendation:  WDOE/SPPR should establish an account with a common ISP allowing dial-up access to the internet from any phone in the state.  Verizon-net, AT&T Worldnet, and AOL are examples of readily available dial-up ISPs presently used by other response groups.

 

Actions:

 

• New computers and support equipment was recently purchased for field response application and was used at the Dalco Passage spill to supplement the mobile command post.  This equipment was deployed early into the Dalco Passage spill and was instrumental to the functioning of the Command and Support operations.
• At the Dalco Passage spill, internet connectivity was made available through the command post provided by Tacoma Fire Department.  Remote access provisions are being researched by Ecology Spills staff.  
• John Williams and Steve Chan have been assigned IT positions on the IMAT.

 

 

Lesson:  A standard needs to be established for a WDOE reporting format, frequency and media.

 

Lesson:  Communications and reporting burdens on field responders should be minimized allow them to focus on the response and to take advantage of available resources at headquarters.

 

Recommendation:  Response notebooks (either WDOE issued or personal) should be used for as long as needed and can be used in lieu of an ICS 214a, provided that times and actions/ observations are consistently recorded, copies are given to the Documentation Unit and it is recognized that they become part of the public record.

 

Recommendation:  A single email account be established for the HSC which will be used for all communications and reporting by the field responders and be accessed by whoever has the HSC watch at headquarters. 

 

Recommendation:  The establishment of a separate in-house web page for the use of WDOE SPPR staff is recommended.  This could act as a remotely available situation status display for headquarters and other field offices and for personnel that may be called upon to relieve on-scene staff.

 

Recommendation:  The HSC or assigned RSIC staff should interact with the Spills Program webmaster to ensure public and in-house web pages are correct and up-to-date.

 

Recommendation:  A standard format for brief evening status reports should be developed (or use the ICS ExecSum report), and all responses should be required to submit this brief report at the end of each day.  These brief evening reports will be invaluable in conveying status to headquarters and in producing after-action reports.

 

Recommendation:  A standard format for after action reports, including lessons learned and recommended actions should be developed by SPPR staff.  Once this format is developed, it is recommended that a searchable database of these reports be maintained on line, with the ability to be interactively updated as actions are completed and further lessons surface. Samples records from the NOAA and Coast Guard spill histories databases are attached to this report in .pdf format for the Ashland Oil spill on the Ohio River and for some historic spills in Washington.  In reviewing these samples note the underlying database record format implicit in the specific fields of information entered.

 

Recommendation:  The HSC or assigned RSIC staff should interact with the Spills Program webmaster to ensure web pages are correct and up-to-date.

 

Actions:

 

• Ecology Spills program policy is to establish a web page as early as possible during significant spills.  A web page was established on day one of the Dalco Passage spill.