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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

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.

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

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

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.)

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.

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

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.

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.

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.

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.

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:

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

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.

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.

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

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

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.

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:

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

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.

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.

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

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

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

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

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

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.

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.

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

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).

Exercise Finding:

Overall this points