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                                                          EPA 903-R-00-007
                                                          PEMA AAR-00-003
              VIGILANT LION EXERCISE 
              VIGILANT LION EXERCISE 
              VIGILANT LION EXERCISE 
              VIGILANT LION EXERCISE     
                             (VL
                             (VL
                             (VL
                             (VL----99)
                                         99)
                                         99)
                                         99)    
                 After Action Report
                 After Action Report
                 After Action Report
                 After Action Report    
     
                           FT. INDIANTOWN GAP
                           FT. INDIANTOWN GAP
                           FT. INDIANTOWN GAP
                           FT. INDIANTOWN GAP    
                       ANNVILLE, PENNSYLVANIA
                       ANNVILLE, PENNSYLVANIA
                       ANNVILLE, PENNSYLVANIA
                       ANNVILLE, PENNSYLVANIA    
                        SEPTEMBER 29
                        SEPTEMBER 29
                        SEPTEMBER 29
                        SEPTEMBER 29----30, 1999
                                             30, 1999
                                             30, 1999
                                             30, 1999 
          
                       





 



Disclaimer:  

The observations in this report have been distilled from reports submitted by the exercise
evaluators, controllers and participants.   The exercise findings flow from the observations.   This
report has been circulated for review among the participating agencies, and their comments have
been incorporated to the extent that is practical.   The "lessons learned" and exercise findings are
the opinions of the report authors and do not necessarily reflect the policies of all the sponsoring
agencies.



 

Acknowledgements:  
 The Pennsylvania Emergency Management Agency (PEMA) wishes to acknowledge the 
contributions and participation of the following individuals and organizations to the planning and 
implementation of the exercise: 
 Environmental Team: Department of Energy's Steve Centore, Kathleen McIntyre, Alex Rebin, 
Lloyd Nelson Brookhaven National Laboratories; Jay Cook, Tom Black, Paul Evancoe, Office of 
Emergency Response, and Darryl Lankford, Bob Morrowski, Lou Palm, and Doug Boyd, ORISE 
provided excellent exercise planning, training and response resources.  The Pennsylvania 
Department of Environmental Protection's Emergency Response Program's Charlie High, Kerry 
Leib, Mark Schaffer, John Maher, Len Insalaco, and Dan Holler provided insight on day-to-day 
hazardous material response to build reliable timelines for the exercise.  The Pennsylvania 
Department of Environmental Protection Bureau of Radiation Protection's Randy Easton and 
Marty Vyienelo along with the US Environmental Protection Agency's Bill Belanger, who also 
spent numerous hours on this report, provided the radiation analysis and data for the isotopes 
simulated in the exercise.  Marty Powell, EPA WMD Coordinator provided invaluable 
environmental impact insight during the planning and execution of this exercise.   
 Emergency Management: The Federal Emergency Management Agency's Dave Hall and Henry 
Skozalek and DOE's Emergency Management Office, Pat Bjerke and Becky Watson, reviewed the 
consequence management issues and commented on impacts that this would cause to the local, 
state, and federal communities in this and the crisis management phases.  The Pennsylvania 
Emergency Management Agency's Bob Churchman, Joe Jordan, Norm Smith, John Bahnweg, 
Bob Long, Ed Burke, Mike Stamilio, Jack Rozman, Bob Broyles and supplied numerous hours 
of planning and operational expertise to ensure the exercise took place.  The Pennsylvania State
Fire Academy's Tim Dunkle, Pat Pauley, Rich Wessel, and Bob McCaa ensured that Incident/
Unified Command issues were thoroughly documented for future training and operational 
opportunities. PEMA and the State Fire Academy continue to reinforce "Vigilant Lion" Lessons 
Learned in internal and external WMD instructional events.   
 Local Responders: -The Lebanon County Emergency Management Agency's Clyde Miller (Dir.), 
Annette Smith (Dep. Dir.), Chris Miller, and John Wilson, coordinated all local efforts without 
which this exercise would never have happened.  Lebanon County Hazmat Team 50, Lickdale Fire 
Police, Annville Union Hose Co., and Richland Fire Companies coordinated efforts with the Ft. 
Indiantown Gap and Good Samaritan scenario responses.  Ft. Indiantown Gap's FD (military) 
Chief Bachman ensured that his unit was available for preliminary radiological training and rapid 
"cognizant" local initial fire response for the exercise.  Daryl Emrich, East Hanover Township 
EMC, provided local emergency management input. 
 Military:  The Military Support to Civil Authorities office under the direction of Colonel Richard 
Matason, Colonel Frank Sharr and Major Richard Dyke did a lot of leg work so that exercise 
players had the use of many of the post's best facilities that were made available for exercise 
players and exercise facilitators In addition, they, along with Lt. Colonel Xavier Stewart, Captains 
Charles Cuthbert and James Gerrity, coordinated and planned for the first full-field exercise 
participation of the 3rd Weapons Of Mass Destruction Civil Support Detachment (formally the 3rd 
Military Support Detachment [MSD] Rapid Assessment Initial Detection [RAID] element).  The 
Civil Air Patrol's Pennsylvania Wing's Majors Rich Gale and Warren Parks provided their 
outstanding training facilities for the two exercise planners training sessions and the Controller's 
Operations Center.  The Unites States Air Force's HAMMER ACE unit was well represented by 


                                                                                                    2



TSGT Tom Kinney and his staff. They were able to plan and work with the civilian Pennsylvania
Urban Search & Rescue communications component to operate the communication trouble desk
and field questions to troubleshoot all communications obstacles that arose during the exercise.
Law Enforcement/EOD: The FBI's Chris Rigopolous (Philadelphia Office) and Jeff Goebel
(Harrisburg Office) coordinated the field and main office planning and response activities. Those
activities then combined with the local and state response structure in an organized manner. Capt
Jeffrey Davis and Lt. Barry Reed Pennsylvania State Police, and Chief Jon Worley, Ft. Indiantown
Gap PD, should be commended for their traffic control, crime scene, and command and control
planning for the local and state law enforcement components. SSGT Ken Erickson, DOD
Indianhead, Sgt. Robert Shilling (City of Reading PD), Capt. Jim Grimm (Allentown FD), Mike
Baker FBI-Philadelphia and ATF's Chris Catone provided extensive technical assistance in the
Explosive Ordnance Disposal/Bomb Squad subject area.

Medical Team: The medical team created scenarios for Good Samaritan Hospital and a private
residence with contamination. Brenda Pittman (Lancaster County EMA), Joan Gill (Good
Samaritan Hospital), Louise Wennburg (Chester County EMA), and Chiquita Morrison (PA
Health) developed the victim's symptoms, medical play, and medical support functions that forced
medical responders and command staff to consider medical issues during the entire exercise.
Gloria Fluck (Ephrata Community Hospital), Denise Freeman (Lancaster County Hazmat), Duane
McClosky (Emergency Health Services Federation), and Linda Williams (PA Dept of Welfare)
provided valuable evaluations and observations. This is the first time public mental health issues
have been addressed in scenarios involving contamination. Critical Incident Stress Management
was not incorporated into the exercise however, there were Peer providers available to address any
issues. The medical planners, through their extraordinary labor, worked through the associated
problems and made it work. Good Samaritan Hospital EMT and First Aid Safety Patrol provided
"real-world" and scenario medical support for the pre-hospital and hospital portions of the
exercise.

Media Team: Linda Vizi (FBI), Karen Sitler & Sandy Roderick (DEP), John Maietta (DMVA),
Marko Bourne (PEMA) provided "real world" and "mock" interviews and press coordination
before, during, and after the exercise. The amount of live coverage that the event received is a
tribute to the hard work that this team performed.

Comfort Team: Cynthia Yearsley and the Salvation Army crew really outdid themselves. The
on-site beverages, meals, and snack food provided over the two days hit the spot. The two
canteens served the 100 observers, 300 first responders, and press corps/VIPs like it wasn't a field
exercise but an indoor event. Hats off to a top-notch chapter and organization!
Safety Team: Tom Dougherty, OSHA, Allentown Office and Rich Gale ensured that overall
safety procedures were followed throughout the exercise. The absence of any major or minor
injuries during the exercise can be attributed to the fine attention to detail.


If there are others who are not listed above, and or not identified in the After Action Report (AAR), the
developers sincerely apologize to those unintentionally omitted. It must be noted that not all agencies
submitted requested follow-up material that was to be included in this After Action Report. For items
that are agency specific, and that are not listed within this AAR,, it is recommended that you contact the
specific agency directly.



 

Manuscript Completed:  April, 2000 
Date Published: May 2000  
 Prepared by: 
Bill Belanger, EPA Region III  
Tom Hughes, PEMA 
Steve Centore, DOE Region I 
 The US Department of Energy's VL-99 After Action Report can be requested through: 
Steve Centore, US DOE Region 1, Emergency Response Coordinator, Brookhaven 
National Laboratory, 53 Bell Avenue, Upton NY 11973 or e-mail:  centore@bnl.gov 
 Abstract: 
 "Vigilant Lion", a two-day exercise sponsored by the Pennsylvania Emergency 
Management Agency (PEMA), in cooperation with the U.S. Department of Energy, 
involved emergency personnel in a mock Weapons of Mass Destruction (WMD) incident 
involving a simulated radiological material release.   This full-scale exercise involved 
more than 300 participants representing 40 local, state and federal emergency response 
agencies that were tasked with managing hazardous materials, explosive ordnance, 
emergency management, law enforcement and emergency medicine response activities. 
Except for the meetings in preparation for the exercise, many of these agencies had never 
worked together before.  
 Although the exercise revealed some minor problems in the overall coordination of 
exercise response actions, none had a detrimental effect on the exercise's overall 
execution.  The primary problems were with the implementation of a Unified Command 
at the individual site locations and with the lack of anyone designated to supervise the 
overall safety of the responders in dealing with a real incident of this kind.   There were 
other operational issues, which arose from people being unfamiliar with their counterparts 
at other levels of government, from the unfamiliar threats they had to address, and from 
artificiality imposed by the exercise logistics.  Interagency cooperation occurred but the 
associated sharing of information did not always take place in a timely manner, 
specifically in the Joint Operations Center and the Federal Radiological Monitoring and 
Assessment Center.  In some cases, a duplication of effort occurred which led to the 
unnecessary engagement of personnel and equipment use. 
 On broad overview, the exercise showed that the various local, county, state and federal 
agencies have the ability to deal with the terrorist incident that was simulated.   Each 
agency came to the exercise with capable and dedicated people who knew their jobs and 
did them well.  The exercise revealed a number of important "lessons learned" which 
should lead to a significantly strengthened ability to respond to a terrorist incident if the 
appropriate corrective measures are implemented. 




                                                                                             4



 

Table of Contents:                                                          Page Number 
                                                    
EXECUTIVE SUMMARY 6 
INTRODUCTION -                                                                   9 
 Needs 
              Assessment                                                         9 
 EXERCISE PLANNING 11 
 Exercise 
                Scope                                                           11 
 Logistics                                                                      12 
                
CONCEPT OF OPERATIONS 16 
 Overall 
               Objectives                                                       16 
 Simulation                                                                     16 
 EXERCISE DEVELOPMENT 17 
       Staff Exercise Development Training                                      17 
 Evaluation 
                    Training                                                    17 
 Player 
              Training 
                                                                                18 
       Key Decision-Maker Tabletop Exercise                                     18 
 EXERCISE SCENARIO 18 
       The First Day                                                            18 
       The Second Day                                                           19 
 Exercise 
                Results 
                                                                                20 
 EXERCISE EXPECTATIONS 20 
 Local 
             Response 
                                                                                21 
 State 
            Response                                                            21 
 Federal 
               Response                                                         22 
 OBSERVATIONS 22 
 Hospital 
                                                                                22 
       Ft. Indiantown Gap                                                       24 
               Incident Command                                                 24 
               Incident Action Plan/Documentation                               26 
               Unified Command                                                  29 
               Command Post Facilities                                          30 
               Joint Operations Center                                          31 
               Depth of Coverage                                                32 
               Site Safety                                                      32 
               Survey Techniques                                                34 
               Federal Radiological Monitoring & Assessment Center              35 
               Traffic Control Points                                           35 
               Communication 36 
               Communication Technical Support                                  37 
               Terminology 38 
               Criminal Investigations                                          38 
               Continuity of Municipal Operations                               38 
               Scene Safety (Exercise Play)                                     39 
               Evidence Collection/Planning                                     39 
               Press 39 
               Bomb Squad/Explosive Ordnance                                    40 
               Exercise Preparation Comments 42 
CONCLUSION                                                                      43 
ANNEXES                                                                    46-128 


                                                                                            5



Executive Summary

 "Vigilant Lion," a two-day exercise sponsored by the Pennsylvania Emergency Management
Agency (PEMA), in cooperation with the U.S. Department of Energy, involved emergency
personnel in a mock Weapons of Mass Destruction (WMD) incident involving a simulated
radiological material release. 

This full-scale exercise involved more than 300 participants representing 40 local, state and
federal emergency response agencies that were tasked with managing hazardous materials,
explosive ordnance, emergency management, law enforcement and emergency medicine response
activities. Except for the meetings in preparation for the exercise, many of these agencies had
never worked together before.  In particular, the county and local teams had not worked directly
with their counterparts from the federal agencies.   In addition, the radiological threat was
somewhat unfamiliar to the hazardous material teams, and there was a need to address the threat
of explosives and booby traps, which were unfamiliar to the radiation experts.  Overall, everyone
was forced into an unfamiliar threat at one point or another.  This provided an opportunity for a
significant learning experience, and also accurately reflects the situation that would occur if a real
incident were to happen. 

The exercise included full-scale response to a simulated incident at a fictitious county in
Pennsylvania (Fig County.)  Two "crime scenes" were simulated in real buildings, the Fig County
office building, and the home of the terrorist. The office building was a two story commercial-
style building which was vacant at the time of the exercise.   The scenario called for a  dispersal
device which spread strontium-90 through the ventilation system.   After several days, "victims"
began to show up at a local hospital with non-specific symptoms.  The hope was that the hospital
personnel would make the connection that all these people worked in the same building.

The second location was the "home" of the terrorist.   This building, which was also unused base
housing, was darkened and fitted with dummy grenades, trip wires, and a simulated bomb.   A
small but real sealed radiation source (Na-22) was included in the "bomb".   This gave the
responders practice in dealing with a real radiation source in simulated but realistic hazardous
conditions.   The explosives experts on the response team were required to use survey meters to
find the bomb in the darkened house.  A radiation safety officer, provided by EPA, assured that
the entry team did not receive significant radiation exposure during this activity.

 In both cases, entries were made using actual protective clothing and under realistic conditions. 
Six cottages were rented to simulate residences that included family "members" and property,
which needed to be interviewed and surveyed immediately.  Exercise planners designed emotional
and physical problems into the exercise to simulate events that would be encountered in a real
event. 

Exercise play involved the activation of emergency operations centers and the deployment of
personnel and air and ground assets from all levels of government.   Vigilant Lion also involved

                                                                                                 6



 the Department of Energy's Radiological Assistance Program (2 teams) and the Pennsylvania
National Guard's 3rd Weapons Of Mass Destruction Civil Support Detachment (formally the 3rd Military
Support Detachment [MSD] Rapid Assessment Initial Detection [RAID] element).   The 3rd WMD CSD
is one of ten federally mandated teams responsible for supporting local and state emergency
response to incidents involving weapons of mass destruction.  This was the first large-scale, joint
agency training exercise that the 3rd CSD actively participated in.  Lebanon County EMA and the
Pennsylvania Department of Environmental Resources provided personnel from their Emergency
Response Team Program and the Bureau of Radiation Protection responded on scene with their
Emergency Response cell.  The Pennsylvania State Police provided on site security and crime
scene expertise.  The Environmental Protection Agency provided a Federal OSC, their Site
Assessment and Technical Assistance (SATA) team and an EPA representative for the FRMAC /
JOC.  The planning and preparation for Vigilant Lion took more than nine months and required
participants to undergo extensive, specialized nuclear, biological and chemical training.

Prior to the exercise, each participating agency developed its own individual objectives to be
accomplished and performance measures for its response to the incident.   Evaluation of these
individual Agency objectives is not included in this report.   It is left to the individual Agencies to
assess their individual performance and any need for improvement.  Instead, this report will focus
on the overall exercise objectives in terms of overall response effectiveness and coordination and
various activities as a whole.  

The exercise revealed some problems in the overall coordination of the response.  The primary
problems were with the implementation of a Unified Command at the individual site locations and
the lack of a designated individual to supervise the overall safety of the responders in dealing with
a real incident of this kind.   There were other operational issues that arose from people being
unfamiliar with their counterparts at other levels of government, from the unfamiliar threats they
had to address, and from artificiality imposed by exercise logistics.  Early on, the interagency
communication and coordination was very good, however, associated sharing of information did
not always take place in a timely manner. 

On a broader scale, the exercise showed that the various local, county, state and federal agencies
have the ability to deal with the terrorist incident that was simulated.   Each agency came to the
exercise with capable and dedicated people who knew their jobs and did them well.  

The exercise revealed the following lessons learned. The principal lessons are:

The Joint Operations Center (JOC) was activated on Day 2 of the exercise.  In theory, this
becomes a group of key decision-making representatives from the main response agencies whose
function is to coordinate the response and to plan at the strategic level.  The unified command
structure, which would be established early in the incident, retains the responsibility to carry out
tactical activities required to bring the event to closure.  During this exercise this concept did not
work as designed.  Upon activation of the JOC, the unified command that had already been
established in the field was largely ignored as officials in the JOC began to communicate directly
with their personnel in the field.  
                                                                                              7



Additionally, the coordination between agencies located in the JOC began to deteriorate as the
law enforcement effort began to focus on the apprehension of the perpetrators.  The information
flow tended toward direct communication between agency representatives as opposed to all
representatives within the JOC sending information to the FRMAC and Unified Command
Structures.  This lack of coordination became most noticeable on the afternoon of the second day
when actions directed along law enforcement lines led to difficulty in attempts to discuss public
safety issues.   These issues include evacuation of civilians, site safety considerations, EMS
support, field interviews and survey, and decontamination procedures.  This problem did not flow
from any particular agency or player, it was simply a symptom of two different response
philosophies.   There is a need to examine these differences in response philosophy and to develop
a common framework that is comfortable for both law enforcement and HAZMAT responders.

The presence of law enforcement people on a crime scene (as opposed to HAZMAT responders
on a spill scene) also made it  necessary for responders to carry credentials in order to move in
and out of the affected area.   Such credentials would be essential in a real incident.  There is a
need for law enforcement and other response organizations to work closely with hazardous
materials response organizations on a more regular basis.   Law enforcement personnel have a
responsibility to respond to the criminal aspect of the incident, are invaluable in securing the
scene, and can provide protection from terrorist threat to the HAZMAT responders.   
Conversely, the HAZMAT response element can protect law enforcement personnel from dangers
from chemical, biological and radiological threats.   The team is complete only when both law
enforcement and HAZMAT responders  understand the responsibilities of the other and the
contributions that each makes to the overall response.

While the crisis management activities are very important at a WMD event, consequence
management, as it relates to public safety, cannot be ignored.  There are many organizations and
political leaders that have a legal responsibility to the public at an incident scene. All response
organizations must work cohesively if there is to be a successful outcome.  Even though a
considerable amount of public safety resources were available through the county or state
response systems, the JOC relied primarily on federal resources.  Training in the Incident
Command System, a clear knowledge of other response agency's capabilities, as well as clearly
understanding the needed relationships in a crisis management/consequence management incident,
is the key to an efficient, coordinated response. 

There needs to be a designated official at the site of the response activity who is responsible for
overall management of site safety.  During the physical response activity, response personnel were
not wearing a consistent set of personal protective equipment.  There seemed to be no one who
was making careful decisions on the protection of personnel for all response personnel.  Instead,
each participating agency made its own decisions, which resulted in inconsistencies.  The most
glaring example of these inconsistencies was when one team surveyed the exterior of the Fig
County building in street clothed while another was in fully encapsulated suits (Level A.)



                                                                                              8



The local response organizations have competent and dedicated people, many of whom are
volunteers.  It is not reasonable to expect these volunteers to attend extensive schooling on every
aspect of chemical, biological and radiological response.   In addition, in a terrorist situation, the
responders themselves may become targets.  There needs to be a rapid response capability to
assist the local responders when the problem goes beyond their normal training and experience.
There is a need for a rapid assistance mechanism to assist the first responders in assessing the
situation, and a rapid assistance mechanism to get technical help to the scene very quickly after a
threat is identified.   This is as much to protect the health of the responders as it is to address the
threat.  The newly commissioned CSD can supply much of this needed mechanism.   In addition,
there is a need for a rapidly available expert consultation service.  A good model for this service
would be the DOE funded REAC/TS function at Oak Ridge, TN.    This service is geared to
provide immediate medical consultation in the event of a nuclear accident.  Similar capabilities for
chemical and biological threats would be quite valuable, and such an assistance service should not
be restricted to medical aspects of the problem.  Responders need a central place to call for
immediate advice before they enter a potentially life threatening situation. 

In the Vigilant Lion Exercise there was significant interaction with the news media.  This was
intended to allow the news media to provide coverage of the exercise itself and to allow them to
see how an actual incident would be handled.   In future exercises and definitely for all actual
events and/or incidents, a large staff of public information officers will be needed to address the
significant number of media issues and requests for information.  We placed the simulated media
interactions late in the exercise after a Joint Information Center had been established.   However
we realized that much of the media coverage would occur during the initial response, and we did
not simulate this press coverage.   Instead, reporters covering the exercise were allowed access to
first response personnel. 

Overall, this exercise must be viewed as a success because of the problems that were identified
and the learning experience it provided..  The fact that everything did not go as smoothly as
planned provided many important lessons for the participating agencies.  While it is apparent from
the exercise that the capability to deal with a radiological terrorist event is in place, there is room
for improvement in the coordination of the available resources.   The Vigilant Lion Exercise
Report, available soon from the Pennsylvania Emergency Management Agency and EPA Region
III, provides many recommendations which should improve the response capability to actual
terrorist incidents.  









                                                                                              8a



 

INTRODUCTION  
 Needs Assessment:   
 
           The United States is fortunate to have been spared the extensive terrorist activity 
that occurs in some parts of the world.   The principle incidents have been the World 
Trade Center bombing, the Oklahoma City bombing and the Bomb at the Olympics in 
Atlanta.  While this comparative lack of terrorist activity is a blessing, it also means that 
we in the United States are relatively inexperienced at dealing with the problem.  Our 
experience is mostly in handling accidents and natural disasters, not deliberate acts of 
terrorism.    
 
           While all the skills that are used to address accidents and natural disasters are also 
useful in dealing with the results of a terrorist act, there are some aspects, which are 
unique.  These include the need for technical experts in chemical, nuclear and biological 
threats, and the need to deal with the law enforcement aspects of a deliberate act.   In 
addition, a terrorist act is a deliberate attempt to cause harm.   The threat may be a 
combined chemical/ biological/ nuclear threat, or a threat from explosive devices, and the 
hazard may be deliberately concealed in order to cause more casualties.   Working in such 
an environment requires a close coordination between many disparate technical 
disciplines as well as among agencies at all levels of government.  This level of 
coordination is seldom required for accidents and natural disasters.  This need for 
coordination is central to the Vigilant Lion Exercise.   
 
           While actual terrorist acts are rare in the U.S., the potential threat cannot be 
ignored.  Worldwide, most acts have involved simple explosives, the notable exception 
being the Sarin subway attack in Japan.   From our limited experience, and drawing on 
the experience of less fortunate countries where terrorism has become common, we can 
build a basis for the skills and resources which would be needed to address a terrorist 
threat.   
 
           Should a terrorist act strike the streets or rural areas of America, the first few 
minutes will be critical. The first people on the scene would be the local emergency 
medical services, firefighters and police. The situation would be chaotic and dangerous. 
For many injured victims, what these responders do in those first minutes could mean the 
difference between life and death.  There is also a threat to these first responders, either 
from the primary terrorist act, or in the event the terrorist makes the responders a target.  
Thus there is a need to consider risks to the responders as well as risks to the public at 
large. 
 
           For nearly a year prior to the exercise, PEMA had been working with other 
agencies to help state and local agencies prepare to respond to terrorist incidents.  DOD 
had delivered the Domestic Preparedness Training Program to the cities of Philadelphia 
and Pittsburgh and PEMA had delivered an NBC Phase I & II course and a 
nuclear/radiological terrorism workshop to the potential exercise participants.  In the 


                                                                                                  9



 

course of this preparation, we determined that one major element lacking in Domestic 
Preparedness training was the adequate addressing of radiological material as a potential 
threat.  In addition, historically, Explosive Ordnance has not been simulated in NBC 
exercises to any significant extent.   
 
        Finally, a new response element has been recently added to the available 
resources.  The Pennsylvania National Guard's 3rd Weapons Of Mass Destruction Civil 
Support Detachment (formally the 3rd Military Support Detachment [MSD] Rapid Assessment 
Initial Detection [RAID] element).   The 3rd CSD is one of ten federally mandated teams 
responsible for supporting local and state emergency response to incidents involving 
weapons of mass destruction.  This was the first joint agency, large scale training exercise 
that the 3rd CSD actively participated in.  They had little experience in dealing with the 
broad scope of support available from the local, state and federal agencies and none of 
these agencies had experience with the 3rd CSD.   The exercise provided the opportunity 
to integrate this new resource into the response structure in the United States.  
Unfortunately, at the time of the exercise the 3rd CSD did not have their $1.5 million 2-
person Unified Command Suite, which capabilities include KU Band, HF, UHF, VHF, 
HF Wideband, and UHF Satcom (.06 MHz  800 MHz) frequencies. 
 In summary, the factors that led to the development of this exercise are:  
 -   WMD training courses that were available did not adequately address nuclear/ 
radiological issues.  The concentration was on chemical threats.  Medical issues were also 
inadequately treated. 
 -  Areas of responsibilities for radiological response were not completely clear, 
especially with the addition of the RAID element.  The existing emergency response 
plans were not designed around a terrorist threat and it was not clear how well they were 
suited to this unique problem. 
 There had been few opportunities for a full-scale exercise involving a large number of 
participants and agencies from all levels of government.   There was a plan on paper and a 
few tabletop exercises had been conducted by various county and state agencies.  What 
we did not know is how the various agencies, in a large-scale, field exercise environment, 
would perform when equipment was mobilized and people actually had to work together 
with other response and non-response personnel that they normally do not work with.  
 -  Because of a canceled exercise in another location, resources were available to 
conduct the exercise. 







                                                                                            10



 

EXERCISE PLANNING  
 Scope of the exercise:  
 
        The exercise included full-scale response to a simulated incident at a fictitious 
county in Pennsylvania (Fig County).  Two "crime scenes" were simulated.   This was 
done using unused buildings at Fort Indiantown Gap.  The Fig County office building was 
a two-story brick building that was temporarily unoccupied at the time of the exercise.  
The home of the terrorist was simulated in base housing.   In both cases, entries were 
made using actual protective clothing and under real-time conditions.  Six cottages were 
set-up as residences so that surveys and interviews would have to be performed.  Most of 
the physical problems, which would be encountered in a real event, were included in the 
exercise.   Realistic dispersion devices and booby traps were set to challenge the 
participants with a realistic situation. 
 
        This exercise was designed to test the concepts and procedures required for local, 
county, state, and federal government agencies to respond to a weapon of mass 
destruction (WMD) event in the Commonwealth of Pennsylvania.  The Vigilant Lion 
exercise concentrated on local response, notifications, crisis management, consequence 
management, criminal (terrorist) investigations, and interagency coordination and 
communication. 
 
        Prior to the exercise, each participating agency developed its individual objectives 
to be accomplished and performance measures for its response to the incident.   
Evaluation of these individual Agency objectives is not included in this report.   It is left 
to the individual Agencies to assess their individual performance and any need for 
improvement.  Instead, this report will focus on the overall exercise objectives in terms of 
overall response effectiveness and coordination and various activities as a whole.  
         This full-scale exercise involved more than 300 participants representing 40 local, 
state and federal emergency response agencies that were tasked with managing hazardous 
materials, explosive ordnance, emergency management, law enforcement and emergency 
medicine response activities. Except for the meetings in preparation for the exercise, 
many of these agencies had never worked together before.  In addition, the radiological 
threat was somewhat unfamiliar to the hazardous material teams, and there was a need to 
address the threat of explosives and booby traps, which were unfamiliar to the radiation 
experts.  This provided an opportunity for a significant learning experience, and also 
accurately reflects the situation that would occur if a real incident were to happen.  
 






                                                                                           11



 

Logistics: 
 Location: 
 
        This exercise was the first large-scale civilian counter-terrorism exercise where 
terrorist response was realistically simulated.   In addition, a number of participating 
agencies had never worked together to this extent and knew little of each other's mission 
and capabilities.  Knowing that the exercise would involve a large number of responders 
converging on one area, we wanted to make sure that we had a big enough "play area" 
that would suit our exercise needs but not pose safety issues to the players or the general 
public.   At first, some of the agencies were in favor of conducting this exercise in the 
City of Hershey/Derry Township, an area with a population of 19,000.  The state police 
academy and a major hospital were in close proximity.  However, the needed approvals 
would have been quite difficult.  In addition, conducting a large-scale realistic exercise in 
a public setting would have generated significant public concern.  There was a real 
possibility that the 911 lines could be tied up with people inquiring about the exercise. 
After considering the issues involved, we decided against holding an exercise as large and 
complex as this in a heavily populated area.  
 
        It was finally decided that we would approach Ft. Indiantown Gap Military 
Reservation, the home of the 3rd Civil Support Detachment, to hold this exercise. A two-
story, brick building, unoccupied at the time due to a change of command (the post had 
recently been turned over to the National Guard and the state was handling the paperwork 
to accept ownership), was obtained.  This building simulated the 550-employee FIG 
city/county office building.  The selected building proved to be an excellent location as 
the incident was more manageable in that there was limited interruption, disruption, 
distraction, or conflict with the civilian community.  Since Lebanon County EMA, based 
in the City of Lebanon, was participating, we asked them to invite the Good Samaritan 
Hospital and associated EMS units.  The timing could not have been better.  The Good 
Samaritan Hospital, City of Lebanon had just completed construction on a new hazardous 
material wing that was designed to care for multiple chemically and/or radiologically 
injured or contaminated victims and wanted to test their in-house site security protocols 
and the facility's effectiveness to care for these individuals in the event of a hazardous 
material incident.   
 Agreements:  
 
        Mutual Aid/Assistance agreements were identified and agreed upon early on in 
the exercise planning stages.  Issues such as overtime, time off, union involvement, were 
resolved by each participating agency. 







                                                                                              12



 

Communication:   
         Communication flexibility, security, and compatibility were issues that faced 
exercise organizers but those issues were surprisingly resolved rather quickly.  It was 
necessary for the exercise controllers and evaluators to communicate effectively so those 
exercise objectives could be evaluated without restricting exercise flow and play.  
HAMMER ACE, the United States Air Force's contingency communication package, 
based at Air Mobility Command's Headquarters, Scott AFB, Illinois, was contacted by 
DOE RAP Region 1 to see if they could support the communication needs and to 
technically assist communication technicians assigned to the exercise.  HAMMER Ace 
provided fourteen encrypted VHF Motorola Saber handheld radios, one base station and 
one VHF repeater to support the RAP Region 1 & 2 communication needs.  They were 
able to use one of the pre-approved US and Providence allocated frequencies for 
HAMMER ACE missions.  The Pennsylvania Urban Search and Rescue Task Force (PA 
TF-1) provided nineteen UHF Motorola HT-1000 hand-held radios with six available 
frequencies and two UHF Motorola repeaters for use by safety, controllers, evaluators, 
and the invited press. 
 Feeding:   
 
        A contract was negotiated between the Lebanon County Emergency Management 
Agency and the FIG Community Club for two lunches.  These lunches were provided 
through a PEMA grant and were to feed the volunteer participants and LEMA personnel. 
State and federal agencies agreed to pay the travel costs of their participating personnel. 
 Documentation [Video, Still Pictures, Written]:  
 
        DOE Region 1 provided two videographers to tape exercise activities on both 
days.  DOE Region 1 produced a 20-minute radiological response training film of the 
exercise to be used for first responder training.  The Federal Emergency Management 
Agency (FEMA) will be using this tape during the FEMA S302 Advanced Radiological 
Incident Operations (ARIO) Course, June 11-16, 2000, at FEMA's Mount Weather 
Emergency Assistance Center, Bluemont (Berryville), Virginia. 
 Media Exercise Coverage:   
 
        The exercise design team wanted to provide the media the access to adequately 
cover the exercise as it unfolded.  A Press Kit was put together and two press briefings 
were held, one two weeks prior, and one at 9:30 a.m. on day one of the exercise.  The 
Department of Military and Veteran Affairs took the lead on coordinating the briefing in 
the VIP/Press Building established for the exercise.  Before the response activities were 
initiated at Ft. Indiantown Gap, the media pool were taken through the "FIG City/County" 
Office building to view first-hand what the responders were going to be facing.  They 
were then taken to a safe distance, under tentage, to view the initial response activities.  
PSP participated in a live news briefing/interview on Day 1 with Reading, PA, radio 
station WEEU, 830AM. 

                                                                                            13



 

 
         Two media information meeting dates were established.  It was decided that the 
PEMA Press Secretary would take the lead on the dissemination of preliminary 
information regarding the exercise.  PEMA Operations and Training designed the various 
press releases, which were then approved by PEMA's Press Secretary.  Due to the 
unforeseen "real world" hurricane events that occurred on day one of the exercise, the 
Pennsylvania's Department of Military and Veteran Affairs Press Secretary took the lead 
for on-site arrangements to ensure the media had the information that they needed to 
adequately describe the unfolding event.  The Pennsylvania Department of Environmental 
Protection provided two working PIO "players" for both days.   
 
         Eight television crews, ten print media observed and reported on the exercise to 
include a team of reporters from Sweden.  Three stations provided live noontime 
coverage of the event on the first day.  One radio station in the City of Reading did a live 
interview with the PA State Police.  Additional information releases were mailed or e-
mailed to numerous emergency management, environmental response, military, fire, law 
enforcement and medical publications throughout the United States.   Media briefing 
times were set and first-responder spokesmen were identified to assist the media 
coverage.  A few agencies provided media players while other agencies provided press 
representatives to cover the exercise event itself. 
 Role-Players:   
 
         Lancaster County EMA and Civil Air Patrol's Pennsylvania Wing were asked to 
find "actors" to be used as city/county employees and family members for two of the 
scenarios.  Both organizations were able to provide them plus injects for the family 
members. 
 Props:   
 
         During the exercise development course participants found out how sensitive it is 
to have an agency make an exercise "device."  Participants feared that if they made the 
device, it would than become "classified" items, and would not be available for exercise 
use.  FBI, DOE, and DOD controllers resolved this issue so that a Radiological Dispersal 
Device (RDD) would be available for hazardous material team and explosive ordnance 
disposal recognition and play. 
 Air Support:  
 
         DMVA, CAP, DOE Region 1 and DOE HQ coordinated the air logistic 
coordination for the two Aerial Measurement Assets (Beechcraft B-200 and Bell 412) to 
operate in FIG airspace in and around the exercise play area. 
 Staffing:   
 


                                                                                          14



 

        Each organization provided at least one controller and one evaluator to support the 
exercise oversight.  All controllers were on one radio frequency and the evaluators on 
another.  Exercise support from PEMA staff was limited due to the Hurricanes Dennis 
and Floyd staff commitments.  The Commonwealth of Pennsylvania was granted three 
Presidential Emergency Declarations through FEMA that in turn led to the opening of one 
Disaster Field Office and seven Disaster Recovery Centers in fifteen counties.  At one 
point in time, there was a serious threat that PEMA might cancel the exercise.  However, 
the PEMA Director agreed to let the exercise move forward with the limited amount of 
PEMA staffing so that other participating agencies would not lose this excellent 
opportunity to test their WMD response capabilities. 
         
Exercise Support Staff Credentials:  
 
        Each agency provided a copy of their ID tags so that the Pennsylvania State Police 
and Ft. Indiantown Gap Police Department had a copy for security purposes.  In a major 
incident, you would not have the luxury to do this but we needed this for safety reasons.  
Controllers included breach of security injects to keep the security net honest. 
 Waivers for Volunteers:  
 
        When Ft. Indiantown Gap was under federal ownership, a waiver was required for 
volunteers to participate in exercises on post.  The wording was slanted more towards 
soldiers and not emergency volunteers.  Requests were made to the state agencies to find 
out who the agency's controllers, evaluators, players, and media personnel would be to 
provide a "duly enrolled" roster to the post commander's exercise designee.  Each 
agency's legal counsel reviewed civil liability and worker's compensation issues.  
 Facility Usage:  
 
        Once the scenario was written, and the exercise play was formulated, exercise 
planners needed to plan for pre-exercise briefings and enough buildings to accommodate 
the anticipated building requests from players.  Exercise planners had to do this in 
advance as to lessen the daily workload on the post's Directorate of Logistics.  A total of 
15 buildings were made available to the exercise players, controllers, evaluators, and 
VIPs/Press. 
         
Exercise Constraints:  
 
        The Ft. Indiantown Gap leadership wanted to make sure that all buildings were 
turned back to the post in good condition.  No incendiary devices were allowed and no 
damage could result from their use, e.g. knocking in doors, breaking windows for entry, 
etc.  In addition, exercise planners needed to demonstrate to the post commander what 
security and traffic flow planning measures were in place.  It was agreed that Rte 26, 
Fisher Avenue, would be shutdown no earlier than 9:00 A.M and no later than 3:00 P.M. 
as to not impede post employees from getting to or leaving their place of employment. 
Exercise planners also needed to notify major employers and the nearest residence outside 

                                                                                           15



 

the post that this exercise would be taking place.  The township officials adjacent to the 
post were also notified and participated in the exercise. 
 Budget:  
 
        Originally, this exercise was scheduled to occur elsewhere in the northeast.  After 
it appeared that some insurmountable logistical issues could not be resolved, the exercise 
was cancelled.  DOE RAP Region 1 approached the Pennsylvania Emergency 
Management Agency to see if the Commonwealth would be agreeable to host the exercise 
in Pennsylvania if financial arrangements could be agreed to.  A few of the state agencies 
and the Lebanon County Emergency Management Agency thought that this would be a 
great opportunity to exercise many facets of the emergency management and radiological 
protection system components, therefore, they agreed to pursue internal avenues to 
conduct the exercise.  DOE Region 1 was able to fund three exercise-training sessions 
(Exercise Design, Exercise Controller/Evaluator, and Search Response Team).  
Associated per diem and lodging costs were paid by course attendees' agencies was more 
palatable than one agency bearing all the costs.  In addition, DOE Region 1 funded some 
of the necessary props (exercise identification caps, video capture, threat assessment, 
building rental, communication support, and Aerial Measurement System flight time). 
 Concept of Operations: 
 Objectives - Overall: 
 
        Each participating organization was asked to provide objectives prior to the 
ORISE Exercise Design Course that was presented April 6-8, 1999, at the Pennsylvania 
Civil Air Patrol Wing Headquarters building, Ft. Indiantown Gap, Annville, 
Pennsylvania.  The exercise objectives list, in its entirety, can be viewed in Annex B.   
The exercise scenario and framework was then built around those objectives to ensure 
that each agency had an opportunity to play out and evaluate those objectives. 
 Simulation: 
 
        Exercise designers did not want to limit the scope to a tabletop demonstration.  
They all wanted an exercise, which would involve full-field mobilization of assets in as 
realistic, a situation as was possible.  To do this, a field setting was chosen which would 
allow for realistic exercise play. The exercise included full-dress response to a simulated 
incident at a fictitious county in Pennsylvania (Fig County.)  Two "crime scenes" were 
simulated in real buildings, the Fig County office building, and the home of the terrorist.  
 In both cases, entries were made using realistic protective clothing and under realistic 
conditions. Most of the physical problems, which would be encountered in a real event, 
were included in the exercise.  
 Exercise play involved the activation of emergency operations centers and the 
deployment of personnel and air and ground assets from all levels of government.   


                                                                                            16



 

Vigilant Lion also involved the Department of Energy's Radiological Assistance Program 
(RAP) and the Pennsylvania National Guard's 3rd CSD.   Very few notifications and 
response times were simulated.  The evaluators wanted to confirm that estimated times in 
the exercise time line were accurate. All participating agencies wanted a good template 
for planning and checklist purposes for a WMD response to back to their own 
organizations. 
 Exercise Development: 
 Exercise Development Staff Training: 
 
       Exercise Design training was supplied by the Department of Energy (DOE) for the 
exercise development team.  A list of the individuals on the design team and who 
contributed to the development of the exercise are listed on page 43.  The DOE Exercise 
Design Course was conducted by Oak Ridge Institute for Science and Education (ORISE) 
and built on what the exercise design team had put together prior to the course.  The 
purpose of this course was to train exercise developers on their responsibilities and to 
provide the basic understanding and skills necessary to develop an emergency 
management/ preparedness exercise.  The training focused on the exercise requirements, 
and the design, development, conduct, and evaluation of a full participation exercise.  
Exercise developers were than able to develop and integrate the components of an 
exercise package.   During the course, attendees developed the exercise purpose, scope, 
objectives, limitations, prerequisites, scenario and formulated a time line.  This training 
greatly improved the quality of the exercise and we recommend it for others planning an 
exercise of this scope and complexity. 
 Evaluator Training:  
 
       On August 11-12, DOE Oak Ridge Institute for Science and Education (ORISE) 
provided a two-day exercise Controller and Evaluator course that culminated with a 
Leadership Tabletop Exercise.  The first day discussed the evaluation and control 
components.  It set the groundwork for the development of exercise evaluation criteria, 
the evaluation organization, and the proactive determination of the final report form.  In 
addition, the attendees were able to identify and develop the control organization, 
simulations, and control logistics.  Attendees refined the exercise objectives and Master 
Scenario Events List (MSEL), initiated formalization of Mission Essential Task Listings 
(MTEL) items, and prepared for the Leadership Tabletop.  Prior to this course, 
participating agencies were requested to bring key decision-makers to this tabletop 
exercise.  Participating agency key decision-makers were provided two scenarios: one 
chemical and the other radiological.  It was decided to provide two scenarios, closely 
paralleled to our scenario, but not too close as to "tip our hand" on the actual scenario 
developed.  DOE ORISE did an excellent job in the facilitation of the two tabletop 
exercises which provided the future Vigilant Lion Exercise Evaluators and Controllers an 
insight on what areas needed to be more defined and what areas would be potential 
bottlenecks. 


                                                                                              17



 

 Player training: 
 
       The exercise involved over 300 players from over 40 different organizations.  The 
players included a wide variety of well-developed skill levels in a wide variety of fields 
including hazardous material response, law enforcement, bomb disposal, health physics 
and radiation safety, biological weapons, and operations and command.   PEMA held 
training sessions for first responders on basic radiation response, though these sessions 
were not given specifically for this exercise and were available to responders statewide.  
This was desirable because the exercise would be primarily radiological in nature and 
local response teams are typically not trained in depth on radiation.  For most players, no 
exercise-specific training was provided.  We anticipated that the training they already had 
would be sufficient.   Key decision-makers from each agency attended a tabletop pre-
exercise described below.  If there were to be a problem because of inadequate player 
training, it would become a lesson learned from the exercise.  It would demonstrate a 
weakness in our ability to deal with terrorism and would need to be remedied. 
  Key decision-makers table top pre-exercise: 
 
       A tabletop exercise for the key decision-makers was held on August 12, 1999.  
This session was intended to facilitate the exercise coordination when the field exercise 
was conducted in September.  There was no real effort to segregate the players from the 
exercise planners for this tabletop exercise.  The only objective was to be sure that each 
participating agency knew its role in relation to the roles of the other agencies.  The intent 
was to avoid unnecessary confusion at the field exercise. Had this pre-exercise tabletop 
not been held, the difficulties inherent in establishing agency coordination may have 
prevented many of the other exercise objectives from being achieved. 
 Exercise Scenario: (Full Scenario  Annex C) 
 The First Day: 
 The following sequence of events was developed as the exercise scenario: 
 
       On Monday evening, September 27th, a disgruntled ex-employee places a 
radioactive dispersal device on the Fig County Office building's HVACC intake vent 
located on the roof (Building 19-76).  Approximately 550 Fig county and city employees 
work in this two-story building.  This device dispersed radioactive material throughout 
the building through the use of a small fan connected to a timer.  Fig City has an 
estimated population of 650,000 and has two trauma hospitals. 
 
       By Wednesday, September 29th, at approximately 4:00 p.m., office workers from 
the Fig County office building are arriving at the local hospitals (Good Samaritan and 
Lebanon VA Hospitals) and secondary care facilities.  Employees are complaining about 
respiratory problems and skin irritations.  Anticipating more patients than one hospital 


                                                                                           18



 

can handle, Good Samaritan institutes its Mass Casualty/Disaster Plan.  Based on 
preliminary data, state and local health officials have pinpointed the origin of the skin 
irritant to the Fig County office building.  The local municipality declared a "State of 
Emergency" upon consultation with county officials. 
 
        The local Fig County hazardous materials team, which has been certified by the 
state, along with Fig County health officials were dispatched to the office building and to 
the local hospitals.  The building's evening shift (approximately 50 people) are evacuated 
by local police and staged at a nearby building.  Night shift employees were instructed to 
stay home due to an unknown chemical release in the building.  As a consequence of the 
hazardous materials team being dispatched, the State Emergency Operations Center is 
then notified and briefed on the current situation, as required under the Pennsylvania 
Emergency Information Reporting System (PEIRS) criteria.  Lebanon County relays their 
intentions to PEMA regarding an issuance of a county declaration.  At this point, the 
Pennsylvania Department of Environmental Protection, Pennsylvania Department of 
Health, and Pennsylvania Department of Labor and Industry are also briefed on the 
magnitude of the "hazardous material" incident.   
 
        The HAZMAT Team arrived to find a heating and air conditioning van parked 
adjacent to the building with a ladder going to the roof. The HAZMAT team discovered a 
suspicious device and note on the HVAC System located on the roof.  The Local EOD 
team was requested to the scene.   
         An anonymous phone call was then received by the county 911 center that 
"radiological material was used in the county office building and that more radiological 
and explosive devices can be found at a residence somewhere in Fig City".  This 
information was then followed by a fax that referenced the same.   
 The Second Day 
 
        All federal response agencies arrived and the FBI became the lead crisis 
management agency and established a Joint Operations Center.  After several hours, the 
Department of Energy's Aerial Measurement System unit, Department of Energy's 
Search Response Team, PANG 3rd CSD, Pennsylvania Department Environmental 
Protections Bureau of Radiation Protection and Emergency Response offices, and the 
Federal Bureau of Investigation's hazardous materials element located additional 
radiological material in a residential area.  
 
        After bringing in more sensitive equipment, the SRT located the unknown 
radiological material on Lazy Eye Street at a rundown, two-story dwelling using a 
vehicle-based search to identify the specific house, then by a search on foot, located the 
device.  The SRT members detect high radiation readings from the radiological material 
from outside the house.  
         As local, state, and federal law enforcement officials entered the dwelling on Lazy 
Eye Street, additional explosive devices were located inside, along with subversive 

                                                                                              19



 

documents and publications that include instructions to build additional explosive 
devices.  Booby traps are both expected and identified in the house.  After rendering safe 
the secondary and tertiary devices, the DOE representative on scene reported that a 
second RDD is located inside the dwelling.  The RDD had a two-hour timer which 
appeared to have been momentarily activated.  
         Termination of the exercise occurred when it was demonstrated that a majority of 
the exercise objectives were completed. 
 EXERCISE RESU LTS:
 
       To present the results and lessons learned form this exercise, a comparison 
between expectations and the results of the exercise play will be provided.  We recognize 
that many actions we would like to see or we expected could not happen due to time 
constraints or other exercise artificialities.  We have tried to account for these limitations 
in interpreting the exercise results as presented by the individual evaluators.  
  Expectations (based on the scenario and individual Agency goals): 
 
       The key decision-makers participated in a tabletop exercise at the Civil Air Patrol 
Wing Headquarters building.   This pre-exercise was to be sure the interactions and 
command structure was well rehearsed and would go smoothly during the two-day full-
scale exercise. Because of this opportunity for rehearsal, the exercise design group 
anticipated a smooth transition from the Incident Command System to a Unified 
Command Structure on the first day.  They also thought that an organized transition to an 
operational Joint Operation Center (JOC) and Federal Radiation Monitoring and 
Assessment Center (FRMAC) would take place.  
 
       The exercise design group expected that each agency would have 24-hour 7-day 
coverage availability and would be deep enough to handle manpower staffing for the 
Incident Command System / Unified Command System, Joint Operation Center, and 
Federal Radiation Monitoring and Assessment Center.  Due to Hurricanes Floyd and 
Dennis, the Federal Emergency Management Agency's Regional Operation Center and 
the State's Emergency Operations Center partially activated for the exercise.   This 
limited State participation off-site to some extent. 
 
       There had been some thought as to whether hospital Emergency Medical 
Personnel would be able to identify and cluster symptoms from "walk-ins."  The exercise 
design group thought that medical personnel at the hospital might or might not be able to 
identify the cause of the symptoms but would at least be able to identify the "sick 
building."  We knew in advance that the symptoms presented to the hospital would not 
come from a radiation exposure, but wanted to give them a sudden cluster of ER patients 
with non-specific symptoms who worked in the same building to see if this would be 
recognized. 


                                                                                           20



 

 
       The exercise design team thought every response organization would use the same 
radiological surveys units (R, mR, etc.) and if not, would be able to convert to both SI 
units and old "U.S. radiation units of measure. 
 
       The exercise design group thought that the FIG on-scene Unified Command 
System would be prioritized in the following format: (most important to least important): 
 1)  Responder Safety  
2) Lifesaving/Victim 
                           Removal 
3)     Incident Site Control  Zone Determination 
4)     Secondary Device Sweep  Inside facility 
5) Public 
              Safety 
6) Evidence 
                 Gathering/Preservation 
 Local Response Expected:  
 
       As patients were rolling into the Good Samaritan Hospital, we expected that some 
on-scene contamination would occur, symptomology review and interviews would be 
conducted promptly which would lead to suspicion of the FIG City/County Office 
building.  Local federal support would come from the Lebanon VA Hospital via a MOA 
with Good Samaritan and the VA.  Once notification to Lebanon County EMA, PEMA, 
PADEP, and PA Health were made, we thought that the local law enforcement agency in 
FIG City would be overwhelmed quickly.  FIG PD presently has 2-3 officers on duty at 
any time.  It was anticipated that the FIG FD would respond quickly and set a safe 
perimeter and wait for the arrival of the county hazardous material team.  Incident 
Command at FIG would transfer from the Police Chief to the Fire Chief to the Lebanon 
County Emergency Management Coordinator. 
 State Response Expected:  
 
       Exercise planners anticipated a quick response by PA State Police (traffic 
control/LE Backfill) and PADEP Emergency Response Team (hazardous material 
technical support) which then would move the command structure into a Unified 
Command System.  It was not clear when and at what point the scene would be 
considered a "crime scene/terrorism event" which would generate the FBI Field 
Response.  Once the scene started to look like a crime scene, it was envisioned that the 
State Police would become the Lead State Agency (still under Unified Command) and the 
FBI Field Office would be contacted and then assume command once on-scene.  Local 
and State emergency declarations, if made, could come at any time; with a fluid exercise 
scenario, we were not sure when that would happen. This determination was made 
concurrently by PA State Police, FBI, and LEMA at 12:20 p.m. 
 Federal Response Expected: 
 


                                                                                        21



 

        The federal involvement on scene would begin once the scene was considered a 
crime scene, which would trigger the involvement of the FBI, DOE Region 1 
Radiological Assistance Program, EPA Region 3, and FEMA Region 3.  FBI-HMRU 
coordination with evidence collection resources would occur. 
 Observations: (based on evaluator comments)                   
 
        The evaluators recorded the following observations.  It must be noted that the 
evaluator comments provided in this document in no way imply a lack of 
competence on the part of any of the participants.  Exercise evaluators as a rule tend 
to find more wrong than right, and the underlying cause of a negative observation is 
frequently due to working new faces from strange agencies or to artificiality's of the 
exercise itself rather than the fault of any participant.  While it would perhaps be 
kinder and gentler to edit out negative observations, we felt the need to present the 
evaluators comments in full.   The reader should keep in mind that, in spite of seemingly 
negative comments, the participants all did their jobs well and to the best of their 
abilities!  Where there was a significant event, which leads to a significant lesson 
learned, an italicized comment will follow the evaluator's comments.  Exercise lessons 
learned are based on the input from many evaluators and interpreted in light of the overall 
exercise. 
 HOSPITAL: 
 
        Exercise "victims" were briefed and costumed at 0630 at the Civil Air Patrol 
Headquarters building at Ft. Indiantown Gap.  They were then transported to the Good 
Samaritan Hospital where additional evaluators and controllers were on station [to 
include an Office of Mental Health (state) representative].  At 8:00 a.m. victims (5) 
started walking into Emergency Department patient entrance, spaced at about 3-minute 
intervals.  Patients registered complaints with triage nurse.  Two of patients were initially 
triaged back to "chairs" to wait.  There was some confusion among staff as to which 
patients were exercise patients since they mixed in with real patients and were not 
wearing specific "exercise identification."  (Evaluators and controllers were wearing 
appropriate caps.)  Intake appeared to be handled smoothly although the exercise 
evaluator did note that the postal worker may not have been identified as an exercise 
patient until rather late in the time period.  Also, at about 08:30 a.m., the Emergency 
Room physician expressed concern for the confidentiality issues of other patients 
speaking to the triage nurse.   
 
        Five patients may have doubled the regular patient flow but certainly did not 
stress the staff in any manner.  At 0840 and 0850 two injects were given to the hospital 
regarding employers, located in the FIG City/County office building, reporting that 30 
employees had called off sick with flu like symptoms and that they had heard some may 
be at Good Samaritan Hospital.  Both employers reported that those at work were 
coughing.  Both employers asked for an update on their employees and stressed their 


                                                                                            22



 

concerns."  Reply was that the employers needed to provide names of anyone they were 
concerned about, and they were not aware of any particular illnesses e.g. flu at this time. 
 
        At 0905 Controllers consulted with the ER Physician and Emergency Department 
(ED) Director and requested that the ED activate its Disaster Plan for the purposes of 
following the exercise on time.  The plan was activated; personnel responded and were 
thoroughly briefed about the incident. Their triage and treatment of patients presented 
was appropriate and efficient.  With the Good Samaritan Hospital's pre-established 
objectives were being observed, the "patients" were released from ED and proceeded 
back to FIG.  Patients were then placed in the FIG Building as workers to be found, 
removed, and decontaminated for the FIG City/County Office Building Scenario.  Good 
Samaritan personnel responded and were briefed as to the exercise information.  
 
        "Early" identification of a pathogen or hazardous material is not likely to happen 
in a Hospital Emergency Department due to the low index of suspicion and high focus on 
individual patient management. 
 Scenario shortfalls:  
 
        The incident began at the Good Samaritan Hospital in Lebanon, PA where the 
players, evaluators, controllers knew information, and Hospital Staff; however, some 
information was either changed or misunderstood.  Things did not start and continue 
exactly as planned.  Minor details regarding patient symptoms/conditions and so forth 
made a difference in the beginning of a critical exercise.  Once the scenario hit its 
anticipated rhythm, the Lebanon County E.M.A. did an excellent job of overcoming some 
obstacles created by the information snag. 
 
        There were a few times when the scenario stalled, or nearly so.  At the onset, at 
the Lebanon Hospital, the initial findings of the ER Staff were not of sufficient severity to 
justify notifying civil authorities.  Time elapsed before an inject was generated to allow 
the scenario to proceed. Several times, observers cited instances where certain things 
were supposed to happen to trigger the next stage in the operation.  When this did not 
occur, a lengthy delay resulted until a controller was forced to freelance to move the 
timeline along.  
         Insufficient patients were available to actually stress the capabilities of the ED and 
activate the emergency plan.  Because of the nature of emergency medical care, it was 
suspected that the Emergency Department would have had to have been totally 
overwhelmed (20-25 patients) before staff would have suspected a common denominator 
to be found.   
 
        Hospital/Medical facilities must be prepared to participate (if possible) in the 
exercise as not to compromise regular patient care.  Even though Controller/Evaluators 
are near the "victims", the victims must also be clearly marked as not to be seated with 
real-world patients.  This scenario did test a triggering of various diagnosis support from 
different departments within the hospital itself. 

                                                                                             23



 

 
       Hospital personnel seem to have a rapport with Lebanon county EMA probably as 
a result of interaction with emergency services on a regular basis. Any reporting chains or 
request for assistance during any kind of emergency would probably be directed toward 
the county EMA.  It was noted that additional resources were not requested from the 
contiguous counties because a sufficient number of injects and symptoms were not 
received to force this outcome.  Exercise controllers and evaluators thought that this 
might occur directly by the county.  In addition, the State EOC was more focused on 
hurricane flooding support so the situation analysis section injects in this area were not 
entered into the state's exercise message traffic flow nor followed up on.  This "real-
world" focus also led to the delay of critical exercise notifications that would have 
mobilized or activated many of the state resources earlier on in the exercise on Day 1. 
 FT INDIANTOWN GAP 
 
       A cumbersome transfer of command occurred from the Incident Command 
System to the Unified Command System.  Although transition from the Unified 
Command System occurred to the Joint Operations Center, it was not as smooth as it 
could have been.  The Federal Radiological Monitoring and Assessment Center knew of 
the transfer of command but did not acknowledge the unified command presence within 
its own established facility.  (Again, the readership must realize that this was not a 
graded exercise!) 
 Incident Command -  
 
       Incident Command was immediately established upon initial arrival of emergency 
response forces, and was maintained (in some form or another) throughout the scenario.  
Initially, there was a delay in setting up the Incident Command System attributed to 1) 
response personnel identification problems, 2) congestion at the scene, 3) an unknown 
amount of resources on-site, enroute, or on standby, and 4) the time-compression reaction 
time written into the scenario.  Usually, even in the biggest of "normal" hazardous material 
incidents, there is some "catch-up" time for putting together the Incident Command structure. 
 Responders were not afforded this luxury in this scenario.  This lead to a period of 
disorganization.  The command structure worked through this period of information and 
resource overload and started to gel really well at approximately 1:00 p.m. once the 
recognition of roles and responsibilities were sorted out by the Lebanon County EMA staff 
and local and state support agencies. 
       The transfer of command process should have been stronger, especially prior to 
the establishment of the JOC.   Transfer of command is a very formal process. It must be 
clearly understood by both the gaining and relinquishing parties, as well as all operational 
elements in the incident, that a transfer of command has taken place.  Responders were 
questioned repeatedly to determine if they were aware of who was in command. At no 
time could any responder identify the command structure beyond his/her immediate 
supervisor. In most cases, even that supervisor was unclear on the command structure. 
Transfer of command and the basic command structure must be communicated 
effectively to all responders through radio communications and periodic briefings. 

                                                                                            24



 

 
       Upon arrival of Lebanon County Hazard Material team, the FIG fire chief 
appeared to concede command to the Lebanon County EMA coordinator by default. 
Personal observation and questioning of the players on the scene indicated that this 
individual was effectively acting as Incident Commander long before any formal transfer 
of command took place.  Again, if an Incident Commander chooses to transfer command, 
he/she must make the transfer clear.  Responding command personnel, especially those 
with technical knowledge crucial to mitigation of the incident at hand, must resist the 
strong temptation to usurp, however innocently or unintentionally, command functions 
until a formal transfer of command has been affected.   
 
       While acting as Incident Commander, the Lebanon County EMA Coordinator 
became too involved in managing the tactical aspects of the incident, specifically the 
operation of the hazardous materials team.  Emergency responders tend to be very `hands-
on' people, reluctant to delegate to subordinates, especially when we possess great 
technical knowledge and expertise on the subject in question. This invariably leads to 
problems with span-of-control, division of labor, unity of command, and organization of 
the command structure. Incident commanders in this situation must either delegate 
tactical issues to subordinates, confining themselves to the strategic goals and incident 
organization issues that are the proper domain of the IC, or decline to accept overall 
command, remaining in charge of their particular tactical element under some other 
incident commander. 
 
       A more formal command structure needed to be established much earlier in the 
incident. The Incident Command System provides for such a structure to insure that no 
commander is overwhelmed by the incident, so that agencies coming in on the incident at 
a later point understand the response structure and their role in it, and so that a common 
terminology vocabulary that all responders can relate to is established. This needed to 
begin very early on in the incident, especially when it can be reasonably anticipated that 
agencies will be responding that are unfamiliar with the terminology and structure of the 
Incident Command System. This is especially true when such agencies are highly likely to 
eventually become the `lead' agency for the incident.  Failure to have such a structure in 
place will increase the chances that such an agency will establish its own system, or, 
worse yet, that parallel command structures will be established. This actually appeared to 
occur for a short time between the arrival of significant State Police resources and the 
arrival of the FBI and establishment of the JOC. If a good system is established and 
functioning well upon arrival of such agencies, they are far more likely to `plug 
themselves in at the appropriate place, and maintain a continuity in the incident command 
structure. The command structure eventually established, although certainly functional, 
bore little or no resemblance in either structure or terminology to the Incident Command 
System that first-response elements are trained in and use. 
 
       Initially the Gap Fire Department Fire Chief assumed command.  However, 
neither a command post nor a hot zone was properly established. When command was 
transferred to Lebanon EMA, neither did they. As a result, the commander was rapidly 
overwhelmed by arriving responders looking for work, the decontamination line was 

                                                                                             25



 

placed some distance from the hot zone, and at least one large conference took place in 
the hot zone. In addition, the 3rd CSD WMD established a redundant decontamination 
line even farther away.   It should be noted that they too need to work under the Incident 
Command System, and ultimately under the Incident Commander.  Not only do they work 
directly for their own CSD WMD commander, but in coordination with the civilian 
Incident Commander.  Most times, responders queried by evaluators had no idea that was 
in charge, where zones and perimeters were established, or where the Command Post was 
located. The situation eventually got sorted out, but only after a considerable time 
elapsed. The "play area" was not clearly defined, and as a result a number of vehicles 
operated by evaluators and observers wound up in the hot or warm zone. This in part 
displaced the decontamination lines" 
  Incident Action Plan/Documentation:  
 
       The incident could have been documented better. It was difficult to determine if 
there was any concerted effort to create an incident log; there did not appear to be.   
Because a Documentation Section was not established, the command and control 
structure evolutions were not charted.  This shortcoming contributed materially to the 
communications problems alluded to previously. There appeared to be no documented 
Resource Status (RESTAT) or Situation Status (SITSTAT) accessible to all players. 
 Complex incidents must be properly documented.  SITSTAT and RESTAT reports, and 
an organizational chart showing the existing command structure should be drawn, posted 
in the Command Post or JOC, and kept current. A designated Scribe should keep an 
Incident Log. This is especially important in incidents like this, where agencies are in 
coming, agency representatives may be changing as higher-ranking individuals arrive, and 
long duration with the possibility of shift changes is anticipated. 
 The Incident Commander must insure that all critical `stakeholders' (such as the 
municipal government) are represented in the unified command structure.  Information 
needs to flow downhill as well as uphill and across levels.  Agencies did not 
communicate well between levels. 
 Exercise Finding: It is important that incident commanders deal with the big strategic 
picture, delegating responsibility for implementation of tactical objectives to subordinate 
elements of the command structure. This is especially crucial in the first stages of in an 
incident. It is impossible for an incident commander, no matter how gifted, to attend to 
tactical details and simultaneously be thinking `an hour or two ahead of the incident' as 
is required of a strategic commander. Command needs to be established early on, and 
clearly marked. All operational personnel must know whom, or at least where, the 
Command Post is.  Zone and site security must be rigidly enforced, to avoid spreading 
contamination or exposing people, and to keep command from getting overwhelmed. 
 The Incident Command/Unified Command structure as it evolved may have looked like 
the one provided below (Figure 1).  This diagram was added to allow readers of the 

                                                                                             26



 

document the opportunity to see what faced the Command Staff during the different crisis 
and consequence management response phases of the exercises. 
 








































                                                                                    27



 

                                                                             THE ICS ORGANIZATION



                                                                        Incident Command                           Information Officer                        Safety Officer           Liaison Officer
                                                                                                                Lebanon County PIO/DMVA                    Department of Labor         Annette Smith
                                                                                                                                                                                       Area Director




     Planning Section            Operations Section                                                                        Logistics Section                  Finance/Admin Section



        Resources - DEP/BRP                                Staging Area                                                           Service Branch



               Situation
                                         Salvation Army                 American Red Cross                                           Communications Unit
                                                                                                                                    (Hammerace/PA TF1)
            Documentation
                                                  Law Enforcement Branch                                                                  Medical Unit A
                                                                                                                                             (Triage)


                         PEMA                                                                                                             Medical Unit B
                                                                              Perimeter Center                                             (Treatment)
                                                                              Group A (FIG/PD)
          Demobilization Unit                                                                                                             Coroner/Morgue
                                                                              Perimeter Center
                                                                               Group B (PSP)
                                                                                                                                  Support Branch
                                                                                ICS Perimeter
                                                                                 PSP Group


                                                                               Bomb Disposal                                                 Facilities
                                                                                   Group



                                                              K-9 Strike Team                 Bomb Disposal Strike                               DMVA/MSCA
                                                                Reading PD                 Team (Allentown 756th                                     PEMA
                                                                                                    EOD FBI)                                          CAP
                                                                                                                                                  Red Cross


                                                                             Evacuation Division



                                                                             Investigation Group




                                                              K-9 Strike Team                     Interrogation
                                                                                                  Strike Team




                                                         Fire Suppression
                                                              Branch



                                       Fire Support Div. A                 Hazmat Group
                                             FIG FD



                                                                        Lebanon Cty Hazmat
                                                                           3rd MSD/RAID
                                                                           DEP/ERT/BRP
                                                                             DEP RAP


                                                           EMS Branch




                                       EMS Division A                       EMS Division B
                                          FIG EMS                          Good Samaritan


                                       Other EMS Units



                                                       Public Works Branch
                                                        FIG Public Works

                                                                                                                                          Figure 1                                                             


                                                                                                                                                                                                        28



 

Unified Command 
 
        The transfer of the Incident Command System to a Unified Command System 
occurred at 11:00 a.m. from the Mobile Command Post to Building 95 where the PA 
State Police had configured the building for coordination of the response with the now 
multiplying response organizations.    The formalized operational transfer was 
cumbersome because many of the key-decision makers, such as the hazardous material 
representatives and staging officers, were engaged in response and support activities.   
 
        The Unified Command System was in place on Day 1 but was not well 
established on Day 2.  There still existed a level of interaction between the response 
organizations but this interaction was not based within a strong command structure.  The 
command structure was a by-product of the command level personnel present.  These 
individuals were of a personality and temperament that facilitated this coordination 
despite a somewhat fragmented unified command.  Having individuals like this at the 
incident may not always be the case.   
 Exercise Finding: 
 The Concept of Unified Command must be further refined in an operational sense.  
Allied professionals from all disciplines who are tasked to respond to emergencies like 
this must receive training and familiarization with the Incident Command System as 
promulgated by the National Fire Academy. This is the terminology and command 
structure that will (or should) have been established by the local (municipal and county) 
first responders well before the arrival of many of these agencies. Understanding the 
language and structure of the system in use will permit a smooth integration of efforts and 
a likewise smooth transition of command responsibility as called for by the dynamics of 
the incident. 
 Training for all responders in the implementation and use of the Unified Command 
incident management structure must be developed and made available. Unified command 
worked, in part, at this incident because the command-level personnel of the involved 
agencies were of a personality and temperament that facilitated unified command. That 
may not had worked together on other large-scale response activities; this may not always 
be the case. Training in unified command is critical to making unified command a 
workable incident command system under a variety of circumstances and conditions.  
 Plans for the rapid and effective communications of information up and down the chain 
of command and across the full spectrum of responders/involved agencies must be 
quickly devised and implemented. As much of this as possible should be done by pre-
planning and exercise. At incidents, commanders must insure themselves that information 
on incident status and action plans are fully communicated (with considerations for 
security issues) to all responding agencies. 
  Command Post Facilities  
 

                                                                                           29



 

       For this exercise, the organizers pre-arranged buildings that would be used as 
command posts and other purposes.   In a real incident, such arrangements would have to 
be made on the spot and it is more likely that sufficient space might not be available at a 
real event location.  In spite of the pre-arranged space, the various command facilities 
were too crowded.   
        There is a need to issue credentials to response personnel so that the only 
occupants of critical facilities are those who belong there.  Credentials were a problem for 
the changeover from the parking lot Incident Command Post to the Command Post in 
Building 95.  There was also a problem with the number of people in the Joint Operations 
Center (JOC  See Figure 2) and credentialing was again a problem.   Response 
individuals presented agency specific identification badges but were not initially allowed 
entrance into the facility.  Some organizations had neither vests nor badges.  It was 
suggested that signs should be developed to help identify command structures so that 
these command and control structures can be assisted by essential support agencies. 
 
       Mobile Command Posts such as those provided by EPA are extremely important 
resources. It would be very worthwhile to include an inventory of the available mobile 
facilities in local emergency plan documents.  This would not guarantee their availability, but 
at least the responders would know from whom to request these resources. 

























                                                                                             30



 

Joint Operations Center Operations:   
 
















                                                                                           
                                         Figure 2 
 
       The transfer of command from the Unified Command structure occurred at 13:00 
hours, however the transition was not seamless.  At this stage of the exercise, a number of 
FBI agents needed to be briefed regarding the current status of the operations and what 
available resources and capabilities were at their disposal.  The transfer of command may 
have been better postponed until those informative briefings occurred.  Once the FBI had 
current assessments, a more active crisis management role could have been initiated. 
        While information was passed back and forth freely at the Strategic Level, it did 
not always filter down to the tactical level. The identification of the isotope was known at 
the JOC a long time before some of the field Radiation survey teams knew what they 
were looking for.   In fact, some teams were never told upon termination of the exercise. 
This would have made a difference in who was used to do the searching, and what 
equipment was used. 
        
Some operational unit chiefs were allowed access into the JOC.  It was noted that the 
CSD, which is an operational hazardous material support team, was represented in this 
strategic setting and at times CSD leadership left the JOC to deal with operational issues. 
  






                                                                                          31



 

Exercise Finding: 
 The Unified Command concept is essential in a situation where multiple agencies with 
different and perhaps overlapping jurisdiction must work together to solve an immediate 
problem.    Traditionally, the Joint Operations Center has been thought to fulfill this role. 
 In this exercise, we note that there are really two separate and distinct functions in need 
of a Unified Command.  These are the strategic and the tactical levels of command.   The 
JOC in its traditional form addresses only the strategic level and substantially ignores 
the tactical.   The observations of this exercise point to the need for a tactical Unified 
Command at the scent of the action in addition to the strategic Unified Command in the 
Joint Operations Center.  The meaning of the terms "strategic" and "tactical" should be 
obvious from the evaluator's observations above. The strategic command tends to be 
concerned with the overall strategy and allocation and coordination of resources.   The 
tactical command is concerned with the detailed response to the incident at the scene of 
the action.  It appeared that some of the Law Enforcement personnel were not familiar 
with the roles, responsibilities, and resources of state and local responders and visa 
versa for the emergency management and environmental management personnel.  In 
addition, some operational support elements need to stay with the unified command 
structure and not in the JOC. 
         
 Depth of Coverage  
 
        Back-up capability was not as expected.  A few of the agencies had enough 
personnel that were familiar with the Incident Command System.  Additional personnel 
were needed from a number of local, state, and federal agencies.  Many of the state 
agencies sent their Emergency Preparedness Liaison Officers (EPLOs).  Since the State 
Emergency Operations Center was not fully activated, the EPLOs were able to fill this 
role.  However, had the State EOC been operational, the EPLOs would have been tasked 
to support state logistical efforts.  Even though the state has run eight (8) Nuclear, 
Biological, and Chemical Weapons of Mass Destruction courses for county and state 
personnel, many of the state responders who responded, had not attended these courses.   
         
Exercise Finding: 
 The state needs to identify more individuals that have completed Incident Command/ 
Unified Command WMD courses and exercise those individuals to support the local 
authorities.   
 Site Safety: 
 
        PSP were not sure where the inner perimeter was and access to the site by various 
agencies was at times confusing.  During the initial response, a pre entry/safety briefing 
was not conducted.  Although identified, the entry backup team was not fully dressed out 
when the first entry occurred.  Early in the exercise the county hazmat team entered the 
the building in full Level A personal protection.  Team 1 entered the building without 

                                                                                               32



 

reading the radiation meter.  Team 2 realized that Team 1 did not have any meter readings 
and realized that their survey meter was saturated as soon as they entered the building.  
Team 2 called Team 1 back to the building entrance.  The Incident Commander instructed 
Team 1 to complete their rescue mission according to their training.  This resulted in 
unnecessary stair climbing in Level A protection.  (What was needed was a higher range 
gamma survey meter.)  One PSP criminal investigator gained access, without escort, to 
the city/county office building and was contaminated.  It was observed at this time that 
the site safety officer was not present.  The 3rd MSD team then resurveyed the exterior of 
the building in Level A protection but this was after the Pennsylvania Department of 
Environmental Protection's Bureau of Radiation Protection personnel surveyed the same 
area in street clothes.   
         
Observations on Site Safety included the following:  
 
        Decontamination Operations: Radiation surveys were done on personnel leaving 
        the Hot Zone but some were not monitored leaving the decontamination area.  
        Specifically, county hazardous material personnel did not seem to be checked 
        after removing their suits.  It did not appear that decontamination back up teams 
        were designated. 
 
        Video Surveillance  Operationally, many of the response teams thought that 
        "Live time feeds" (to JOC/UCS, etc.), could have enabled responders to operate 
        more effectively for four reasons.   
         
        1)  Responders could have a "Quick Look" through the use of Robotics that could 
             be used for victim and secondary device search and assessments if robotics 
             with video were used optimally; 
        2)  The Incident Safety Officer could monitor the Responder Safety while 
             operating in Level As;  
        3)  Videotaped documentation could later be used in the evidence processes;  
        4)  Subject expert, whether EOD or radiation, could support the response 
             (backstop) if something could or did go wrong, that individual could respond, 
             if necessary, and know where the dangers or mistake could be averted in the 
             second attempt. 
 
        Hazardous material teams did not appear to share resources (decontamination and 
survey equipment) and look into mobile transportation for equipment and personnel if the 
scene is as large as it was at this scenario.  The sharing of resources was compounded 
because a clear staging area/manager was never established. 
 
        Level A entry teams could not have climbed and fit through roof hatches.  SOPs 
for response to such situations should address the need to conduct Level A work on 
rooftops and the use of aerial trucks, ladders, hydraulic platforms, etc.  More generally, 
the responding organizations should have a better understanding of Level A operations 
(removing patients and hauling equipment can be difficult).  

                                                                                           33



 

 Exercise Finding:   
 
       Overall this points